Is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia The priority nursing diagnosis would be?

Diabetes mellitus (DM) is a chronic disease characterized by insufficient insulin production in the pancreas or when the body cannot efficiently use the insulin it produces. This leads to an increased concentration of glucose in the bloodstream (hyperglycemia). It is characterized by disturbances in carbohydrate, protein, and fat metabolism. Sustained hyperglycemia has been shown to affect almost all tissues in the body. It is associated with significant complications of multiple organ systems, including the eyes, nerves, kidneys, and blood vessels.

Nursing care planning goals for patients with diabetes include effective treatment to normalize blood glucose levels and decrease complications using insulin replacement, a balanced diet, and exercise. The nurse should stress the importance of complying with the prescribed treatment program through effective patient education. Tailor your teaching to the patient’s needs, abilities, and developmental stage. Stress the effect of blood glucose control on long-term health.

NOTE: This nursing care plan is recently updated with new content and a change in formatting. Nursing assessment and nursing interventions are listed in bold and then followed by their specific rationale in the next line. Still, when writing nursing care plans, follow the format here.

Risk for Unstable Blood Glucose Level 

The goal of diabetes management is to normalize insulin activity and blood glucose levels to prevent or reduce the development of complications that are neuropathic and vascular in nature. Glucose control and management can dramatically reduce the development and progression of complications. 

Nursing Diagnosis: Risk for Unstable Blood Glucose Level as evidenced by inadequate blood glucose monitoring, inability to follow diabetes management

Risk factors

• Inadequate blood glucose monitoring
• Lack of adherence to diabetes management 
• Medication management
• Deficient knowledge of diabetes management
• Developmental level 
• Lack of acceptance of diagnosis
• Stress, sedentary activity level 
• Insulin deficiency or excess

May be evidenced by

A risk diagnosis is not evidenced by signs and symptoms. Interventions are directed at prevention. 

Desired outcomes

• Patient has a blood glucose reading of less than 180 mg/dL; fasting blood glucose levels of less than <140 mg/dL; hemoglobin A1C level <7%.
• Patient will achieve and maintain glucose in satisfactory range (specify). 
• Patient will acknowledge key factors that may contribute to unstable glucose levels

Nursing Assessment and Rationale

1. Assess for signs of hyperglycemia.
Hyperglycemia results when there is an inadequate amount of insulin to glucose. Excess glucose in the blood creates an osmotic effect that increases thirst, hunger, and increased urination. The patient may also report nonspecific symptoms of fatigue and blurred vision.

2. Assess blood glucose levels before meals and at bedtime.
Random blood glucose test results should be between 140 to 180 mg/dL. Non-intensive care patients should be maintained at pre-meal levels <140 mg/dL.

3. Monitor the patient’s HbA1c-glycosylated hemoglobin. 
This is a measure of blood glucose over the previous 2 to 3 months. A level of 6.5% to 7% is desirable.

4. Weight daily. 
To help assess the adequacy of nutritional intake. 

5. Assess for anxiety, tremors, and slurring of speech. Treat hypoglycemia with 50% dextrose.
These are signs of hypoglycemia, and D50 is the treatment for it.

6. Assess feet for temperature, pulses, color, and sensation.
To monitor peripheral perfusion and neuropathy.

7. Assess bowel sounds by auscultation and note any reports of abdominal pain, bloating, nausea or vomiting. 
Hyperglycemia disrupts gastric motility in the stomach, duodenum, and jejunum and may affect the choice of interventions.  

8. Monitor urine albumin to serum creatinine for renal failure.
Renal failure causes creatinine >1.5 mg/dL. Microalbuminuria is the first sign of diabetic nephropathy.

9. Assess the pattern of physical activity.
Physical activity helps lower blood glucose levels. Regular exercise is a core part of diabetes management and reduces the risk for cardiovascular complications.

10. Monitor for signs of hypoglycemia.
A patient with type 2 diabetes who uses insulin as part of the treatment plan is at increased risk for hypoglycemia. Manifestations of hypoglycemia may vary among individuals but are consistent in the same individual. The signs of hypoglycemia result from both increased adrenergic activity and decreased glucose delivery to the brain. Therefore, the patient may experience changes in LOC, tachycardia, diaphoresis, dizziness, headache, fatigue, cold and clammy skin, hunger, shakiness, and visual changes.

11. Explore patient’s health beliefs about physical exercise and review exercise program recommendations with the patient.
Stress that the patient should exercise at the same time and the same intensity each day. Exercise should be done preferably when the blood glucose levels are at their optimum. For patients starting their exercise program, emphasize the need for a slow and gradual increase in the intensity of their exercise regimen.

12. Determine the blood glucose levels of the patient before exercising.
The patient should not begin exercising if their blood glucose levels are above 250 mg/dL and have ketones in their urine. Elevated blood glucose levels during exercise increase glucagon secretion, and ultimately, the liver produces more glucose resulting in a further increase in blood glucose levels.

13. Assess the patient’s adeptness in self-monitoring of blood glucose.
Methods for SMBG must match the skill level of the patient.

14. Assess the patient’s current knowledge and understanding of the prescribed diet.
Nonadherence to dietary guidelines can result in hyperglycemia. An individualized diet plan is recommended.

Nursing Interventions and Rationale

1. Administer basal and prandial insulin.
Adherence to the therapeutic regimen promotes tissue perfusion. Keeping glucose in the normal range slows the progression of microvascular disease.

2. Watch out for signs of morning hyperglycemia.
As the name suggests, Morning hyperglycemia is an elevated blood glucose level arising in the morning due to an insufficient level of insulin. Causes include the dawn phenomenon (normal blood glucose levels until 3 AM, then levels begin to rise), insulin waning (progressive increase in glucose levels from bedtime to morning), and Somogyi effect (nocturnal hypoglycemia then rebound hyperglycemia).

3. Teach the patient how to perform home glucose monitoring.
Blood glucose is monitored before meals and at bedtime. Glucose values are used to adjust insulin doses.

4. Report BP of more than 160 mm Hg (systolic). Administer hypertensive as prescribed.
Hypertension is commonly associated with diabetes. Control of BP prevents coronary artery disease, stroke, retinopathy, and nephropathy.

5. Instruct the patient to avoid heating pads and always to wear shoes when walking.
Patients have decreased sensation in the extremities due to peripheral neuropathy.

6. Instruct patient to take oral hypoglycemic medications as directed: 

• 6.1. Sulfonylureas: glipizide (Glucotrol), glyburide (DiaBeta), glimepiride (Amaryl)
  Sulfonylureas stimulate insulin secretion by the pancreas, used mostly in type 2 diabetes to control blood glucose levels. They also enhance cell receptor sensitivity to insulin and decrease the liver synthesis of glucose from amino acids and stored glycogen. 
• 6.2. Meglitinides: repaglinide (Prandin)
  Stimulates insulin secretion by the pancreas.
• 6.3. Biguanides: metformin (Glucophage)
  These drugs decrease the amount of glucose produced by the liver and improve insulin sensitivity. They enhance muscle cell receptor sensitivity to insulin.
• 6.4. Phenylalanine derivatives: nateglinide (Starlix)
  Stimulates rapid insulin secretion to reduce the increases in blood glucose that occur soon after eating.
• 6.5. Alpha-glucosidase inhibitors: acarbose (Precose), miglitol (Glyset).
  Inhibits the production of glucose by the liver and increases the body’s sensitivity to insulin. Used in controlling blood glucose levels in type 2 diabetes.
• 6.6. Thiazolidinediones: pioglitazone (Actos), rosiglitazone (Avandia)
  Sensitizes body tissues to insulin and stimulates insulin receptor sites to lower blood glucose and improve the action of insulin. 
• 6.7. Incretin modifiers: sitagliptin phosphate (Januvia), vildagliptin (Galvus)
  Increases and prolongs the action of incretin which increases insulin secretion and decreases glucagon levels. 

7. Instruct patient to take insulin as directed:

• 7.1. Rapid-acting insulin analogs: lispro insulin (Humalog), insulin aspart
  Has a clear appearance. Have an onset of action within 15 minutes of administration. The duration of action is 2 to 3 hours for Humalog and 3 to 5 hours for aspart. Patient must eat immediately after injection to prevent hypoglycemia. 
• 7.2. Short-acting insulin (regular insulin): regular, Humulin R
  Short-acting insulins have a clear appearance, has an onset of action within 30 minutes of administration, duration of action is 4-8 hours. Regular insulin is the only insulin approved for IV use.
• 7.3. Intermediate-acting insulin (NPH insulin): neutral protamine Hagedorn (NPH), insulin zinc suspension (Lente)
  They appear cloudy and have either protamine or zinc added to delay their action. Onset of action for the intermediate-acting is one hour after administration; duration of action is 18 to 26 hours. This type of insulin should be inspected for flocculation, a frosted-whitish coating inside the bottle. If frosted, it should not be used. 
• 7.4. Long-acting insulin: Ultralente, insulin glargine (Lantus)
  Have a clear appearance and do not need to be injected with a meal. Long-acting insulins have an onset of one hour after administration, and have no peak action because insulin is released into the bloodstream at a relatively constant rate. Duration of action is 36 hours for Ultralente is 36 hours and glargine is at least 24 hours. They cannot be mixed with other insulin because they are in a suspension with a pH of 4, doing so will cause precipitation.
• 7.5. Intermediate and rapid: 70% NPH/30% regular
  Premixed concentration has an onset of action similar to that of a rapid-acting insulin and a duration of action similar to that of intermediate-acting insulin.

8. Instruct patient on the proper injection of insulin. 
The absorption of insulin is more consistent when insulin is always injected in the same anatomical site. Absorption is fastest in the abdomen, followed by the arms, thighs, and buttocks. It is recommended by the American Diabetes Association to administer insulin into the subcutaneous tissue of the abdomen using insulin syringes. 

9. Educate patient on the correct rotation of injection sites when administering insulin. 
Over time, injection of insulin in the same site will result in lipoatrophy and lipohypertrophy with reduced insulin absorption. Repeated use of an injection site can cause the development of fatty masses called lipohypertrophy, which can impair the absorption of insulin when used again.

10. Instruct the patient on the proper storage of insulin.
Insulins should be refrigerated, not be allowed to freeze, avoid extremes of temperatures, and avoid exposure to direct sunlight. To prevent irritation from “cold insulin,” vials may be stored at temperatures of 15º to 30ºC (59º to 86ºF) for 1 month. Opened vials are to be discarded after that time, while unopened vials may be stored until their expiration date. Instruct patient to keep a spare vial of the insulin types prescribed. Cloudy insulins should be thoroughly mixed by rolling the vials between the hands before drawing the solution. 

11. Instruct patient that insulin vial that is in use should be kept at room temperature. 
Keeping insulin at room temperature helps reduce local irritation at the injection site. 

12. Stress the importance of achieving blood glucose control.
Control of blood glucose levels within the nondiabetic range can significantly reduce the development and progression of complications.

13. Explain the importance of weight loss to obese patients with diabetes.
Weight loss is an important factor in the treatment of diabetes. Weight loss of around 5-10% of the total body weight can reduce or eliminate the need for medications and significantly improve blood glucose levels.

14. Explain the importance of having consistent meal content or timing.
The recommendation is three meals of equal size, evenly spaced meal times (5-6 hours apart), with one or two snacks. Pacing food intake throughout the day places more manageable demands on the pancreas.

15. Refer the patient to support groups, diet, and nutrition education, and counseling.
To help the patient incorporate weight management and learn new dietary habits.

16. Educate the patient on maintaining consistency in food and the approximate time intervals between meals.
A consistent amount of food and time interval between meals helps prevent hypoglycemic reactions and maintain overall blood glucose control.

17. Educate the patient about the health benefits and importance of exercise in the management of diabetes.
Exercise plays a role in lowering blood glucose and reducing cardiovascular risk factors for patients with diabetes. Exercise lowers blood glucose levels by increasing the uptake of glucose and improving the utilization of insulin.

18. Review exercise precautions for patients taking insulin.
Hypoglycemia may occur hours after exercise, stressing the patient’s need to eat a snack at the end of the exercise session.

19. Provide instructions to patients using self-monitoring blood glucose (SMBG).
Frequent SMBG is another important factor in diabetes management. When patients know their SMBG results, they can adjust their treatment regimen and obtain optimal blood glucose control. Additionally, SMBG helps motivate patients to continue their treatment. It can also help in monitoring the effectiveness of exercise, diet, and oral antidiabetic agents.

20. Observe and review the patient’s technique in self-monitoring blood glucose (SMBG).
Determines if there are errors in SMBG due to incorrect technique (e.g., blood drop too small, improper cleaning and maintenance, improper application of blood, damage to reagent strips). The patient may obtain erroneous blood glucose values when using incorrect techniques in SMBG. Additionally, the patient should compare their device’s result with lab-measured blood glucose levels to determine the validity of the device’s reading.

21. For patients using insulin pumps, educate the patient on the importance of maintaining its patency.
The needle or tubing in an insulin pump may become occluded (from battery drainage or depletion of insulin), which may increase the patient’s risk for DKA.

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References and recommended sources to further your reading about this care plan guide for Diabetes Mellitus:

Is hyperglycemia a nursing diagnosis?

What nursing diagnosis is appropriate for diabetes mellitus?

What are the priority interventions included in the nursing management of hyperglycemia?

What are the nursing interventions of diabetes mellitus?