Cues Nursing Background Goals And Objectives Nursing Interventions & Evaluatio

Diagnosis Knowledge Rationale

Subjective: Unstable blood NOC: Blood Glucose Level NIC: Hyperglycemia
 Weakness glucose level Diabetes Self-Management Management
 Fatigue related to
inadequate Goal (Long Term)
Objective: blood glucose After effective nursing
 Fainting monitoring or interventions, the client will be
 Cold to touch medication able to maintain glucose in
 Sweating management satisfactory range and verbalize
 Hgt stat upon and insulin plan for modifying factors to
hospitalization deficiency prevent or minimize
– 50 mg/dl evidenced by complications.
blood glucose
 Blood glucose
levels below or Objectives:
monitoring:
above normal After nursing interventions, the The nurse will:
- Day 1: 6 AM+
levels, client will be able to:
195mg/dl;
weakness,
11AM=167mg/
fatigue, and 1. Assess risk/contributing 1. Determine individual
dl; 6PM=
altered level of factors: factors that may contribute to
204mg/dl
consciousness unstable glucose as listed in
- Day 2: 6 AM+
risk factors.Client or family
1146mg/dl;
history of diabetes, known
11AM=154mg/
diabetic with poor glucose
dl; 6PM=
control, eating disorders (e.g.,
161mg/dl
morbid obesity), poor
- Day 3: 6 AM+
exercise habits, or a failure to
171mg/dl;
recognize changes in glucose
11AM=198mg/
needs or control due to
dl; 6PM=
adolescent growth spurts or
189mg/dl
pregnancy can result in
problems with glucose
stability.

2. Assist client to develop 2. Perform fingerstick glucose
preventive strategies to avoid testing. Ascertain whether
glucose instability:
Determine the client’s
awareness and ability to be
responsible for dealing with
the situation. Age, maturity,
current health status, and
developmental stage all affect
a client’s ability to provide
for his or her own safety.
client and SO(s) are adept at
blood glucose monitoring and
are testing according to plan.
All available glucose
monitors will provide
satisfactory readings if
properly used and maintained
and routinely calibrated.
Note: Unstable blood glucose
is often associated with
failure to perform testing on a
regular schedule
Review medical necessity for
regularly scheduled lab
screening and monitoring tests
for diabetes. Screening tests
may include fasting plasma
glucose or oral glucose
tolerance tests. In the known
or sick diabetic, tests can
include fasting and daily (or
 numerous times in a day) fi
ngerstick glucose levels. Also,
in diabetics, regular testing of
hemoglobin (Hgb) A 1 C and
the estimated average glucose
(eAG) help determine glucose
control over several months.

Discuss home glucose

monitoring according to
individual parameters (e.g.,
six times a day for a normal
day and more frequently
during times of stress) to
identify and manage glucose
variations.

Discuss how the client’s

antidiabetic medication(s)
work. Drugs and
combinations of drugs work
in varying ways with different
blood glucose control and
side effects. Understanding
drug actions can help the
client avoid or reduce the risk
or potential for hypoglycemic
reactions.

3. Review type(s) of insulin

3. Promote wellness used, such as rapid, short-
acting, intermediate, long-
acting, premixed, and the
 delivery method—
subcutaneous, inhaled, or
pump. Note times when short-
acting and long-acting
insulins are administered.
These factors affect timing of
effects and provide clues to
potential timing of glucose
instability.

Check injection sites. Insulin

absorption can vary from day
to day in healthy sites and is
less absorbable in
lypohypertrophic (lumpy)
tissues

Review client’s dietary

program and usual pattern;
compare with recent intake.
Identifies deficits and
deviations from therapeutic
plan, which may precipitate
unstable glucose and
uncontrolled hyperglycemia.

4. Observe for signs of

4. Maintain blood glucose levels hypoglycemia—changes in
within appropriate range LOC, cool and clammy skin,
rapid pulse, hunger,
irritability, anxiety, headache,
lightheadedness, and
shakiness. Once carbohydrate
metabolism resumes, blood
glucose level will fall, and as
insulin is being adjusted,
hypoglycemia may occur. If
client is comatose,
hypoglycemia may occur
without notable change in
LOC. This potentially
lifethreatening emergency
should be assessed and
treated quickly per protocol.

Monitor laboratory studies,

such as serum glucose,
acetone, pH, and HCO3 – .
Blood glucose will decrease
slowly with controlled fluid
replacement and insulin
therapy. With the
administration of optimal
insulin dosages, glucose can
then enter the cells and be
used for energy. When this
happens, acetone levels
decrease and acidosis is
corrected

Administer rapid-acting
insulin, such as regular
(Humulin R), lispro
(Humalog), or aspart
(Novalog) by intermittent or
continuous IV method, for
example, IV bolus followed
by a continuous drip via pump
of approximately 5 to 10
units/hour so that glucose is
reduced by 50 to 75
mg/dL/hour. Rapid-acting
insulin is used in
hyperglycemic crisis. The IV
route is the initial route of
choice because absorption
from subcutaneous tissues
may be erratic. Many believe
the continuous method is the
optimal way to facilitate
transition to carbohydrate
metabolism and reduce
incidence of hypoglycemia.