Topic 5: Musculoskeletal, Metabolism, And Multisystem Complexities


1. Describe pathophysiological changes and abnormal findings associated with musculoskeletal, metabolic, and multisystem health dysfunctions.

2. Evaluate a research-based nursing intervention or treatment tool for the management of diabetes.

Assignment 3

Evidence-Based Practice Project: Intervention Presentation on Diabetes:

Please use the article below for the assignment, thanks.

Heinemann, L., Stuhr, A., Brown, A., Freckmann, G., Breton, M. D., Russell, S., & Heinemann, L. (2018). Self-measurement of Blood Glucose and Continuous Glucose Monitoring – Is There Only One Future?. 
European endocrinology
14(2), 24–29.

 Identify a research or evidence-based article published within the last 5 years that focuses comprehensively on a specific intervention or new treatment tool for the management of diabetes in adults or children. The article must be relevant to nursing practice.

Create a 12-15 slide PowerPoint presentation (not including the title page and references) on the study’s findings and how they can be used by nurses as an intervention. Include speaker notes for each slide and additional slides for the title page and references.

Include the following:

1. Describe the intervention or treatment tool and the specific patient population used in the article.

2. Summarize the main idea of the research findings for the specific patient population. The research presented must include clinical findings that are current, thorough, and relevant to diabetes and nursing practice.

3. Provide a description of how the treatment tool or intervention can be integrated into nursing practice. Provide evidence to support your discussion. Reflect how the treatment tool or intervention will affect nursing practice and the disease process.

4. Explain why psychological, cultural, and spiritual aspects are important to consider for a patient who has been diagnosed with diabetes. Describe how support can be offered in these respective areas as part of a plan of care for the patient. Provide examples.

You are required to cite a minimum of three sources to complete this assignment. Sources must be published within the last 5 years and appropriate for the assignment criteria and relevant to nursing practice.

While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center. 

This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion. 

You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.

Musculoskeletal, Metabolism, and Multisystem Complexities By Angel Falkner and Sue Z. Green

Essential Questions

· What are the pathophysiological changes and abnormal findings associated with musculoskeletal, metabolic, and multisystem health dysfunctions?

· Which musculoskeletal, metabolic, and multisystem health conditions are the most prevalent?

· How does the nurse manage these health conditions to restore the patient to optimal health?

· What measures do nurses use to help transition patients to being independent?


The musculoskeletal system is the framework for movement and function. Diseases of this system encompass a wide array of disorders that often lead to physical disabilities and loss of function for patients (Cherney, 2018). Because of this, it is essential for nurses to understand the complexities and ways they can promote health and wellness for the patient suffering from musculoskeletal diseases. The metabolic system is fueled by the endocrine system and its many hormones. Alterations in hormone synthesis and release lead to a wide range of diseases, the most common of these being diabetes mellitus (National Institute of Diabetes and Digestive and Kidney Diseases [NIDDK], n.d.a). Diabetes affects millions of patients and often exists in conjunction with multiple comorbidities (American Diabetes Association [ADA], 2018b). It is essential for nurses to be well informed regarding its management and ways to promote health and wellness for the patient with diabetes. Sepsis, a multisystem complexity, is a growing concern worldwide that leads to devastating outcomes for patients (Centers for Disease Control and Prevention [CDC], 2018c). Nurses must be knowledgeable regarding early warning signs and the need for prompt treatment to help decrease sepsis rates and associated outcomes.

Musculoskeletal Pathophysiology

Normal Function

The musculoskeletal system is composed of voluntary muscles and connective tissues. The connective tissues are the bones, joints, cartilage, ligaments, tendons, and fascia (Lewis et al., 2017). The musculoskeletal system has a variety of functions that allow for body movement (see Table 5.1).

Table 5.1

Function of the Musculoskeletal System

System Component





· Collagen fibers (fibrous connective tissue)

· Calcium

· Phosphorus

· Osteoblast

· Osteocytes

· Compact bone

· Spongy bone

· Protects internal organs.

· Bears weight of body.

· Stores minerals.

· Produces red and white blood cells.

· Lever for muscles and muscle contraction.


Fibrous connective tissue

Types of joints:

· Hinge

· Ball and socket

· Pivot

· Condyloid

· Saddle

· Gliding

Allows for:

· Flexion

· Extension

· Adduction

· Abduction

· Circumduction

· Rotation

· Thumb-finger opposition


Fibrous connective tissue

Types of cartilage:

· Hyaline

· Elastic

· Fibrous

· Supports soft tissue.

· Allows smooth surface for place of connection for bones in joint movement.


· Voluntary or skeletal muscle fibers

· Connective tissue

· Blood vessels

· Nerve fibers

Produces voluntary movement as a result of neuronal stimulation.


Fibrous connective tissue

Provides joint stability by connecting bones together at a joint.

· Allows controlled movement within a joint.

· Prevents excessive movement within a joint.


Fibrous connective tissue

Attaches muscles to bone as an extension of the muscle sheath that adheres to the periosteum.


Layers of connective tissue with intermeshed fibers

· Surrounds bundles of muscle, nerves, and blood vessels to allow for limited stretching.

· Surrounds individual muscles.

Note. Adapted from 
Medical-Surgical Nursing (10th ed.), by S. L. Lewis, L. Bucher, M. M. Heitkemper, M. M. Harding, J. Kwong, & D. Roberts, 2017, Elsevier; and 
Essentials of Pathophysiology (4th ed.), by C. M. Porth, 2014, Lippincott, Williams, & Wilkins/Wolters Kulwer.

The bones protect underlying organs, support the weight of the body, provide a structural framework to enable coordinated movement, and store minerals (Lewis et al., 2017). Among the components of the bones are compact bone, spongy bone, bone marrow, blood vessels, and, nerves (see Figure 5.1). The skeletal bones are vital in hematopoiesis, which is the production of blood cells (see Figure 5.2).

Figure 5.1

Composition of Bones

Figure 5.2

Bone Marrow and Hematopoiesis

Bone remodeling
 is the adult, lifetime process of bone repair and replacement for skeletal maintenance. As areas require renewal, a tightly balanced sequence of bone resorption and formation is initiated (Porth, 2014). First, 

 dissolve and resorb calcified bone and existing 

bone matrix
 over a process of approximately 2–4 weeks (Myneni & Mezey, 2017; Porth, 2014) (see Figure 5.3). Then, 

 form new bone. Bone formation occurs when the osteoblasts place repeating layers of new matrix (Huether, McCance, Brashers, & Rote, 2017). The osteoblasts aid in the calcification process of the minerals to strengthen the bone (Huether et al., 2017; Porth, 2014). The process of bone remodeling takes approximately 4–6 months (Domazetovic, Marcucci, Iantomasi, Brandi, & Vincenzini, 2017; Porth, 2014). The lag time between bone resorption and bone calcification is a vulnerable period for the bone. Also, if the osteoclasts excessively remove bone, which occurs with 

, then the bone is more fragile (Domazetovic et al., 2017; Florencio-Silva, Sasso, Sasso-Cerri, Simões, & Cerri, 2015).

Figure 5.3

Bone Remodeling

The skeletal muscles are attached to bones and account for 40% to 45% of the body’s weight (Porth, 2014). Skeletal muscles are composed of skeletal muscle fibers, connective tissue, blood vessels, and nerve fibers (see Figure 5.4).

Figure 5.4

Skeletal Muscle Structure

Body movement occurs from the contraction of these muscles as a result of motor neuron stimulation of the muscle fibers (see Figure 5.5) at the neuromuscular junction (see Figure 5.6).

Figure 5.5

Innervation of the Skeletal Muscle

Figure 5.6

Neuromuscular Junction

Abnormal Findings

Alterations in the musculoskeletal system can be due to injury, infection, inflammatory diseases, noninflammatory conditions, or tumors (Huether et al., 2017). For example, bone loss and muscle atrophy are both associated with the aging process and prolonged bedrest (Lewis et al., 2017). Pain may be the first sign of a musculoskeletal system problem. The involved area may exhibit numbness, edema, increased warmth, muscle spasms, decreased range of movement, stiffness, or tenderness (Huether et al., 2017; Porth, 2014). Diagnostic tests may be ordered for detection, diagnosis, and determination of the extent or severity of a condition. A variety of tests may be ordered depending on the patient’s needs (see Tables 5.2 and 5.3). After diagnosis, some testing may be ordered routinely to monitor the progress of a degenerative disorder. The diagnoses of osteoarthritis, osteoporosis, and rheumatoid arthritis are among the most common musculoskeletal system disorders. These progressive, degenerative conditions lead to pain, joint deformities, and limitations in mobility.

Table 5.2

Common Serum Studies for Musculoskeletal Diagnostic Testing

Category of Testing

Diagnostic Test

Abnormal Finding

Markers of Muscle Injury


Used in monitoring muscular dystrophy and dermatomyositis.

Creatine kinase (CK)

Increased levels occur with progressive muscular dystrophy, polymyositis, and traumatic injuries.


Increased levels occur with trauma to muscles.

Mineral Metabolism

Alkaline phosphatase

Elevated levels found in bone cancers, healing fractures, osteomalacia, osteoporosis, and Paget’s disease.


Decreased levels found in hypoparathyroidism, osteomalacia, and renal disease. Increased levels found in hyperparathyroidism and some bone tumors.


Decreased levels found in osteomalacia. Increased levels found in chronic kidney disease, healing fractures, and osteolytic metastatic tumor.

Serologic Studies

Anti-DNA antibody

Diagnosis of systemic lupus erythematosus.

Antinuclear antibody (ANA)

Antibody presences found in systemic lupus erythematosus. May also be found in scleroderma, rheumatoid arthritis, and some healthy populations.

Complement, total hemolytic (CH50)

May be depleted in rheumatoid arthritis or systemic lupus erythematosus.

C-reactive protein (CRP)

Elevated levels indicate inflammatory process, infections, or active widespread malignancy.

Erythrocytes sedimentation rate (ESR)

Elevated levels indicate inflammatory process, especially in rheumatoid arthritis and rheumatic fever.

Human leukocyte antigen (HLA)-B27

May be present in autoimmune disorders, such as ankylosing spondylitis or rheumatoid arthritis.

Rheumatoid factor (RF)

Auto-antibody presence may indicate of rheumatoid arthritis or other connective tissue disease.

Uric acid

Elevations are associated with gout.

Note. Adapted from 
Medical-Surgical Nursing (10th ed.), by S. L. Lewis, L. Bucher, M. M. Heitkemper, M. M. Harding, J. Kwong, & D. Roberts, 2017, Elsevier; and 
Understanding Pathophysiology (6th ed.), by S. E. Huether, K. L. McCance, V. L. Brashers, & N. S. Rote, 2017, Elsevier.

Table 5.3

Other Common Musculoskeletal Diagnostic Tests

Category of Testing

Diagnostic Test

Abnormal Finding

Bone Mineral Density (BMD) Measurements

Dual Energy X-Ray Absorptiometry (DXA)

Change in bone density, metabolic bone disease.

Quantitative Ultrasound (QUS)

Changes in density, elasticity, and strength of bone—often used at the heel.



Insertion of arthroscope into a joint for biopsy; diagnosis of abnormalities of the articular cartilage, joint capsule, ligaments, or meniscus; removal of loose bodies, or surgical repair of joint structures.

Invasive Procedures


Reveals joint inflammation, infection, tears of the meniscus, and subtle fractures.

Electromyography (EMG)

Detection of lower neuron dysfunction, primary muscle disease, or peripheral vessel disease.

Radioisotope Studies

Bone Scan

Radioisotope injection reveals increased bone uptake in certain fractures, osteomyelitis, osteoporosis, and primary and metastatic malignant bone lesions. Reveals decreased bone uptake in avascular necrosis.

Radiologic Studies


Inadequate bone density.

Computed Tomography (CT) Scan

Bony abnormalities, soft tissue abnormalities, or various types of musculoskeletal trauma.


Contrast injection reveals cervical or lumbar intervertebral disc abnormalities.

Magnetic Resonance Imaging (MRI)

Avascular necrosis, cartilage tears, disc disease, ligament tears, osteomyelitis, or tumors.

Myelogram With or Without CT

Nerve impingement, subtle lesions or injuries of nerves. Reveals how bone is affecting nerve roots.

Miscellaneous Studies

Duplex Venous Doppler

Detect lower venous blood flow abnormalities, such as a deep vein thrombosis.


Records variation in volume and pressure of blood passing through tissues.

Somatosensory Evoked Potential (SSEP)

Can reveal subtle dysfunction of lower motor neuron and primary muscle disease. May be used in spinal surgery for scoliosis to detect neurologic compromise.


May reveal cause of inflamed joint or response to anti-inflammatory drug therapy.

Note. Adapted from 
Medical-Surgical Nursing (10th ed.), by S. L. Lewis, L. Bucher, M. M. Heitkemper, M. M. Harding, J. Kwong, & D. Roberts, 2017, Elsevier; and 
Understanding Pathophysiology (6th ed.), by S. E. Huether, K. L. McCance, V. L. Brashers, & N. S. Rote, 2017, Elsevier.

Prevalent Problems


The wear and tear on synovial joints, especially through repetitive actions, results in degeneration of the protective cartilage at the juncture of two bones known as 

osteoarthritis (OA)

degenerative joint disease (DJD)
. The pressure triggers an inflammatory reaction causing pain and edema of the affected joint. Obesity adds to the weight bearing down onto the cartilage. The inflammation and the continued weight pressure gradually disintegrate the cartilage, causing further friction between the bones. OA is more common after the age of 40 (Huether et al., 2017). For example, OA can gradually destroy the cartilage between two bones, allowing them to meet in Stage IV of the disorder (Figure 5.7).

Figure 5.7

Joint Degeneration Related to Osteoarthritis


Fractures occur due to direct trauma to a bone and when a bone is no longer firm because of disease. Osteoporosis
 is a condition of decreased bone mineral density making the bone porous and increasing the risk of fractures (see Figure 5.8). The normal storage of minerals is part of the structural integrity of the bone. Over time, minerals are lost, causing the bone to become thinner, weaker, and prone to fractures. Osteoporosis is the most common disease affecting the bones (Huether et al., 2017).

Figure 5.8

Stages of Osteoporosis

The honeycombing of the bone is generally asymptomatic. A sudden fracture may occur in the humerus, vertebrae, pelvic, hip, or other bones (Huether et al., 2017; Porth, 2014). The fracture may occur spontaneously or during an event that should have minimal bone trauma, such as coughing, falling, lifting, jumping, sudden movement, or walking (Lewis et al., 2014; Porth, 2014). Postmenopausal women or others with low estrogen may notice a loss of height or development of a curvature of the upper back known as a 

dowager’s hump
. The curvature is caused by vertebral compression fractures and this 

kyphotic posture
 can be an overt sign of osteoporosis. Risk factors for osteoporosis include:

· Family history

· Caucasian

· Increased age

· Female

· Small stature

· Fair, pale skin

· Thin build

· Early menopause

· Late menarche

· Nullparity

· Obesity

· Weight below normal

· Acidosis

· Low dietary calcium and vitamin D intake

· High caffeine intake

· Sedentary life style

· Smoker

· Excessive alcohol consumption

· Liver or kidney disease

· Rheumatoid arthritis (Huether et al., 2017; Lewis et al., 2017).

Figure 5.9

Dowager’s Hump

Rheumatoid Arthritis

A healthy immune system protects the body and its functions; however, an overactive immune system does not recognize healthy body components and treats them as if they are the enemy of the body. In 

rheumatoid arthritis (RA)
, an overactive immune system attacks healthy tissue, especially in synovial joints. This aggression on the tissue causes inflammation, which in turn causes destruction of connective tissues. If left untreated, the inflammation leads to deformity and loss of function (see Figure 5.10).

Figure 5.10

Stages of Rheumatoid Arthritis

Figure 5.11

Joint Destruction Related to Rheumatoid Arthritis

Musculoskeletal Dysfunction and Nursing Management

Restoration of Function

For minor injuries, the treatment is the RICE method. RICE is an acronym for rest, ice, compression, and elevation. The inflammatory process makes soft tissues swell at the injury site. Rest allows time for the injury site to remain at a stable place without expectation of movement or work of the bones, muscles, and soft tissues. Ice to the site for the first 24-48 hours causes vasoconstriction of the blood flow to prevent and reduce edema and pain. Compression restricts the edema, aiding its flow into the bloodstream for removal and pain reduction. Elevation of the site, preferably at or above heart level, provides gravity to assist the removal of excess fluids and pain reduction. Later short application of warmth to the area aids in fluid redistribution and enhanced healing blood flow.

Pain associated with musculoskeletal injuries and disorders can be relieved through nonpharmacological and pharmacological means. Applications of heat and cold, sometimes alternating, can reduce muscle and joint discomfort and reduce swelling. Acupressure, acupuncture, exercise regimens, transcutaneous electrical nerve stimulation (TENS) units, and massage are also therapeutic measures for many chronic musculoskeletal conditions. Pharmacological therapy includes muscle relaxants, NSAIDs, and opioid and nonopioid analgesics. Osteoarthritis disorders may be able to delay joint replacement with intra-articular injections of corticosteroid, hyaluronic acid, or autologous conditioned serum (Barreto & Braun, 2017; Ong et al., 2016). Musculoskeletal disorders that have autoimmune components may benefit by pharmacologic therapy aimed at immune suppression. The patient may have prescriptions for one or more of the following:

· antimetabolite or chemotherapeutic agent, such as methotrexate;


 disease-modifying antirheumatic drug (biologic or biologic DMARD)/

tumor necrosis factor (TNF) inhibitor
, such as adalimumab or etanercept;

· corticosteroid;


disease-modifying antirheumatic drug (DMARD)
, such as celecoxib or hydroxychloroquine sulfate;


Janus kinases (JAKs) inhibitor
, such as Tofacitinib; and

· adjunct medications for associated conditions, such as folic acid for its depletion and a thyroid hormone replacement, such as levothyroxine sodium, for accompanying hypothyroidism.

Relief for RA

Brad had an onset of acute pain in his left hip. Later, the pain ceased in his the hip, but his right hand joints became painful for several days, accompanied by swelling and pink-to-red areas over the joints. He self-administered ibuprofen in both incidents. He continued having incidents of acute pain, redness, and swelling that were not well relieved by the NSAID. His primary practitioner ordered corticosteroids, which provided some relief. Because of his elevated CRP and ESR test results, Brad was referred to a health practice with a rheumatologist and a nurse practitioner where he was diagnosed with rheumatoid arthritis. Brad’s antinuclear antibody (ANA) studies did not show a positive result for several more months. He began a regimen of methotrexate, folic acid, and adalimumab, and he experienced much improvement.


Fractures heal through hematoma formation, soft tissue callus formation, ossification, and bone remodeling (see Figure 5.12). The fractured bones are placed in anatomical alignment and then immobilized. Sometimes surgery is necessary for this to occur. The immobilization is necessary to maintain the alignment while the bone heals. The increased vascularization from the hematoma and the soft callus formation allow for 

 and osteoblasts to initiate healing. 

Soft callus formation
 forms the granular tissue base for the repair. Fibroblasts are cells that produce collagen fibers to bridge the break in the bone. Next, 

 and bone remodeling follow. Ossification is the depositing of minerals into the soft callus and osteoclast resorption of excess callus. Once ossification occurs, the bone is firmer and immobilization devices, such as casts or splints, can be removed (Porth, 2014). Healing occurs in 10 to 18 weeks in adults (Porth, 2014). Aging, diet, smoking, and metabolic processes involving calcium levels affect the ability for bone healing (Porth, 2014).

Figure 5.12

Repair of Fractures

Joint Replacement

Arthritic changes or injury may lead to joint replacement, known as 

. Arthroplasty corrects deformities from disease or trauma. The implantation of a prosthetic joint relieves pain and improves range of motion after recovery from the surgery. Use of the artificial joint implant begins soon after surgery. For example, someone with a knee replacement will ambulate in the room or into the hall the same day as the surgery, using a walker and assistance from a physical therapist. Applications of ice and analgesia reduce pain and edema. The patient is discharged to home or a rehabilitation center. Physical therapy assists the patient in strengthening the muscles around the joint and promoting the person’s optimal range of motion.

Infection is a possible complication of joint implants. Previously, care required the use of prophylactic antibiotics prior to dental procedures. The thought was that the possible release of bacteria into the bloodstream could ultimately reach the joint and cause osteomyelitis. Now the recommendation is that prophylactic antibiotics are unnecessary except where there have been previous complications (American Dental Association, 2018).

Time for a Replacement

Sidney, a nurse, found that her knee joints were painful, warm, and swollen by the end of her shift. She sought health care and was managed with muscle strengthening exercises, NSAIDs and corticosteroid injections, and later autologous conditioned serum injections. After several years, the treatments no longer provided relief and diagnostic studies revealed that her knee joints were bone on bone
Sidney had a bilateral total knee replacement. She was walking that same day. After a few months of physical therapy, she resumed her normal workload with fully functioning knees. The orthopedic surgeon told Sidney that she would continue to notice improvements in endurance and mobility over the following 18 months to 2 years.

Check for Understanding

1. Compare and contrast the pathophysiology of three prevalent problems of the musculoskeletal system.

2. What therapeutic measures can the nurse apply to musculoskeletal disorders?

3. Which pharmacologic agents are effective for musculoskeletal disorders?

Transition to Independence

Psychosocial Support

Patients with musculoskeletal disease will require a great deal of psychosocial support to cope with the complexities of their condition and the ways in which it will affect their lives. With the limitations and pain associated with musculoskeletal diseases, many patients may experience depression or depressed mood when dealing with the changes they may need to make in their day-to-day lives. Appropriate mental health assessments are necessary to provide patients with the adequate support and resources needed. In addition, the support of family and friends is essential to adjust to the nuances of such disease processes (Vargas-Prada & Coggon, 2015). The 

social determinants of health (SDOH)

 are also an important consideration. Limitations, such as insurance, finances, and transportation, can also affect the patient’s compliance with disease treatment and management. The nurse should gain information regarding SDOH through basic question-and-answer interviewing and provide the patient with resources and support, as needed.

Cultural Considerations

Cultural variances may also affect the patient’s treatment plan and management of musculoskeletal diseases. Pain is a prominent factor in musculoskeletal disease. Different cultures may express pain differently—some patients may remain stoic even if they are experiencing a great amount of pain, making the nurse’s assessment for pain more difficult. The nurse must develop ways to evaluate for pain and discuss the importance of pain management with the patient to manage the patient’s disease (Pillay, van Zyl, & Blackbeard, 2014). When treatment recommendations call for rest or time away from work, some patients may neglect to follow such advice. From a cultural perspective, this may be due to a need to provide for the family regardless of injury or illness. Pain is expressed and perceived differently depending upon culture (Liao, Henceroth, Lu, & LeRoy, 2016). In some cultures, pain may be considered part of life and something that people must learn to deal with and move forward. Cultural preferences may also negate Western medicine’s treatment of musculoskeletal disease and opt for homeopathic remedies, such as massage. The nurse must uphold the cultural beliefs and preferences of patients and provide recommendations and education without disrespecting their decision in managing their disease.

Spiritual Considerations

Many patients turn to their spirituality and religion as a coping mechanism for pain management. Relying upon the support and advice from spiritual leaders as well as turning to prayer and meditation has been an effective component of chronic pain management for many patients (Dedeli & Captan, 2013). Turning to prayer and seeking comfort and council from spiritual leaders as well as those within the patient’s spiritual or religious community may be extraordinarily important to the patient and aid in the ability to cope. The nurse must be aware of this and offer chaplain services or facilitate the patient’s religious leader visiting the patient, if needed. In addition, the nurse must help accommodate spiritual practices and traditions as part of the patient’s plan of care.

Contributing Factors

As with many other diseases, musculoskeletal diseases have varying contributing factors, such as genetic/familial components, obesity, and medical history (e.g., hypertension and drug/alcohol use). Many musculoskeletal diseases have genetic components, such as autoimmune diseases like RA; however, a majority of these disorders are largely preventable and occur as a result of repetitive movement or injury and are also heavily influenced by lifestyle choices and comorbidities, such as obesity. Work injuries may often be related to ergonomics and poor body mechanics and may be affected by proper education and training to prevent further or repeated injuries. In addition, worker’s compensation cases are often financially detrimental to employers and leave employees with extended amounts of time off work. Comorbidities, such as obesity, often lead to musculoskeletal disease as well, possibly because of the increased weight putting excessive stress on the joints, which causes deterioration.

Lifestyle choices, such as alcohol and drug use, also have effects on the musculoskeletal system. Long-term alcohol abuse causes the malabsorption of calcium by the digestive system, leading to osteoporosis and OA. Many illicit drugs, such as opioids and methamphetamines, have been shown to slow bone growth in children, adolescents, and young adults (National Institute on Drug Abuse, 2017). Various illicit drugs affect the muscles, causing cramping and weakness (National Institute on Drug Abuse, 2017). Smoking cigarettes has also been shown to alter the absorption of calcium, thereby contributing to osteoporosis and OA (Abate, Vanni, Pantalone, & Salini, 2013).

Prevention and Health Promotion


Nutritional recommendations for patients with musculoskeletal disease are very similar to recommendations made for many other diseases. The importance of a well-balanced diet with a variety of fruits and vegetables in addition to lean proteins and low-fat dairy products are all central components advised for patients diagnosed with musculoskeletal disease (Boros, 2017). In addition to these basic diet elements, recommendations for foods that aid in combatting inflammation associated with musculoskeletal disease are essential as well. Seasonings such as garlic, turmeric, ginger, cinnamon, and cayenne have anti-inflammatory effects (Arthritis Foundation, n.d.b). Foods that are rich in 

omega 3 fatty acids
, such as fish, are noted to aid in a delay of osteoarthritis and reduce inflammation (Arthritis Foundation, n.d.a; Boros, 2017). Supplements such as glucosamine, chondroitin, calcium, magnesium, and phosphorus are all beneficial for the patient with musculoskeletal disease (Boros, 2017). Patients living with RA require folic acid, calcium, magnesium, selenium, zinc, and vitamins B6, B12, C, and E because deficiencies of these vitamins and minerals are common with the disorder (Kennedy, n.d.).


The key to physical activity when it comes to musculoskeletal diseases is moderation. While physical activity has been known to promote mobility and decrease pain, extreme amounts of physical activity can promote the manifestation of disease, such as OA (Curtis et al., 2017). This is not to understate the importance and benefits of physical activity in helping decrease incidence of musculoskeletal disease as well as manage symptoms. Exercise such as walking, swimming, cycling, yoga, and tai chi are all extraordinarily beneficial, promote mobility, and increase strength and coordination (Manson, Rotondi, Jamnik, Ardern, & Tamim, 2013). In some instances, physical activity may not be an option if pain is out of control; however, after focusing on adequate pain control, a key element in the patient’s plan of care should be increasing physical activity. This may start with small, brief walks, as the patient is able to tolerate them. The nurse can remain a positive source of encouragement, reassuring the patient than any movement at all is more beneficial than no movement.


Medication therapy for musculoskeletal diseases varies depending upon the nature of the injury or disorder. Acute injuries, such as fractures, may be treated by opioid or nonopioid oral pain medications and anti-inflammatory medications. Chronic illnesses require medications on a long-term basis to treat the root cause of the disease, such as immunosuppressants to treat autoimmune disease, such as RA. Patients require in-depth education regarding medication use, side effects, and the importance of compliance. Patients may also need assistance with navigating their insurance coverage and required co-pays. This may require collaboration with case management to assist the patient in applying for insurance coverage, if necessary.

Immunologic Considerations

Medication therapy for autoimmune musculoskeletal diseases, such as RA, may include immunosuppressant drugs. Because of the direct impact upon the patient’s immune system, patients may have a decreased ability to fight infection and may become more susceptible to communicable diseases, such as influenza and pneumonia. Patients should be educated on the importance of remaining current on all vaccinations to help protect them from contracting easily spread illnesses. In addition, patients should be educated regarding proper hand hygiene and avoiding others who are sick as methods to decrease the risk of contracting communicable disease. If patients do get sick or have signs and symptoms of an infection, they should report such findings to their medical provider right away in order to receive prompt and adequate treatment (Giorgi, 2016).

Resources for Nonacute Care

With acute injuries, such as fractures, there will be a significant amount of time needed for rehabilitation and therapy to return to the previous level of functioning. Depending upon the severity of the injury, this may be anywhere from weeks to months. Therapy may begin in the acute care setting and will continue after the patient discharge on an outpatient basis. Collaboration with interdisciplinary team members, such as case management, may be needed to assist in approval and coordination of therapy with the patient’s insurance or assisting the patient in applying for insurance, if needed. After the predetermined amount of therapy is completed, an evaluation of the patient by the provider and physical therapist is performed and the patient may get approval to return to regular activities, including work, school, and typical physical activities. Acute and chronic patients may need assistance acquiring the appropriate assistive equipment necessary, including crutches, walkers, wheelchairs, and home equipment, such as grab bars and raised toilet seats, if indicated. Assistive equipment may be needed in acute injuries as well as chronic disease management of progressive diseases such as OA, RA, or other DJD.

Additional support for those with musculoskeletal disorders is available through various Internet resources. For example, the National Osteoporosis Foundation is an organization with educational information and links for further resources and support. The Arthritis Foundation is a beneficial resource for educational information for living with arthritis, links for support, and care resources. The Arthritis Foundation receives Centers for Disease Control and Prevention (CDC) funding for exploration of more than 100 forms of arthritis (CDC, 2018a). The National Institute of Health provides the National Institute of Arthritis and Musculoskeletal and Skin Diseases and the Osteoporosis and Related Bone Diseases National Resource Center websites. Both sites have education and research information.

Check for Understanding

1. How does nutrition support health for those with musculoskeletal disorders?

2. What types of physical activity are beneficial for those with musculoskeletal disorders?

3. What support groups are available for those with musculoskeletal disorders?

Metabolism Pathophysiology


The pathophysiology of metabolism begins with the endocrine system, which consists of a number of important organs that secrete hormones responsible for various functions within the body. Once the hormones are released by the primary organ, the hormones bind to receptor sites located on the surface of target cells, and the cells then stimulate the appropriate response from the associated organ (Morley, 2016). For instance, the 

 secretes the hormone insulin, which signals the liver, muscle, and fat cells to take in 

 from the bloodstream to use as energy (Qaid & Abdelrahman, 2016). In addition, the pancreas secretes the hormone 

, which is released in response to a decrease in blood glucose levels and stimulates the liver to release glucose and increase blood glucose levels (Qaid & Abdelrahman, 2016).

Normal Function

When the body is functioning correctly, the hormones are released by the appropriate organ and illicit the appropriate response by binding to the appropriate target organ cells. The 

posterior pituitary gland

anterior pituitary gland
 within the brain are responsible for the secretion of many of the body’s hormones (Figure 5.13 illustrates the hormones secreted by each gland).

Figure 5.13

Pituitary Gland and Associated Hormones

In addition to the pituitary gland, several peripheral organs produce hormones as well, such as the pancreas. The pancreas is responsible for secreting 

, which regulates blood glucose levels within the body. The 

adrenal glands
, located just on top of each kidney, are responsible for the secretion of the 


, and 

. The 

parathyroid gland
, located on the 

thyroid gland
 itself, is responsible for secretion of 

parathyroid hormone
, which regulates the body’s 


Abnormal Findings

When the body is under stress from illness or other alterations, such as birth defects, surgery, trauma, cancer, infection, or autoimmune disease, the production and secretion of hormones is disrupted. This disruption causes manifestation of symptoms related to hormone regulation interruption. Diseases that are caused by hormone disruption include diabetes, hypothyroid, Cushing’s syndrome, polycystic ovary syndrome, and many others.

Prevalent Problems

Diabetes Mellitus




One of the most prevalent metabolic endocrine disorders is 

diabetes mellitus
. According to the CDC (2017), approximately 7.2% or 23.1 million people within the United States have been diagnosed with diabetes. Diabetes is a disease of the pancreas, in which the pancreas does not produce insulin (

Type 1
) or does not know how to utilize insulin effectively (

Type 2
), leading to increased 

blood glucose

 levels (NIDDK, 2016b).

Diabetes and Nursing Management

The primary component in either type of diabetes that causes distress and eventually organ damage is alteration in blood glucose level. The blood glucose level being too low (

) or too high (

) is the main cause of damage and associated symptoms in the diabetic patient, which is why management and maintenance of a normal blood glucose level is the central feature in proper treatment of the disease. Maintenance of normal blood sugar levels begins with recognizing the signs and symptoms of hypoglycemia and hyperglycemia and being familiar with interventions necessary to return the blood glucose level to normal. Nursing management of diabetes involves a great deal of patient education and health promotion because self-care is essential for patients who have this disease.

Hypoglycemia is characterized by blood glucose levels less than 70mg/dL, as well as symptoms such as decreased 

level of consciousness (LOC)


, and 

. Typically, hypoglycemia can be treated with oral glucose tablets or liquid, if the patient cannot take medications by mouth, subcutaneous glucagon or intravenous dextrose may be administered until blood glucose levels are restored to normal limits. High blood glucose levels (hyperglycemia) are characterized by blood glucose levels greater than 130mg/dL, and symptoms such as increased thirst, increased frequency of urination, or sweet or fruity smelling breath. Treatment of elevated blood glucose levels includes the administration of insulin. Higher doses and intravenous insulin infusions may be indicated in emergent situations until blood glucose levels are returned to normal.

Diabetic Ketoacidosis

Persistent hyperglycemia greater than 250mg/dL may lead to 

diabetic ketoacidosis (DKA)
, a severe and possibly life-threatening complication of hyperglycemia. This complication is more commonly associated with type 1 diabetes and has a significant risk of 


 (Tran et al., 2017). Symptoms of DKA include nausea, vomiting, abdominal pain, dehydration, 

, and 


 (Seth, Kaur, & Kaur, 2015). Severe DKA may lead to 
Kussmaul respirations, hypotension, coma, and death. Clinical diagnostic criteria for DKA are as follows:

· Blood glucose >250mg/dL,

· Arterial pH <7.3, and

· Serum bicarbonate <15mEq/l

Causes of this complication of diabetes include infection, 

myocardial infarction (MI)
, or other insult to the body that causes an extreme stress state. In addition, noncompliance is a contributing factor to the development of DKA (Seth et al., 2015). Treatment involves correcting the underlying cause of stress to the body, such as treatment of MI or infection. Education is also a strong component during treatment, particularly in instances when noncompliance is the underlying cause of DKA. In addition, metabolic imbalances and elevated glucose levels must be corrected. Insulin is administered via intravenous infusion during the initial treatment. Electrolyte imbalances are treated aggressively with replacement of potassium, bicarbonate, and phosphate in acute care management for DKA (Tran et al., 2017). Rehydration is established slowly with intravenous administration of 

 solutions (Tran et al., 2017). Slow rehydration improves response to insulin therapy (Tran et al., 2017). Once the metabolic imbalance is corrected and blood sugar levels are restored to normal, the administration of basal-bolus subcutaneous insulin can begin per provider orders and the intravenous infusion can be discontinued.

Helping patients manage the complexities of their disease is important in keeping blood glucose levels within normal limits (WNL) which is considered a blood glucose level between 80-130mg/dL prior to meals (
preprandial) (ADA, 2018). Achieving targeted blood glucose goals is only achieved in approximately 50% of diabetic patients, making compliance with diabetes treatment and management a very real concern (García-Pérez, Álvarez, Dilla, Gil-Guillén, & Orozco-Beltrán, 2013). Obtaining and maintaining normal blood glucose levels is only part of the battle, as the ADA has indicated the importance of the 

Hemoglobin A1c
 in diabetic control. Hemoglobin A1c measures the average levels of glucose within the blood over the past 3 months. In patients without diabetes, this level should be between 4% and 5.9%. The latest evidence-based recommendation from the ADA is to maintain a Hemoglobin A1c level of less than 7.0% for patients with diagnosed diabetes, anything over 8% indicates poorly managed diabetes (Edelman, 2017). In established diabetes patients, the A1c level should be monitored every 3 months if the patient is uncontrolled and every 6 months if well controlled. Decreasing the A1c level even by a minimum of 1% has been shown to decrease microvascular damage associated with diabetes (Davis, n.d.).

Transition to Independence



Diabetes is a complex and multifactorial disease that requires a great deal of support, resources, and education for patients to live well and manage their disease process to avoid complications and associated 

. Psychosocial, cultural, and spiritual support is essential to managing the complexities of DM. To focus solely on the physiologic complexities of DM would be an oversight and leave the patient’s care incomplete.

Psychosocial Support

Psychosocial support may involve SDOH
 that are contributory to the development and management or mismanagement of diabetes. SDOH such as minimal insurance coverage or absence of insurance, limited finances, transportation, and nutrition are all elements that may prohibit proper disease control. To assist patients with diabetes, all of these factors must be taken into account in order to provide patient-centered care that helps identify needs and problems and then assist with developing solutions that will enable patients to manage their health (Young-Hyman et al., 2016).

To determine the patient’s needs, an assessment must take place. In addition to assessing for SDOH, the provider may also assess for psychosocial comorbidities that may occur in patients with diabetes, such as depression, anxiety, and eating disorders (Young-Hyman et al., 2016). Obtaining this information during an assessment can be done with a simple question and answer session with the nurse. Upon discovery of the patients’ needs, appropriate resources can be provided. For instance, if the patient does not have insurance, the nurse can collaborate with case management to assist the patient in applying for insurance coverage. If the patient displays signs and symptoms of depression, the nurse can collaborate with social work to refer the patient to the appropriate resources for mental health care. After elements such as SDOH and psychosocial distress are managed, patients may be better able to focus on the management of their disease process.

Cultural Support

Cultural support is another dimension of care that can have a profound impact on management of care for patients with diabetes. Many cultures have a deep connection to social gatherings and celebrate with the making and consuming of a wide array of foods. Patients with diabetes often feel a degree of stress related to lifestyle changes that are recommended as a key factor in disease management. For patients with strong cultural associations to food, this stress may be increased. Customs and traditions may be considered priority over eating healthy for that person (Attridge, Creamer, Ramsden, Cannings-John, & Hawthorne, 2014).

For instance, the Italian culture is often characterized by large family gatherings that include eating in abundance, often with foods such as pastas, breads, and meats that are high in fat content such as pork or beef (Zimmerman, 2017). A patient of Italian heritage, who is newly diagnosed with diabetes, has received nutrition counseling that advises to avoid these foods. For this patient, a family gathering may become extraordinarily stressful. The patient may feel ostracized for avoiding these foods, or it may even be considered rude, for example, to refuse to eat a specially prepared meal regardless of the patient’s reasons. Knowing this, the nurse must remain sensitive to the cultural differences that patients may have that make lifestyle changes more difficult. The nurse can work with the patient to develop an individualized plan of care that might enable them to create feasible changes. This may include tips such as portion control and learning to cook with meats that are lower in fat content or switching to whole grain pasta.

Spiritual Considerations

The diagnosis of diabetes is often associated with feelings of discouragement, loss of control, and despair, leading to the increased need for spiritual or religious support (Sridhar, 2013). Patients who follow a religion devoutly may find comfort in turning to prayer for support in dealing with the new diagnosis of diabetes. In addition, these patients may turn to their respective religious leaders and their religious community for guidance and comfort. Relying on spiritual and religious support has been shown to increase the chances of compliance with diabetes self-care and management (Watkins, Quinn, Ruggiero, Quinn, & Choi, 2013). Having a strong support system can be extraordinarily helpful for patients handling the complexities of diabetes, so it is constructive for nurses to encourage and support their patients’ spiritual needs and offer chaplain services as indicated.

Contributing Factors

Contributing factors to the development of diabetes and subsequent complications are numerous and multifactorial. They include diet, genetics, obesity, and alcohol, and tobacco use. Type 1 diabetes is an autoimmune disease and its primary cause is genetics and familial history; there are no other compounding factors to its onset; however, lifestyle choices, such as drug or alcohol abuse, improper diet, weight gain, and lack of regular exercise, play a key role in the management of disease and the development of complications. With the incorporation of lifestyle modifications and self-care, type 1 diabetes can be well managed, even though a cure does not exist.

While there is a genetic component related to the development of type 2 diabetes, the primary causes are associated with lifestyle choices, such as nutrition, inactivity, and weight gain. Just like type 1 diabetes, other lifestyle choices, such as drug and alcohol use, can exacerbate the disease and lead to other comorbidities. Fortunately, with incorporation of positive lifestyle changes, type 2 diabetes can be well managed and in some cases reversed entirely.

Prevention and Health Restoration





Health promotion is critical in caring for patients with type 1 diabetes and type 2 diabetes. Providing the education and resources required is necessary to enable patients to manage their health and avoid development of comorbidities and complications. Education involves elements such as nutrition, exercise, and medication therapy.


Nutrition guidelines for the diabetic patient are largely the same for type 1 diabetes and type 2 diabetes. Limiting high carbohydrate foods and sugar is a primary focus. Recommendations for dietary intake should include lean meats, whole grains in small portions, fresh vegetables, fresh fruits, and low-fat dairy products in moderation. The 

glycemic index (GI)
 is an essential tool for the diabetic patient when making food choices. The GI measures how a food containing carbohydrates raises blood glucose. The foods are rated depending on their effect on the blood glucose level. The nurse should advise the patient to consume low or medium GI foods most of the time. If foods with a high GI are consumed, they should be combined with low GI foods to balance out the meal. Table 5.4 provides an overview of GI foods (ADA, 2014a).

Table 5.4

Glycemic Index Foods

Glycemic Index Level

Associated Foods

Low GI Foods (<55)

· 100% stone-ground whole wheat bread

· Steel-cut oatmeal

· Sweet potatoes

· Legumes

· Some fruits, such as berries

Medium GI Foods (56-69)

· Whole wheat, rye, and pita bread

· Quick oats

· Brown rice

High GI Foods (70 or more)

· White bread

· Instant oatmeal

· Rice, pasta

· Potatoes

· Snack foods

· Melons and pineapple

Note. Adapted from “Glycemic Index and Diabetes,” by the American Diabetes Association, 2014.

Alcohol consumption is ill advised for patients with diabetes, but if it does occur, it should be limited to 1 portion per day. According to the ADA (2017a), one portion equates to one 12-ounce beer, a 5-ounce glass of wine, or 1.5-ounces of liquor. Patients with diabetes should be educated on the effect alcohol can have on their bodies. The biggest side effect is hypoglycemia, which may occur up to 24 hours after consumption. Patients should be advised to drink only with a meal, and blood sugar levels should be monitored more frequently if alcohol will be consumed.

Medical Alert Identification

In the event of an emergency, there may be no time or ability to disclose important facts regarding health history. For patients with diseases such as diabetes, these details may mean the difference between life and death. The ADA recommends that all patients diagnosed with diabetes should wear a medical alert identification tag of some form (necklace, bracelet, etc.) to notify medical personnel of their needs if they are unable to communicate. These identification systems are a low-cost way of relaying important details and can also provide an easy way to allow medical personnel to notify the patient’s family there has been an emergency (ADA, 2014b).


Physical activity is an important component in diabetes management. Physical activity may be a hurdle for many patients who have been sedentary for years. Encouraging any kind of physical activity, from walking, dancing, hiking, or swimming is an essential part of diabetes lifestyle education. Patients should be encouraged to find an activity they find enjoyable and to start slowly and set reasonable goals. Studies have shown that consistent physical activity has a direct impact on a cell’s sensitivity to insulin, enabling the body to utilize insulin more efficiently and control blood glucose levels (Bird & Hawley, 2016). Hemoglobin A1c levels may contribute to decreasing the need for insulin therapy and 

oral antidiabetic medications

 (ADA, 2016a). Regular physical activity can also help patients lose weight, which also has a positive impact on the body’s ability to utilize insulin and regulate blood glucose levels (ADA, 2016b).

It is also important for patients with diabetes to understand the effect physical activity can have on their blood glucose levels. Physical activity can cause hypoglycemia, which is why patients must adjust their carbohydrate intake prior to partaking in physical events. The 15-15 rule is a guide that helps patients manage their carbohydrate intake if they are going to be physically active. This rule involves checking the blood glucose level and consuming 15-20 grams of carbohydrates if the reading is less than 100mg/dL. The blood sugar level is then checked 15 minutes later and, if the reading remains less than 100, 15 grams of carbohydrates are consumed again. The process is repeated every 15 minutes until the blood sugar reaches the normal range. If hypoglycemia does occur, the patient should be advised to take a break before beginning physical activity again, and they should be encouraged to discuss options with their medical provider regarding the medical management of the disease (ADA, 2017b). Examples of foods that equate to approximately 15 grams of carbohydrates include:

· 4 glucose tablets,

· 1 glucose gel tube,

· 4 ounces of juice or regular soda, and

· 1 tablespoon of sugar or pure honey (ADA, 2015a).

Medication Therapy



Medication therapy for the management of diabetes is different for each type and often combines oral antidiabetic medication and insulin therapy. In type 1 diabetes, patients will always require insulin because with type 1 diabetes, the pancreas does not make any insulin independently. Patients may have an implanted insulin pump that secretes insulin in small continuous doses around the clock in addition to extra doses that are administered upon the patient’s discretion depending upon the blood sugar level at the time. If patients do not have an implanted pump, they administer insulin subcutaneously at meal times and at bedtime, depending on their blood sugar readings. There are many different types of insulin—rapid acting, short acting, intermediate, and long acting. The types of insulin prescribed will be determined by the patient’s medical provider. The patient may also be on a combination of two or more types of insulin, shorter acting to be administered upon consumption of meals and long acting to help control the blood sugar levels throughout the day (ADA, 2015b).

Patients with type 2 diabetes may begin medication therapy by being prescribed oral antidiabetic medications. There are several types of oral antidiabetic medications. One type, called 
secretagogues, stimulates the beta cells in the pancreas to produce more insulin. Another type is called 
biguanides, which helps reduce the excessive amount of glucose released by the liver in patients with type 2 diabetes. These medications in combination with exercise and alterations in nutrition is the initial treatment for type 2 diabetes. If lifestyle modifications and oral antidiabetic treatment do not affect the patient’s blood glucose levels, subcutaneous insulin may be added to the patient’s management regimen. Much like insulin therapy in type 1 diabetes, there may be an indication for a combination of insulins such as short and long acting (University of California San Francisco, n.d.).

Patients require in depth education regarding blood glucose monitoring, as well as how to detect hyperglycemia and hypoglycemia and associated self-treatment. Patients also must be educated regarding the steps of administration of subcutaneous insulin, needle disposal, insulin storage, and, if indicated, maintenance and management of insulin pumps. In addition to education provided to the patient, the patient’s family members and friends should be educated so they can assist the patient if necessary.

Figure 5.14

Insulin Pump

Multi-Organ Effects


If unmanaged, diabetes can have extensive and profound negative impacts on multiple organs throughout the body. The primary cause of this is the effect of persistent high blood glucose levels in the body, which causes damage to the small blood vessels (

microvascular damage
) and large blood vessels (
macrovascular damage), both of which effect the heart, brain, kidneys, peripheral vascular system, and eyes (Forbes & Cooper, 2013).

Cardiovascular Damage

Cardiovascular disease is the leading cause of death and disability in patients with diabetes (Low Wang, Hess, Hiatt, & Goldfine, 2016). Four primary factors contribute to the development of cardiovascular disease in the diabetic patient: 


metabolic syndrome

insulin resistance

 (as a component of metabolic syndrome), and 

 (National Heart, Lung, and Blood Institute, n.d.).

Atherosclerosis is the development of plaque or fat deposit buildup within the arteries, leading to cardiovascular complications, such as 

coronary artery disease (CAD)
 and MI. In patients with uncontrolled diabetes and long-term hyperglycemia, atherosclerosis is more prominent (National Heart, Lung, and Blood Institute, n.d.). Metabolic syndrome is a combination of symptoms frequently seen in patients with type 2 diabetes. This includes a large waistline, high 

 level, high 

, and hypertension, as well as hyperglycemia and insulin resistance. Insulin resistance, a common occurrence in diabetic patients and a key factor in metabolic syndrome, also contributes to the formation of cardiovascular disease and damage. Hypertension is a common comorbidity associated with diabetic patients and contributes to vessel damage and complications of cardiovascular disease (National Heart, Lung, and Blood Institute, n.d.).

The combination of these four factors places the body in a chronic low inflammatory state, leading to cardiovascular damage (Kaur, 2014). Lifestyle modifications are the initial treatment and is often strongly recommended in conjunction with pharmaceutical intervention (Kaur, 2014). The nurse is instrumental in the education process and can assist with creating a plan of care that is personalized and helps the patient manage self-care to avoid life threatening complications associated with diabetes and its comorbidities.

Neurologic Damage

Diabetic patients are at an increased risk for a 

cerebrovascular accident (CVA)
 or a 

transient ischemic attack (TIA)
 because of the microvascular and macrovascular damage to the blood vessels associated with persistent hyperglycemia. In addition, patients with diabetes are more likely to develop HTN and high cholesterol, which further increases the risk for CVA. CVAs and TIAs are caused by an occlusion of a blood vessel within the brain causing a decrease of blood flow to that area of the brain (Zhou, Zhang, & Lu, 2014). Effects of decreased blood flow to the brain are often permanent and lead to devastating complications, such as speech and motor deficits. Similar to cardiovascular risk, prevention often begins with lifestyle modifications in addition to tight blood glucose management. Again, the nurse supports patients in developing a plan of care that enables them to make sustainable changes and continue to be compliant with their diabetic treatment regimen.

Renal Damage

Because of the highly vascular nature of the kidneys, they are highly susceptible to microvascular damage that is often an effect of diabetes. Over time, persistently elevated blood sugars cause the kidneys to work harder to filtrate toxins, which ultimately leads to damage that causes the kidneys to “spill” 

 into the urine (American Heart Association, 2017). This spilling of albumin into the urine (

) is detectable with a 

 test and is frequently a classic indication of kidney damage in those with diabetes. The primary treatment for kidney disease is ideally prevention, which is achieved with tight management of blood glucose levels. This reiterates the importance of education and self-care. The nurse can provide insight and education regarding the reasons for vascular damage and highlight the importance of regularly checking blood glucose levels and self-administering correct doses of prescribed insulin, as well as diet and exercise.




Provision of education and resources for self-management of diabetes is essential. The vast amount of information patients with diabetes need to learn and manage on a daily basis can be overwhelming, especially to the newly diagnosed diabetic patients. Blood glucose monitoring, medication therapy, and lifestyle modifications such as diet and exercise, are all fundamentals that patients must become familiarized with to manage their disease and prevent complications. Education may be provided in a number of ways. From classes to one-on-one education with the registered nurse (RN) or the diabetes educator, there are a number of ways to provide necessary details regarding diabetes management.


There are several devices the diabetic patient must learn to use to manage diabetes effectively. Blood glucose self-monitoring is essential maintain a normal blood glucose level. The patient should be educated on the particular model of glucose monitor, including varying controls and how to access blood glucose records. The proper way to use a 

 and obtain a blood sample for the blood glucose reading should be overviewed, and the patient should model the correct way to obtain such a sample, if possible. This may be helpful in giving the nurse an indication if further education is required and allows the patient to ask questions and express concerns. In addition to glucose self-monitoring, patients require education regarding the use of the insulin pump, if this is indicated, or the proper way to administer subcutaneous insulin, if this is the preferred or recommended method of insulin therapy.

According to the ADA, patient education that focuses on self-management should include the following (Beck et al., 2017):

· diabetes pathophysiology and treatment options;

· healthy eating;

· physical activity;

· medication usage;

· preventing, detecting, and treating acute and chronic complication;

· healthy coping; and

· problem solving.

Details such as type of insulins, insulin storage, preparing and administering insulin in correct dosages, supplies indicated, proper handling and discarding of biohazard materials, such as needles, are all essential elements that should be included in diabetes education. The nurse can be valuable in providing education regarding these components. In addition, the nurse should consult the diabetes educator as well as the representatives for various devices that may be contacted to provide specific education regarding different device management and diabetes education.

Making Healthy Choices



Lifestyle modifications may be the most obvious treatment and prevention method for diabetes, but it is also the most difficult for many patients. This issue is complicated further depending on SDOH as well. Noncompliance with lifestyle modifications and treatment regimens associated with diabetes is a primary reason for mismanagement, persistent hyperglycemia, complications and comorbidity development, and even increased risk of morbidity and mortality (Blackburn, Swidrovich, & Lemstra, 2013).

Understanding the reality of noncompliance in the diabetic patient, the nurse must develop new and innovative ways to encourage and educate the diabetic patient. The nurse may use new ways of providing education, such as using YouTube videos, interactive education, the teach-back method, and referring patients to support groups to provide psychosocial support in their daily management of diabetes. In addition, the nurse may consult with a certified diabetic educator (CDE) and nutrition services to provide the patient with dietary recommendations, recipes, advice, and tips for eating well and avoiding feelings of deprivation that may lead to falling into old habits (Burke, Sherr, & Lipman, 2014).

Shared decision making
 is of utmost importance in patient education and involves presenting patients with varying options for managing care and allowing them to be actively involved in deciding what would work best for them (Burke et al., 2014). For instance, a patient may be offered an insulin pump or the choice to administer subcutaneous insulin to manage his diabetes. The patient takes the information and education provided and decides that the pump is the more convenient option. Another patient may decide she is not comfortable with that option and would prefer to administer the medication independently. Shared decision making allows patients to be active participants in the management and direction of their treatment and care rather than simply “following doctor’s orders” (NIDDK, n.d.b).

The diabetic diet may be drastically different from what the patient was eating prior to diagnosis. The diabetic diet focuses on eating lean proteins, whole grains, fresh fruits and vegetables, and low-fat dairy products while avoiding refined sugar, fried and fatty foods, and processed white carbohydrates (NIDDK, 2016a). In addition, portion control and limiting intake may be a new concept to many patients recently diagnosed with diabetes. The nurse needs to provide education that encourages making small changes one step at a time and finding ways to eat well even if dining out or enjoying social events with friends and family. Encouragement should be provided, but the nurse should remain realistic, as many patients have been known to have several cycles of weight loss and gain before they achieve long-term success (García-Pérez et al., 2013). Nurses may also recommend that patients attend nutritional education classes specifically tailored to patients with diabetes. According to the ADA (2017c), goals for nutrition management in diabetic patients include:

· achieving and maintaining ideal body weight;

· attaining personalized glycemic, blood pressure, and cholesterol goals; and

· delaying or preventing complications of diabetes.

This also includes personalization based on cultural, health literacy, willingness and ability to make behavioral changes and involves the provision of tools necessary to accomplish such goals (ADA, 2017c).

Lifestyle modifications also include incorporation of physical activity. Many patients may be very 

, so increasing activity may seem like an extraordinary feat. Encouraging small changes may be helpful at first. Activities such as going for a family walk in the evening, parking the car farther away when going shopping or out to eat, or finding a fun activity such as bowling, bicycling, or swimming are all good ways of including physical activity to daily life. Physical activity goals as outlined by the ADA (2017c) include:

· Children and adolescents should engage in 60 minutes of activity per day for a minimum of 3 days per week.

· Adults should engage in 150 minutes of moderate to vigorous activity per week (spread over 3 days per week).

· People of all ages should decrease sedentary behaviors.

· Older adults should incorporate flexibility and balance training (such as yoga or tai chi).

Recommendations for physical activity in patients with diabetes go beyond maintaining or losing weight. The benefits of physical activity have been shown to have a stark impact on lowering hemoglobin A1c levels and assist in maintaining normal blood glucose levels overall (ADA, 2017c).

Living Conditions/SDOH

SDOH may contribute to the difficulties of diabetes management and self-care (Walker, Smalls, & Egede, 2015). For instance, if a patient is underinsured or uninsured, being able to afford the medications and equipment necessary to manage diabetes may be next to impossible. Financial concerns are also a factor in dietary choices. If a patient is able to purchase foods that are processed and higher in fat or sugar content because they cost much less than healthy option, the patient may resort to the option that makes financial sense at the time, thus jeopardizing the patient’s self-care. In addition, psychological stress associated with diabetes, such as the development of depression, ineffective coping skills, and lack of familial support, may lead to improper management and self-care of diabetes (Walker, Gebregziabher, Martin-Harris, & Egede, 2014).

These SDOH require the nurse to be innovative in their approach to patient education and management of care. The nurse must work in conjunction with social work, CDE, dietary, and other interdisciplinary health care providers to help the patient develop a plan of care that will address their varying needs, such as 

food insecurity
 or insurance needs. The nurse may be able to reach out to community resources that can provide resources, such as access to healthy foods or free support groups for patients with diabetes. The American Association of Diabetes Educators has a wealth of education on its websites, tools, and resources to get in contact with a CDE in the patient’s area, and diabetic education classes (American Association of Diabetes Educators, n.d.).

Check for Understanding

What is the pathophysiology of the multi-organ effects of diabetes?

How does nutrition support health for those with diabetes?

What types of physical activity are beneficial for those with diabetes?

Sepsis, Shock, and Multisystem Response


, also known as septicemia, is the body’s response to infection, in which the body releases immune system components into the blood stream causing systemic inflammation and possibly leading to 

septic shock
. Stages of sepsis include 

systemic inflammatory response (SIRS)
, sepsis, 

severe sepsis
, and septic shock. Sepsis begins with a basic infection from a disease process or injury, such as pneumonia or traumatic injury during a motor vehicle accident. The infection spreads from the primary source into the bloodstream, causing SIRS throughout the body, making it the very early stage of sepsis. On an annual basis in the United States, more than 1.5 million people suffer from sepsis and 250,000 people die from it, causing an increase in research and formation of sepsis protocols to decrease these results (CDC, 2018b). Those who are most People who are the susceptible to contracting sepsis are pediatric, geriatric, trauma, and burn patients, as well as those with compromised immune systems, preexisting health conditions, and invasive medical equipment, such as a central line. A comparison of each stage of sepsis and associated signs and symptoms are provided below:


· Temperature >38.3 or < 36 degrees (°) C

· Heart rate >90 beats per minute (


· Respiratory rate >20 breaths/minute (

) or PaCO2 <32mmHg


White blood cell (WBC)
 count >12,000 cells/mm3 or <4000 cells/mm3

· Sepsis

· Two or more of the signs and symptoms of SIRS in addition to confirmed or suspected infection

· Temperature >38.3 or < 36° C

· Heart rate >90 beats per minute (tachycardia)

· Respiratory rate >20 breaths/minute (tachypnea) or PaCO2 <32mmHg

· White blood cell (WBC) count >12,000 cells/mm3 or <4000 cells/mm3

· Severe sepsis: Symptoms of sepsis plus one or more of the following:

· Mottled skin


Capillary refill
 >3 seconds

· Urine output <0.5mL/kg over a 1-hour period or renal replacement therapy (dialysis)

· Lactic acid level >2mmol/L

· Change in LOC

· Platelet count >100,000per mL


Disseminated intravascular coagulation (DIC)


Acute lung injury (ALI)

acute respiratory distress syndrome (ARDS)

· Cardiac dysfunction

· Septic Shock: Exists if severe sepsis is diagnosed plus one or more of the following:


Mean arterial blood pressure (MAP)
 <60mmHg despite aggressive fluid resuscitation

· Maintaining baseline MAP of 60mmHg even with the infusion of vasopressor medications (Cheung et al., 2015)

Diagnostic tests should be performed within 3 hours of the patient developing symptoms to confirm diagnosis of sepsis and begin intervention quickly to avoid progression and multi-organ failure (Society of Critical Care Medicine, 2018). Diagnostic tests that should be done if sepsis is suspected include blood cultures and a 

lactic acid laboratory test
. Treatment of sepsis involves 

broad-spectrum antibiotic
 therapy, which should be administered after blood cultures have been drawn. This is to ensure the offending bacteria are accurately identified prior to being treated. In addition, intravenous fluid resuscitation is the first line treatment for initial presenting symptoms of sepsis (Society of Critical Care Medicine, 2018). Blood pressure support with intravenous 

 medications are administered if the patient’s blood pressure does not respond to fluid resuscitation. Treatment may also require higher level of acute care, such as admittance to an intensive care unit (ICU), as well as temporary supportive breathing with a 

 if the patient’s respiratory function is severely compromised (Maggio, 2018).

Nursing care for patients with sepsis goes beyond management of complexities of treatment. Nurses are in a unique position because they can observe subtle signs of deterioration and report such findings in order to avoid progression to septic shock, related complications, and even death (Kleinpell, 2017). A slight change in LOC, change in vital signs, or change in lab results may alert the nurse to collaborate with the patient’s physician and make changes to the patient’s treatment plan as needed. Another key feature of managing patients with sepsis includes being supportive of and providing education to the family of the patient who may express feelings of fear, sadness, anxiety, helplessness, or disbelief as their loved one receives life-sustaining treatment. Education should also include prevention measures, such as treating basic infections before they become out of control and monitoring wounds and burns for signs and symptoms of infection. Changes, such as a slight increase in temperature, irritability, increased redness or swelling in the surrounding affected area, are warning signs that should be reported to the patient’s medical provider promptly in order to prevent progression to into sepsis.

Example: Sepsis in the Hospital

Amy is a nurse caring for a 63-year-old female patient who was admitted with cellulitis of her right lower extremity. The patient is placed on antibiotics and intravenous fluids for dehydration. The patient’s blood pressure has been within normal limits since admission, and her baseline mental status is totally alert and oriented. At noon, Amy goes into the patient’s room to assess her. The patient tells Amy she is so happy to “see her beautiful granddaughter” and to “tell her all about college.” Amy reorients the patient, but the patient falls asleep mid-conversation. Amy takes the patient’s blood pressure and it is 88/50; two hours ago, it was 128/75. The patient is also tachycardic with a heart rate of 122. Amy assesses the patient’s affected extremity and notices that the swelling and redness has increased substantially. Amy also notices the patient feels extremely warm and her temperature is reading 38.5° C. Amy immediately recognizes the symptoms of SIRS and early sepsis. She notifies the physician with these findings.

Reflective Summary

The nurse is in an invaluable position to advocate for patient needs, provide education, promote wellness, and offer support. Whether caring for patients with diseases of the musculoskeletal or metabolic system, the underlying skills of critically assessing and formulating individualized plans of care remain a cornerstone. The nurse is able to provide holistic care by remaining knowledgeable regarding the complexities of these vast diseases and learning key signs of deterioration. Additionally, the nurse remains cognizant regarding SDOH, shared decision making, and spiritual needs that will affect the patient’s treatment plan and outcomes.

Key Terms

Acute Lung Injury (ALI): A type of respiratory failure caused by acute hypoxemia and commonly manifesting as Acute Respiratory Distress Syndrome (ARDS).

Acute Respiratory Distress Syndrome (ARDS): A lung disease that occurs from the buildup in the alveoli in the lungs, causing deprivation of oxygen (hypoxia) and leading to respiratory failure.

Adrenal Glands: The endocrine organs located on top of either kidney, which are responsible for the secretion of cortisol, aldosterone, epinephrine, and norepinephrine.

Albumin: A protein produced in the liver that is responsible for maintenance of intravascular osmotic pressure, which keeps fluid within the bloodstream instead of leaking out into the tissues.

Androgens: The steroid hormone, such as testosterone, influencing male sexual traits and female sexual behavior.

Anterior Pituitary Gland: The endocrine organ responsible for the secretion of major hormones: adrenocorticotropic hormone (ACTH), thyroid-stimulating hormone (TSH), follicle stimulating hormone (FSH), luteinizing hormone (LH), growth hormone (GH), and Prolactin.

Arthroplasty: The surgical reconstruction or replacement of a joint.

Atherosclerosis: Plaque buildup that causes occlusions of the coronary arteries.

Biguanides: The class of oral antidiabetic medication that reduces the amount of glucose released by the liver in patients with type 2 diabetes.

Biologic: A biologic, disease-modifying, antirheumatic drug (biologic DMARD); a drug classification that suppresses a component of the immune system, such as a tumor necrosis factor (TNF) inhibitor.

Blood Glucose: The source of energy within the body derived from food intake.

Bone Matrix: The intercellular substance of bone tissue consisting of organic and inorganic components.

Bone Remodeling: The lifetime process of bone repair and replacement for skeletal maintenance.

Broad-Spectrum Antibiotic: Type of antibiotic used treat a wide range of bacteria, including gram-positive and gram-negative infections.

Calcium: The
 major electrolyte within the body; levels are controlled by the secretion of parathyroid hormone; responsible for providing electrical energy to the nervous and muscular system; provides strength to the skeletal system.

Capillary Refill: The test of the nailbeds to monitor blood flow in the extremities. After slight pressure is placed onto the nailbeds, if the nailbed turns pink within 3 seconds, the result is considered normal; anything greater than 3 seconds may be sign of decreased blood flow to the area.

Cerebrovascular Accident (CVA): The damage that occurs to an area of the brain caused by the occlusion of a blood vessel leading to the affected area; can cause permanent effects, such as paralysis and speech deficits.

Cholesterol: The type of fat produced by the liver; increased cholesterol leads to wide range of disease processes, such as coronary artery disease (CAD).

Comorbidities: The presence of two or more chronic diseases in addition to a primary diagnosis.

Coronary Artery Disease (CAD): The chronic occlusion of the coronary arteries that may lead to myocardial infarction (MI) if untreated.

Degenerative Joint Disease (DJD): The wear and tear on synovial joints, especially through repetitive actions, resulting in degeneration of the protective cartilage at the juncture of two bones.

Diabetes Mellitus: The endocrine disorder characterized by abnormally high blood glucose levels, caused by the pancreas being unable to produce insulin (type 1) or the body’s inability to utilize insulin correctly (type 2).

Diabetic Ketoacidosis (DKA): Severe complication of uncontrolled blood glucose levels, typically seen in type 1 diabetes; can lead to coma and death if untreated.

Diaphoresis: The body’s production of excessive amounts of sweat.

Disease-Modifying Antirheumatic Drug (DMARD): A drug classification for medications that suppresses a component of the immune system.

Disseminated Intravascular Coagulation (DIC): The disorder that causes the proteins responsible for blood clotting to become overactive, leading to severe bleeding or occlusion that impedes blood flow to major organs.

Dizziness: A symptom described as the feeling of “spinning.”

Dowager’s Hump: A curvature of the upper back often caused by osteoporosis-related vertebral compression fractures.

Fibroblasts: The cells that produce collagen fibers to bridge breaks in bones.

Food Insecurity: The state of being without a reliable source of nutritious food because of financial reasons or inaccessibility.

Glucagon: The hormone released by the pancreas that promotes breakdown of glycogen to glucose in the liver; stimulates the increase of blood glucose levels in response to drop in blood sugar levels.

Glucocorticoids: The hormone cortisol, which is produced by the adrenal glands, is responsible for control of inflammation, and can be administered systemically if the body does not produce sufficient amounts.

Glucose: The simple sugar utilized as the primary source of energy within the body.

Glycemic Index (GI): A system of ranking foods based on the amount of carbohydrates they contain and the effect they will have on blood glucose level.

Hemoglobin A1c: The blood test that measures the average blood glucose level over the course of the past 3 months, used to help diagnose diabetes as well as monitor the status of those already diagnosed with diabetes. Normal is <5.7%; those at risk for diabetes have levels between 5.7% to 6.4%; in patients with diabetes, the goal is to keep this level <7.0%.

Hyperglycemia: The blood glucose level >140 with symptoms that may include polydipsia, polyuria, and sweet smelling breath. If left untreated, this may cause severe symptoms, such as coma, alteration in vital signs, and death.

Hypertension: The elevation in blood flow against the artery walls. Blood pressure readings above 130/90 may lead to host of diseases, if uncontrolled.

Hypoglycemia: The blood glucose level <70 with symptoms that may include decreased LOC or diaphoresis.

Insulin: The hormone secreted by the pancreas that is responsible for regulating the blood glucose level within the body.

Insulin Resistance: The body’s inability to respond to the insulin that the pancreas produces.

Isotonic: An intravenous solution that is equal to the concentration/composition of normal blood, administered in the instance of blood loss or dehydration.

Janus Kinases (JAKs) Inhibitor: The pharmacologic agent that inhibits JAK, which is a cytokine/enzyme of the inflammatory process.

Respirations: Type of hyperventilation associated with a metabolic acidotic state and increased morbidity.

Kyphotic Posture: Excessive curvature of the thoracic spine resulting in a hump on the back.

Lactic Acid Laboratory Test: Test that measures the level of lactic acid in the body; an increased level may indicate decreased oxygen level and an early indication of sepsis.

Lancet: A small medical device used to obtain a small sample of blood from the tip of the finger for diabetic blood glucose monitoring.

Level of Consciousness (LOC): The level of consciousness of an individual; fully awake, lethargic, drowsy.

Macrovascular Damage: A complication of diabetes caused by prolonged elevated blood glucose levels, damaging larger blood vessels, such as the coronary arteries, peripheral arteries, and cerebrovascular vessels; increases risk for myocardial infarction (MI) and cerebrovascular accidents.

Mean Arterial Blood Pressure (MAP): The average pressure in the patient’s arteries during one cardiac cycle.

Metabolic Syndrome: The term for a collection of conditions that occur together: obesity, insulin resistance, diabetes, hypertension, and high cholesterol.

Microalbuminuria: The presence of albumin in the urine; an early sign of kidney damage.

Microvascular Damage: A complication of diabetes caused by prolonged elevated blood glucose levels, damaging the small blood vessels of the body and leading to retinopathy, nephropathy, and neuropathy.

Mineralocorticoids: The steroid hormone, such as aldosterone, that is produced by the adrenal glands and is responsible for the sodium and water balance within the body.

Morbidity: Death rates associated with a specific disease or condition.

Mortality: Death rates based on place, time, and cause; refers to the greater population, sick or well.

Myocardial Infarction (MI): The occlusion of one or more major coronary arteries within the heart, leading to oxygen deprivation to an area of the heart and cardiac muscle death, if untreated.

Omega 3 Fatty Acids: Type of fat found in foods, such as fish, aids the body with many processes, such as lowering triglyceride levels, decreasing pain and stiffness of the joints, and decreasing inflammation throughout the body.

Oral Antidiabetic Medications: The first type oral medications prescribed to type 2 diabetes patients. These medications help control the efficacy of insulin produced or aid in the promotion of the secretion of insulin.

Ossification: The depositing of minerals into the soft callus for fracture repair.

Osteoarthritis (OA): The wear and tear on synovial joints, especially through repetitive actions, resulting in degeneration of the protective cartilage at the juncture of two bones.

Osteoblasts: Cells that build bone matrix and aid in calcification of bone minerals.

Osteoclasts: Cells that dissolve and resorb bone matrix.

Osteoporosis: A condition of decreased bone mineral density making the bone porous and increasing the risk of fractures.

Pancreas: Endocrine organ within the abdomen responsible for secreting digestive hormones and enzymes.

Parathyroid Gland: The four small endocrine organs located on the thyroid gland, responsible for secreting parathyroid hormone.

Parathyroid Hormone: The hormone secreted by the parathyroid gland that is responsible for the management of calcium levels within the body.

Polydipsia: Extreme thirst.

Polyuria: Excessive amount of urination or sensation to urinate.

Posterior Pituitary Gland: The endocrine organ responsible for the secretion of major hormones: oxytocin and vasopressin (antidiuretic hormone).

Preprandial: Blood glucose level obtained prior to meals.

Rheumatoid Arthritis (RA): A chronic, inflammatory autoimmune disease that destroys synovial joints and has other systemic effects.

Secretagogues: The type of oral antidiabetic medication that promotes secretion of insulin.

Sedentary: Term for inactivity or lack of physical exercise.

Sepsis: Bloodstream infection stemming from an infection that may lead to severe sepsis, septic shock, or even death.

Septic Shock: The final stage of sepsis in which the vital signs are deteriorating rapidly and the patient may go into respiratory failure.

Severe Sepsis: Severe sepsis occurs when sepsis progresses in combination with damage to at least one organ.

Shared Decision Making: A decision-making process in which individuals who will be affected by the decision have a participatory voice or share in the decision.

Social Determinants of Health (SDOH): Conditions of living, such as housing, socioeconomics, transportation needs, or quality of education, that directly impact health and access to health care needs.

Soft Callus Formation: The granular tissue base for the repair of a fracture.

Systemic Inflammatory Response (SIRS): The pathophysiologic response to infection or injury that involves the immune system responding to insult and causing severe inflammation.

Tachycardia: Increased heart rate >100 beats per minute.

Tachypnea: Respiratory rate greater than 20.

Thyroid Gland: The butterfly-shaped endocrine organ located within the throat, responsible for secretion and management of the thyroid hormones thyroxine and thyroid-stimulating hormone, which are primarily related to metabolism.

Transient Ischemic Attack (TIA): The temporary interruption of blood flow in a vessel leading to the brain that causes temporary, stoke-like symptoms; can be a precursor to a major cerebrovascular accident (CVA).

Triglyceride: Storage form of fats in the body.

Tumor Necrosis Factor (TNF) Inhibitor: The pharmacologic agent that inhibits TNF, which is a component of the inflammatory process.

Type 1 Diabetes: Chronic condition in which the pancreas does not produce insulin, which is the hormone needed to allow glucose to enter into the cells to produce energy.

Type 2 Diabetes: Chronic condition in which the body resists the effects of insulin. or the pancreas does not produce enough insulin to maintain a normal glucose level.

Urinalysis: Evaluation of the urine to identify infection, blood, albumin, or other abnormalities.

Vasopressor: Intravenous medication that causes the constriction of blood vessels and helps increase the blood pressure.

Ventilator: Machine that assists with ventilation in patients who are in acute and chronic respiratory failure.

White Blood Cell (WBC): Type of blood cell called leukocytes, which are first line responders in the infection process.


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Rubric Criteria

Collapse All Rubric


7.25 points

Criteria Description

Current relevant article to nursing practice with focus on specific intervention or new treatment tool for diabetes management in adults or children

5. Target

7.25 points

Current relevant article to nursing practice with focus on specific intervention or new treatment tool for diabetes management in adults or children is thorough.

0Intervention or Treatment Tool and Specific Patient Population of Study

7.25 points

Criteria Description

Description of the intervention or treatment tool and the patient population used in article.

5. Target

7.25 points

Description of the intervention or treatment tool and the patient population used in article is thorough.

0Summary of Article

21.75 points

Criteria Description

Summary of the main idea of the research findings for the patient population, including current and relevant clinical findings to diabetes and nursing practice.

5. Target

21.75 points

Summary of the main idea of the research findings for the patient population, including current clinical findings that are relevant to diabetes and nursing practice is thorough.


21.75 points

Criteria Description

Description of integration of treatment tool or intervention into nursing practice including evidentiary support and effect on nursing practice and disease process.

5. Target

21.75 points

Description of integration of treatment tool or intervention into nursing practice including evidentiary support and effect on nursing practice and disease process is thorough.

Inclusion of the Psychological, Cultural, and Spiritual Aspects

21.75 points

Criteria Description

Explanation of the importance in considering psychological, cultural, and spiritual aspects for a patient who has been diagnosed with diabetes including a description of the support that can be offered with provided examples.

5. Target

21.75 points

Explanation of the importance in considering psychological, cultural, and spiritual aspects for a patient who has been diagnosed with diabetes including a description of the support that can be offered with provided examples is thorough.

Presentation of Content

36.25 points

Criteria Description

Presentation of Content

5. Target

36.25 points

The content is written clearly and concisely. Ideas universally progress and relate to each other. The project includes motivating questions and advanced organizers. The project gives the audience a clear sense of the main idea.


7.25 points

Criteria Description


5. Target

7.25 points

The layout is visually pleasing and contributes to the overall message with appropriate use of headings, subheadings, and white space. Text is appropriate in length for the target audience and to the point. The background and colors enhance the readability of the text.

Language Use and Audience Awareness (includes sentence construction, word choice, etc.)

7.25 points

Criteria Description

Language Use and Audience Awareness (includes sentence construction, word choice, etc.)

5. Target

7.25 points

The writer uses a variety of sentence constructions, figures of speech, and word choice in distinctive and creative ways that are appropriate to purpose, discipline, and scope.

Mechanics of Writing

7.25 points

Criteria Description

Includes spelling, punctuation, grammar, language use

5. Target

7.25 points

No mechanical errors are present. Appropriate language choice and sentence structure are used throughout.


7.25 points

Criteria Description

Uses appropriate style, such as APA, MLA, etc., for college, subject, and level; documents sources using citations, footnotes, references, bibliography, etc., appropriate to assignment and discipline.

5. Target

7.25 points

No errors in formatting or documentation are present.

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