7.5 Diabetes Mellitus

Diabetes mellitus (DM) is a chronic medical condition marked by persistently elevated blood glucose levels, a condition called hyperglycemia. This occurs as a result of the body’s inability to properly regulate blood glucose due to issues with insulin secretion by the pancreas, cellular insulin resistance, or both.

Pathophysiology

The pathophysiology of diabetes mellitus is related to dysfunction of the islet cells of the pancreas. As previously discussed in the “Review of Anatomy and Physiology of the Endocrine System” section, the islet cells regulate the secretion of insulin and glucagon to balance blood glucose levels.

During type 1 diabetes, the immune system mistakenly attacks and destroys beta islet cells, leading to an absolute deficiency of insulin. During type 2 diabetes, the body’s cells become resistant to the effects of insulin and/or the pancreas does not produce sufficient insulin to meet the body’s needs. Gestational diabetes occurs during pregnancy and typically resolves after the baby is born. However, gestational diabetes increases the mother’s risk of developing type 2 diabetes later in life. Latent autoimmune diabetes in adults (LADA) is a type of diabetes that starts in adulthood and slowly gets worse over time. Like type 1 diabetes, LADA occurs when the pancreas stops making insulin because an autoimmune process is damaging islet cells in the pancreas. However, unlike type 1 diabetes, in LADA the process happens slowly so people often don’t need to take insulin right away.^[1]

The development of type 1 DM is influenced by genetics, autoimmune factors, and/or viral infections. Autoimmune factors and viral infections can destroy the islet cells of the pancreas, rendering them incapable of producing insulin.

The development of DM type 2 is influenced by a combination of genetic, lifestyle, and environmental factors. Risk often increases as individuals age, with greater onset occurring after age 45. Family history, obesity, metabolic syndrome, and lifestyle factors such as lack of physical activity increase risk for the development of DM type 2. Metabolic syndrome is a group of conditions that increase the risk of coronary heart disease, diabetes, and stroke. The conditions include elevated blood pressure, blood glucose, and triglyceride levels, as well as increased waist circumference.^[2] Women who experienced gestational diabetes during pregnancy are also at greater risk for developing DM type 2. Additionally, certain ethnic groups, including African Americans, Hispanics, Native Americans, and Pacific Islanders, also have increased genetic risk for developing DM type 2.^[3]

Potential Long-Term Complications

In all types of diabetes, insulin does not effectively facilitate the uptake of glucose by the body’s cells. Elevated blood sugar levels damage blood vessels and nerves and can lead to long-term, serious complications. Examples of complications related to DM include the following^[4]:

• Cardiovascular Disease: Damage to blood vessels due elevated blood sugar can result in arteriosclerosis, atherosclerosis, coronary artery disease, and heart attacks.
• Hypertension: DM damages the lumen of blood vessels and can lead to rigidity and development or exacerbation of high blood pressure, which further increases the risk of heart disease.
• Kidney Failure: DM is a leading cause of kidney disease, referred to as diabetic nephropathy. Over time, DM can cause kidney failure, which may necessitate renal dialysis or kidney transplantation.
• Blindness: Damage to the blood vessels in the eyes causes diabetic retinopathy and reduced vision. If left untreated, vision impairment and eventually blindness can occur.
• Stroke: DM increases the risk of stroke due to its impact on cerebral blood vessels, making them susceptible to clot formation or rupture, which can result in a stroke.
• Neuropathy: DM causes nerve damage, often affecting the legs and feet. Symptoms include pain, tingling, and numbness called paresthesia.
• Peripheral Vascular Disease: DM may cause circulatory problems in the lower extremities, which can result in foot ulcerations and nonhealing foot wounds that can result in amputation.

Acute Complications: Hypoglycemia and Hyperglycemia

Clients with diabetes mellitus can develop acute complications called hypoglycemia (low blood glucose levels) and extreme hyperglycemia (high blood glucose levels).

Hypoglycemia

Hypoglycemia is defined as blood glucose levels below 70 mg/dL. Hypoglycemia is a common side effect of medications used to lower blood sugar, especially insulin or oral medications that affect the release of insulin (e.g., sulfonylureas and biguanides). Common causes of hypoglycemia in clients taking diabetic medications include the following^[5]:

• Too much insulin administered or too high of dose of oral medication
• Excessive physical activity
• Mismatch of medication administration and meal administration or delayed or missed meals
• Excessive alcohol consumption

Initial signs and symptoms of hypoglycemia include confusion, hunger, shakiness or tremors, sweating, tachycardia, anxiety and irritability, weakness or fatigue, dizziness or lightheadedness, and blurred vision. A low blood glucose level triggers the release of epinephrine (the “fight or flight” hormone) that causes symptoms such as tachycardia, sweating, tingling, and anxiety. Left untreated, hypoglycemia can cause serious neurological effects, such as loss of consciousness, seizures, coma, and death due to lack of glucose delivery to brain cells.^[6]

Hypoglycemia may be difficult to recognize in the elderly and in people who are taking beta-adrenergic blocking drugs.

Nurses must monitor clients diagnosed with diabetes mellitus very closely for signs and symptoms of hypoglycemia and provide rapid treatment. A general rule used by the American Diabetes Association is the 15-15 Rule, which suggests consuming or administering 15 grams of a carbohydrate, followed by a 15-minute wait and then remeasurement of blood glucose level to assess if blood glucose has returned to normal levels. These steps are repeated until blood glucose is at least 70 mg/dL.^[7] Most agencies have a “Hypoglycemia Protocol” for immediate treatment without the need to first notify the provider. See the following box for an example of a hypoglycemia protocol, but always follow agency policy.

Hyperglycemia

Hyperglycemia occurs when a fasting blood glucose level is above 126 mg/dL, and severe hyperglycemia is generally defined as greater than 250 mg/dL. Hyperglycemia can cause acute complications called diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS):

• Diabetic Ketoacidosis (DKA) occurs during severe hyperglycemia episodes if the client’s pancreas is no longer producing insulin. It most commonly occurs in clients with type 1 DM, but it can also occur in clients with type 2 diabetes if their pancreas is no longer producing insulin. Because of the lack of insulin available to transport glucose into cells, the body breaks down fatty acids for energy, and ketones are created. Ketones cause metabolic acidosis, which can be a life-threatening condition. DKA is often triggered by a combination of factors, including uncontrolled high blood sugar and increased stress on the body, such as infection or trauma. In some cases, individuals are not aware they have type 1 DM until they are hospitalized with DKA and the diagnosis of diabetes mellitus is established. DKA is also associated with elevated potassium levels that can cause life-threatening cardiac arrhythmias. DKA is typically treated with insulin drips, IV fluids, and medications to restore normal electrolyte and pH balance.
• Hyperosmolar Hyperglycemic State (HHS) is an extremely severe hyperglycemia that occurs in individuals with type 2 DM. Because the pancreas of an individual with DM type 2 is still producing some insulin that moves glucose into cells, fatty acids are not broken down into ketones, so DKA does not occur. However, the blood glucose level becomes so abnormally elevated that severe cellular dehydration occurs, resulting in life-threatening hypotension and elevated serum sodium levels. HHS is typically triggered by prolonged periods of extremely high blood sugar, often due to illness, infection, or inadequate management of DM. HHS is treated with IV fluids, insulin drips, and medications to restore electrolyte balance.^[10],[11] See Table 7.5a comparing the signs and symptoms of hypoglycemia and hyperglycemia.

Table 7.5a. Signs and Symptoms DKA and HHS^[12],[13]

Assessment

Clinical manifestations of diabetes mellitus are related to chronically elevated blood sugar levels, resulting in damage to blood vessels, nerves, and tissues. See Table 7.5b for a summary of potential assessment findings across body systems for clients with diabetes mellitus.

Table 7.5b. Clinical Manifestations of Diabetes Mellitus and Potential Complications^[14],[15]

Diagnostic Testing

Diagnostic testing related to DM includes several tests to identify the presence of elevated blood glucose or glucose in the urine. The most common tests used to diagnose type 2 DM are fasting blood glucose, hemoglobin A1C, and glucose tolerance test. See Figure 7.8^[16] for an infographic from the Centers for Disease Control and Prevention comparing lab results for normal, prediabetes, and type 2 diabetes.

Common diagnostic tests for DM include the following^[17],[18]:

• Fasting blood glucose (FBG): FBG assesses an individual’s blood glucose level when they have had no caloric intake for at least eight hours (although water intake is permitted). The blood sample must be collected before food, insulin, or oral antidiabetic agents have been administered. Normal fasting blood glucose range is between 70-100 mg/dL. Diabetes mellitus is diagnosed when fasting blood glucose levels consistently measure 126 mg/dL or higher on two separate tests. Impaired fasting glucose is identified in levels that range between 100 to 125 milligrams per deciliter (mg/dL), which means blood glucose levels are elevated, but not high enough to be classified as diabetes.^[19],[20]
• Random blood glucose: Random blood glucose measures the level of glucose in the blood at any given time, without the requirement for fasting. This test is often used for quick assessments of blood sugar levels, especially during emergency or urgent care settings. The normal range for random plasma glucose levels is typically less than 140 mg/dL.^[21],[22] Random blood sugar greater than 200 mg/dL can be a sign of diabetes mellitus.
• Hemoglobin A1C (HbA1C): Hemoglobin A1C assesses an individual’s average blood glucose levels over the preceding two to three months. HbA1C is a form of hemoglobin, a protein found in red blood cells. When glucose is in the bloodstream, it attaches to hemoglobin, forming glycated hemoglobin. The percentage of hemoglobin that is glycated is directly proportional to the average blood glucose levels during the red blood cells’ life spans, which is approximately 120 days. The normal range for HbA1C is typically less than 5.7%. An HbA1C level between 5.7% and 6.4% (or 39-47 mmol/mol) is indicative of prediabetes, which means that blood glucose levels are higher than normal but not yet in the diabetic range. An HbA1C level of 6.5% (or 48 mmol/mol) or higher is diagnostic of diabetes mellitus.^[23],[24]
• Oral glucose tolerance tests (GTT): GTT evaluates the body’s ability to regulate blood glucose levels, especially after consuming a high dose of glucose. The results are typically reported as blood glucose levels measured at different time points (such as fasting 1 hour post-glucose consumption and 2 hours post-glucose consumption). These are the normal results by time frame:
  • Fasting blood glucose (FBG): Less than 100 mg/dL
  • 1-hour post-glucose load: Less than 200 mg/dL
  • 2-hour post-glucose load: Less than 140 mg/dL

Elevated blood glucose levels at any of these time points may indicate impaired glucose tolerance and diabetes mellitus.^[25],[26]

• C-peptide: C-peptide is generally found in amounts in the blood equal to the amount of insulin because insulin and C-peptide are linked when they are first produced by the pancreas. Therefore, the level of C-peptide is an indirect measure of the amount of insulin being produced by the pancreas. A C-peptide test may be ordered when diabetes mellitus has been initially diagnosed to determine if type 1 or type 2 diabetes mellitus (DM) is present. Type 1 DM is diagnosed when the pancreas does not make any insulin, so the level of C-peptide is also low. In type 2 DM, the pancreas continues to produce insulin, so C-peptide levels are normal or high. Fasting C-peptide levels are typically around 0.5 to 2.0 ng/mL.^[29],[30]
• Urine Tests for Ketones or Glucose
  • Ketones: Ketones are metabolic byproducts of fatty acid metabolism, typically produced in the liver. In healthy individuals, ketones are efficiently metabolized, and only minimal amounts appear in the urine. However, under specific circumstances in clients with DM type 1, such as lack of food intake when ill or the development of DKA, elevated ketone levels in the urine indicate the body is using fat as the major source of energy. Ketones may be monitored using urine ketone strips for clients with blood glucose levels over 240 mg/dL to watch for DKA and determine the need for prompt follow-up.
  • Glucose: Normally, there is very little or no glucose in urine. When blood glucose levels are very high in the blood, such as in uncontrolled diabetes, the glucose spills over into the urine. Glucose can also be found in urine when the kidneys are damaged or diseased. In the first part of the renal tubule, called the proximal tubule, glucose is reabsorbed from the filtrate into the bloodstream. The proximal tubule can only reabsorb a limited amount of glucose. Therefore, if the blood glucose level exceeds about 160 – 180 mg/dL, the proximal tubule becomes overwhelmed and begins to excrete glucose in the urine.^[31],[32]

See Appendix A for normal reference ranges of common laboratory tests.

Nursing Diagnoses

Nursing priorities for clients with diabetes mellitus revolve around managing blood glucose levels, preventing complications, providing health teaching, and promoting self-management of this chronic disease at home.

Nursing diagnoses for clients with diabetes are crafted based on a thorough assessment of the client’s condition, medical history, and their unique requirements. Common nursing diagnoses related to DM are the following^[33]:

• Readiness for Enhanced Knowledge
• Imbalanced Nutrition
• Impaired Skin Integrity
• Ineffective Coping
• Ineffective Health Maintenance
• Risk for Infection

Outcome Identification

Outcome identification includes setting short- and long-term goals and creating expected outcome statements customized for the client’s specific needs. Expected outcomes are statements of measurable action for the client within a specific time frame that are responsive to nursing interventions. Examples of expected outcomes for clients with DM include the following:

• The client will achieve and maintain stable blood glucose levels within the target range.
• The client will demonstrate understanding of diabetes self-management strategies following the health teaching sessions, including accurate monitoring of blood glucose levels and administration of medications, healthy diet choices, and physical activity as tolerated.
• The client will achieve and maintain healthy weight.
• The client will demonstrate healthy skin integrity with no skin ulcers.

Interventions

Medical Interventions

Medical interventions for DM are designed to help individuals manage their blood glucose levels within a target range, prevent the development of complications, and improve their overall health and well-being. Specific interventions can vary based on the type of diabetes, the individual’s needs, and the health care provider’s recommendations. Medical interventions typically include medication therapy, blood glucose monitoring, dietary counseling, and weight management.

Medication Therapy

Medication therapy may include oral antidiabetic medications, insulin, or other injectable medication.

Non-Insulin Antidiabetic Medications

Non-insulin antidiabetic medications are prescribed for clients with type 2 DM. They may be used alone or in combination with insulin. See Table 7.5c for an overview of common non-insulin antidiabetic medications, their mechanisms of action, and nursing considerations.

Table 7.5c. Non-Insulin Antidiabetic Medications

Insulin Therapy

Insulin therapy is used for individuals with type 1 DM and in some cases of type 2 DM when insufficient insulin is being produced by the pancreas or tight glycemic control is warranted in the hospital. The primary purpose of insulin therapy is to regulate and normalize blood glucose levels by supplementing or replacing the body’s natural insulin production.^[52],[53] for an image of an insulin vial and the orange-capped syringe specifically used to administer insulin.

There are many different types of insulin with different times of onset, peak, and duration. Table 7.5d summarizes insulin classes.^[54],[55]

Table 7.5d. Insulin Classes

Many types of insulins are available in prefilled pens with a dial to select the number of units to be administered. These pens are helpful for clients in self-administration of insulin. See Figure 7.10^[56] for an image of a prefilled syringe.

Insulin pumps are small, programmable devices that deliver a continuous supply of insulin into the body, mimicking the function of a healthy pancreas. Bolus doses of insulin can also be self-administered to cover meals or correct high blood sugar levels.

The pump's settings are programmable, allowing users to customize basal rates, insulin-to-carbohydrate ratios, and correction factors to match variations in daily activities, diet, and metabolism for clients. The pump contains a reservoir filled with rapid-acting insulin, which is connected to the body via small, flexible tubing. The insulin is delivered subcutaneously, typically in the fatty tissue beneath the skin. Some advanced insulin pumps are integrated with continuous glucose monitoring systems. This combination allows for real-time monitoring of blood glucose levels and automated adjustments to insulin delivery, enhancing overall blood sugar control. Insulin pumps can contribute to better blood sugar management by reducing the risk of hypoglycemia (low blood sugar) and offering more precise control over insulin dosage. The pump offers greater flexibility in terms of lifestyle and meal timing, as users can adjust insulin delivery based on their daily routines. This can lead to a more convenient and adaptable approach. See Figure 7.11^[57] for an image of an individual with an insulin pump and continuous glucose monitoring system.

Blood Glucose Monitoring

Routine monitoring of blood glucose levels is a common component of diabetes management for clients with type 1 DM and for some clients with type 2 DM depending upon their prescribed medication therapy. Individuals typically check their blood glucose levels before meals and at bedtime and may administer additional insulin based on their glucose level before eating. See Figure 7.12^[58] for an image of a blood glucose monitoring device.

A continuous glucose sensor (CGS) is a medical device designed to monitor and track blood glucose levels in the interstitial fluid. The sensor transmits real-time data to a display device, often a dedicated receiver or a smartphone app. This allows individuals with diabetes, as well as their health care providers, to observe trends and patterns in glucose levels. The sensor has customizable alarms and alerts to notify users of high or low glucose levels. This feature helps individuals take prompt action to address potential issues and maintain better control over their blood sugar. Some advanced CGS integrate with insulin pumps, creating a closed-loop system. This allows for automated adjustments to insulin delivery based on real-time glucose data, contributing to more precise and responsive diabetes management. See Figure 7.13^[59] for an image of a continuous glucose sensor.

Dietary Counseling

Referrals are made to registered dieticians to assist with blood glucose management through dietary modifications and carbohydrate counting. Controlling carbohydrate intake, portion sizes, and choosing foods with a low glycemic index can help stabilize blood sugar levels. Diabetic education is multifaceted and successful when individualizing for each client. Dietary counseling principles are described in the following box.

Meal planning is a critical aspect of diabetes management, and there are various strategies to help individuals with diabetes maintain stable blood glucose levels. Two popular meal planning approaches are the exchange system and carbohydrate counting. These methods provide structure and flexibility to create balanced meals while helping individuals manage their blood sugar effectively.

Exchange System

The exchange system is a meal planning method that categorizes foods into three main groups: carbohydrates (CHO), meat and meat substitutes, and fats. This approach simplifies meal planning by assigning specific portion sizes to each food group, allowing for the substitution of foods within the same group without significantly affecting blood glucose levels.^[61]

• Carbohydrates (CHO): This group includes foods like bread, rice, pasta, cereal, fruits, and starchy vegetables. In the exchange system, CHO foods are categorized into serving sizes with approximately equal carbohydrate content, making it easier to control blood sugar.
• Meat and Meat Substitutes: This group comprises sources of protein, such as lean meats, poultry, fish, tofu, legumes, and dairy products. These are essential for building and repairing body tissues.
• Fats: The fats group includes sources of dietary fat like oils, nuts, seeds, and butter. While fats don't directly impact blood glucose, managing their intake is important for overall health and weight control.

Using the exchange system, individuals can create balanced meals by selecting a certain number of servings from each food group, providing predictability in blood glucose responses. This system is particularly helpful for those who prefer structured meal planning.

Carbohydrate Counting

Carbohydrate counting is a flexible and individualized approach to meal planning for people with diabetes. It focuses primarily on carbohydrates because they have the most significant impact on blood glucose levels. With carbohydrate counting, individuals keep track of the total grams of carbohydrates they consume in a meal, regardless of the food source. One carbohydrate choice is equal to 15 grams of carbohydrate. This method allows for more variety in food choices, as long as the total carbohydrate intake is consistent.^[62],[63]

Carbohydrate counting involves these steps:

• Identifying carbohydrate-containing foods in a meal.
• Estimating the total grams of carbohydrates in each food item.
• Keeping track of the cumulative carbohydrate intake for the entire meal.

By understanding how different foods affect blood sugar and monitoring carbohydrate intake, individuals can better control their post-meal blood glucose levels. Carbohydrate counting is particularly useful for those who want more flexibility in their food choices and are willing to track carbohydrate intake accurately.^[64]

Insulin may be administered after meals based on carbohydrate intake. See an example of this process in the following box.

Weight Management & Exercise

Maintaining a healthy weight can improve blood glucose control, particularly in type 2 diabetes. Regular exercise can promote weight loss. Exercise increases cellular sensitivity to insulin and promotes the uptake of glucose from the bloodstream, thus helping to regulate blood glucose levels.

Exercise can also prevent common complications of diabetes, such as heart disease, peripheral arterial disease, kidney disease, and stroke. It also has a positive impact on mental health, reducing stress and anxiety, which can contribute to improved self-management of diabetes. See the following box for exercise guidelines for individuals with diabetes.^[65]

Nursing Interventions

Nursing interventions for diabetes management are essential in providing holistic care and support to individuals with diabetes. These interventions aim to help clients effectively manage their condition, prevent complications, and improve their overall quality of life. Nursing interventions include blood glucose level monitoring, medication management, health teaching, foot care, and health screening.

Blood Glucose Level Monitoring

During inpatient care, provider orders often indicate bedside blood glucose monitoring before every meal and bedtime. If insulin is prescribed, there is often a “sliding scale” component, where rapid-acting insulin is administered based on the blood glucose level. This sliding scale corrects for the blood sugar level before the meal. Added to this amount are units of insulin for the amount of carbohydrates consumed. Addressing both the blood sugar and quantity of carbohydrates consumed helps maintain tight glycemic control. See a common sliding scale insulin order in the following box.

Medication Management

Nurses administer prescribed antidiabetic medications during inpatient care and provide health teaching regarding the purpose of the medications, dosages, timing, and potential side effects. It is vital for clients to understand the onset, peak, and duration of insulin, as well as the importance of timing insulin administration with meal intake and carbohydrates consumed to prevent hypoglycemia. Nurses also teach clients how to self-administer insulin with return demonstration to ensure understanding.

Nurses also collaborate with health care providers to adjust medication prescriptions based on clients' changing needs, responses to treatment, and potential barriers for medication therapy at home.

Foot Care

Clients with diabetes are at high risk for foot ulcers and injuries due to decreased blood flow and sensation of the lower extremities. Good foot care is vital for clients to keep their feet healthy. Nurses teach clients about proper foot care such as inspecting the feet daily (including between the toes), wearing appropriate footwear at all times, and avoiding walking barefoot. Individuals should trim toenails carefully and immediately report any nonhealing breaks in the skin to their health care provider. Only podiatrists or specially trained nurses should trim toenails of diabetic clients to prevent unintended injury and potential infection. Annual podiatrist visits are recommended with immediate care for injuries or ulcers to prevent infection and potential amputation. See Figure 7.14^[67] for an infographic from the Centers for Disease Control and Prevention on tips for healthy feet.

Figure 7.14 Tips for Healthy Feet

Health Teaching

Nurses provide comprehensive health teaching to individuals with diabetes and their family members. In many institutions, diabetic nurse educators provide extensive teaching on topics such as the nature of diabetes, blood glucose monitoring, medication management, and lifestyle modifications. However, all nurses continue to reinforce this information during every encounter to help promote effective self-management of this chronic condition. Return demonstration of skills related to blood glucose monitoring and administration of injections are vital to ensure client understanding.

Common health topics include the following:

• Monitoring their blood glucose levels using glucometers or continuous glucose monitoring systems.
• Interpreting blood glucose readings and making necessary adjustments to their treatment plan.
• Recognizing and managing episodes of low blood sugar (hypoglycemia) and high blood sugar (hyperglycemia) and when to notify the provider.
• Performing good foot care.
• Participating in routine care to prevent diabetic complications, such as annual eye and podiatrist exams.
• Understanding the importance of regular exercise and nutritional eating to reduce the risk of atherosclerosis and arteriosclerosis.
• Empowering clients to take an active role in their care by understanding the disease, treatment plan, and appropriate self-management.
• Managing their medication administration according to their blood glucose levels when ill. Although food intake may decrease when ill and cause a drop in blood glucose, blood glucose can also be elevated due to the effects of cortisol that is released as part of the immune response. Clients should be advised to check their blood glucose more frequently, at least every four hours and as needed and to modify insulin administration according to the results. If their blood glucose is greater than 240 mg/dL, they should check their urine for ketones and notify their provider. They are encouraged to maintain their fluid intake as well.

Health Screenings

Nurses promote routine health screenings for clients with diabetes, including annual eye exams and routine kidney function tests, lipid profiles, and blood pressure monitoring. Kidney function tests often include microalbumin, an early detection of kidney dysfunction. Nurses also coordinate referrals to specialists, such as ophthalmologists, podiatrists, or endocrinologists.

Evaluation

Evaluation focuses on the effectiveness of the nursing interventions by reviewing the client’s expected outcomes to determine if they were met by the time frames indicated. During the evaluation phase, nurses use critical thinking to analyze reassessment data and determine if a client’s expected outcomes have been met, partially met, or not met by the time frames established. If outcomes are not met or only partially met by the time frame indicated, the care plan should be revised. Reassessment should occur every time the nurse interacts with a client, reviews updated laboratory or diagnostic test results, or discusses the care plan with others on the interprofessional team.

Nurses refer to the previously identified outcome statements and perform reassessments to determine if they have been met by the current nursing care plan or if additional interventions are required. For example, the nurse would perform assessments related to the previously established outcome criteria and determine if they were “met” or if additional interventions are required.