RISK FOR UNSTABLE BLOOD GLUCOSE
At risk for variation of blood glucose/sugar levels from the normal
• Deﬁcient knowledge of
• Lack of adherence to diabetes
• Developmental level
• Physical activity level
• Dietary intake
• Physical/mental health status
• Inadequate blood glucose
• Lack of acceptance of diagnosis
• Weight gain or loss
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Physical regulation
• Tissue integrity
The patient will
• Be free from symptoms of hypoglycemia/hyperglycemia.
• Have serum glucose to the prescribed desired range.
• Verbalize understanding of how to control blood glucose level.
SUGGESTED NOC OUTCOMES
Blood Glucose Level; Diabetes Self-Management; Knowledge:
Diabetes Management, Weight Control
INTERVENTIONS AND RATIONALES
Determine: Assess patient for symptoms of low serum glucose level
and maintain a patient airway if indicated. A low serum glucose
may not be detected in some patients until moderate to severe cen-
tral nervous system impairment occurs, which can lead to a compro-
mised airway and cardiac arrest.
Assess for the underlying cause (e.g., inadequate dietary intake;
illness such as nausea, vomiting, or diarrhea; and too much insulin)
to help patient prevent future episodes and adapt treatment strate-
gies and lifestyle changes.
Monitor or instruct patient to monitor glucose levels with a glu-
cometer at regular intervals to identify and respond early to ﬂuctua-
tions in glucose levels that occur outside normal parameters.
Assess family understanding of prescribed treatment regimen. The
family plays an important role in supporting the patient.
Assess patient’s knowledge of hypo/hyperglycemia to ensure ade-
quate management and prevent future episodes.
Monitor for signs and symptoms of hyperglycemia (polyuria, poly-
dipsia, polyphagia, lethargy, malaise, blurred vision, and headache).
Early detection ensures prompt intervention and management.
Assess for the underlying cause of elevated serum glucose level,
including inadequate dietary intake, illness, and poor medication
management to prevent future episodes and develope treatment
strategies such as changes in lifestyle.
Perform: Perform immediate ﬁnger stick with a glucometer to deter-
mine glucose level, which will guide treatment strategies. Administer
insulin, as prescribed, to treat elevated blood glucose levels.
Provide patient with glucose tablets or gel if he or she is
conscious and has ability to swallow. Administer intravenous glucose
if patient is unconscious or cannot swallow. Immediate treatment in
the form of oral or intravenous glucose must be administered to
reverse the low serum glucose level. If patient becomes nauseated,
turn patient on side to prevent aspiration.
Protect patient from injuries, such as falls. Symptoms of low
serum glucose place patient at risk for injury especially when driving
and performing other potentially dangerous activities.
Evaluate serum electrolyte levels. Administer potassium, as
prescribed. With elevated blood glucose levels, potassium and
sodium levels may be low, normal, or high, depending on the
amount of water loss. Consider performing serum testing for
HgbA1c (glycosylated hemoglobin A3C level) to evaluate average
blood glucose levels over a period of approximately 2–3 months and
to assess the adherence and effectiveness of the treatment regimen.
Inform: Teach patient and family self-management of hypoglycemia
and hyperglycemia including glucose monitoring at regular intervals
to treat abnormal glucose levels early and medication management,
nutritional intake, exercise, and regular follow-up visits with the
physician to ensure adequate understanding and management of the
treatment regimen to prevent future hyperglycemic events. Patient
and family teaching may include referrals to a diabetic educator, dia-
betic education classes, and a dietician.
Manage: Consult physician if signs and symptoms persist. Changes
in prescribed medications may be needed, such as with oral
hypoglycemic agents or insulin dosing. Call for emergency medical
services if patient is unstable outside the hospital.
SUGGESTED NIC INTERVENTIONS
Bedside Laboratory Testing; Health Education; Health Screening;
Nutritional Counseling; Teaching: Disease Process; Teaching:
Oldroyd, J., et al. (2006). Randomized controlled trial evaluating lifestyle
interventions in people with impaired glucose tolerance. Diabetes Research
and Clinical Practice, 72(2), 117–127.