Unstable blood glucose refers to fluctuations outside the normal range of blood sugar levels, manifesting as either hyperglycemia (high blood sugar) or hypoglycemia (low blood sugar). It’s crucial to understand that experiencing unstable blood glucose doesn’t automatically indicate diabetes. Transient conditions such as dehydration or pregnancy can also disrupt blood glucose levels, which typically normalize once the underlying cause is addressed.
However, for individuals with diabetes, unstable glucose levels are a prevalent and significant concern. Maintaining stable blood glucose is paramount in diabetes management. Uncontrolled diabetes can lead to severe, long-term complications affecting various organ systems, including the heart, kidneys, eyes, and nerves. Therefore, nurses play a vital role in identifying potential causes of unstable glucose levels and empowering patients and their families with the knowledge and resources needed for prevention and management.
Risk Factors for Unstable Blood Glucose
Identifying risk factors is the first step in preventing unstable blood glucose. These factors can be broadly categorized and include:
- Denial of Diagnosis: When patients deny or fail to accept their diabetes diagnosis, they are less likely to adhere to necessary lifestyle changes and treatment plans.
- Deficient Knowledge: Lack of understanding about diabetes, its management, and the importance of blood glucose control directly contributes to unstable levels.
- Poor Adherence to Diabetes Management: Inconsistent medication intake, irregular glucose monitoring, and neglecting dietary recommendations are major contributors to glucose instability.
- Financial Strain: The cost of medications, monitoring supplies, and healthy food can create a significant barrier, leading to suboptimal diabetes management.
- Dietary Intake: Both the quantity and quality of food intake significantly impact blood glucose. Irregular meal patterns and consumption of high-carbohydrate, high-sugar diets can cause instability.
- Weight Changes: Significant weight gain or loss can affect insulin sensitivity and glucose metabolism, leading to fluctuations.
- Pregnancy: Hormonal changes during pregnancy can induce insulin resistance, leading to gestational diabetes and unstable blood glucose.
- Activity Level: Both insufficient and excessive physical activity without proper management can disrupt glucose balance.
- Stress: Physiological stress triggers hormonal responses that can elevate blood glucose levels.
- Developmental Level: Children and adolescents undergoing growth spurts may experience fluctuations in insulin sensitivity and glucose needs.
Note: A risk diagnosis signifies a potential problem that hasn’t yet manifested. Nursing interventions at this stage are focused on proactive prevention.
Expected Outcomes for Stable Blood Glucose
Establishing clear goals is essential for effective nursing care planning. For patients at risk for unstable blood glucose, common expected outcomes include:
- Patient Identification of Risk Factors: The patient will be able to articulate personal factors that contribute to the risk of unstable blood glucose.
- Maintenance of Blood Glucose Within Normal Limits: The patient will consistently maintain blood glucose levels within the target range recommended by healthcare providers.
- Demonstration of Proper Glucose Monitoring Technique: The patient will accurately and confidently demonstrate the correct procedure for monitoring blood glucose levels using a glucometer.
Nursing Assessment for Unstable Blood Glucose Risk
A comprehensive nursing assessment is the foundation of personalized care. It involves gathering subjective and objective data to understand the patient’s specific risk factors and needs.
1. Identify Factors Increasing Risk: Nurses need to investigate various factors that can predispose a patient to unstable glucose. This includes:
- **Access to Medications and Supplies:** Assess if the patient has consistent access to prescribed medications and glucose monitoring equipment.
- **Eating Habits:** Evaluate for patterns of overeating, undereating, or irregular meal schedules.
- **Weight Status:** Note if the patient is obese, underweight, or experiencing rapid weight changes.
- **Exercise Patterns:** Determine the patient's typical activity level, including both insufficient and excessive exercise.
- **Life Stages:** Consider life stages like adolescence and pregnancy, which can influence glucose stability.2. Evaluate Patient’s Understanding of Diabetes (if applicable): For patients with diagnosed diabetes or at risk, assessing their knowledge is crucial.
- **Open-ended Questions:** Use open-ended questions to encourage discussion and gauge understanding.
- **Knowledge of Medications:** Ask patients to explain how their insulin or oral antidiabetic medications work, why they are necessary, and proper administration techniques.
- **Glucose Monitoring Knowledge:** Assess their understanding of glucose monitoring procedures and the importance of regular checks.
- **Recognition of Hyper/Hypoglycemia:** Evaluate their ability to identify the signs and symptoms of both hyperglycemia and hypoglycemia and appropriate initial responses.3. Assess for Nonadherence to Treatment Plan: Nonadherence is a significant barrier to stable glucose levels.
- **Medication Adherence:** Inquire about missed medication doses and reasons for nonadherence.
- **Glucose Monitoring Consistency:** Assess the frequency and regularity of blood glucose monitoring.
- **Dietary Adherence:** Explore the patient's dietary habits and adherence to recommended dietary guidelines.
- **Direct Questions:** Use direct, yet non-judgmental questions, such as "How many insulin doses have you missed in the past two weeks?" or "Can you describe what you typically eat in a day?"4. Medication Review: A thorough medication review is essential, as many medications can impact blood glucose.
- **Prescription and Over-the-Counter Medications:** Review all medications, including antidepressants, corticosteroids, oral contraceptives, antibiotics, certain heart and blood pressure medications, and over-the-counter cold remedies.
- **Potential Interactions:** Identify medications that may elevate or lower blood glucose levels or interfere with diabetes medications.5. Dietary and Eating Pattern Assessment: Dietary habits are directly linked to glucose control.
- **Meal Timing and Consistency:** Assess for irregular meal times, skipped meals, and meal consistency.
- **Carbohydrate and Sugar Intake:** Evaluate the patient's consumption of carbohydrates and sugary foods and drinks.
- **Dietary History:** Obtain a detailed dietary history to identify potential areas for improvement.6. Alcohol Intake Assessment: Alcohol consumption can significantly affect liver function and glucose regulation.
- **Impact on Liver Function:** Explain how alcohol metabolism by the liver can interfere with glucose control.
- **Hypoglycemia Risk:** Educate patients about the increased risk of hypoglycemia, especially when alcohol is consumed on an empty stomach or with antidiabetic medications.
- **Consumption Patterns:** Assess the frequency, amount, and context of alcohol consumption.7. Family Support Assessment: Social support plays a crucial role in diabetes management.
- **Support System Evaluation:** Determine the level of family and social support available to the patient.
- **Practical Support:** Assess if lack of support is contributing to difficulties in obtaining medications, administering insulin, or preparing healthy meals.8. Monitor Hemoglobin A1C (HbA1c): HbA1c provides a long-term measure of glucose control.
- **Average Glucose Levels:** Explain that HbA1c reflects average blood glucose levels over the past 2-3 months.
- **Long-Term Monitoring:** Utilize HbA1c results to monitor the effectiveness of diabetes treatment and identify trends in glucose control over time.
- **Target Ranges:** Be aware of recommended HbA1c target ranges for adults with diabetes, typically below 7%.Nursing Interventions for Unstable Blood Glucose Risk
Effective nursing interventions are critical for preventing and managing unstable blood glucose. These interventions are designed to empower patients to take control of their glucose levels.
1. Glucose Monitor and Technique Check: Ensure patients can accurately monitor their blood glucose.
- **Monitor Functionality:** Verify that the patient's glucose monitor is working correctly.
- **Demonstration of Technique:** Observe the patient as they demonstrate their glucose monitoring technique, from fingerstick to meter reading.
- **Correction of Errors:** Provide immediate feedback and correction if any steps are performed incorrectly.2. Insulin Administration Technique Check: For patients using insulin, proper administration is vital.
- **Insulin Preparation:** Ensure the patient knows how to accurately draw up insulin or use an insulin pen correctly.
- **Injection Site Rotation:** Confirm understanding of subcutaneous fat site rotation to prevent lipohypertrophy.
- **Site Preparation:** Verify that the patient is cleaning the injection site appropriately before each injection.3. Glucose Level Log Recommendation: Encourage consistent self-monitoring and record-keeping.
- **Logbook Provision:** Provide patients with a physical logbook or instruct them on using digital tools for recording glucose levels.
- **Pattern Identification:** Explain how a glucose log helps identify patterns and trends in blood glucose fluctuations.
- **Communication with Provider:** Emphasize the importance of sharing the glucose log with their healthcare provider to inform treatment adjustments.4. Referral to a Registered Dietitian: Dietary counseling is essential for diabetes management.
- **Personalized Dietary Plans:** Refer patients to a registered dietitian for individualized meal planning and dietary education.
- **Food Choices and Label Reading:** Dietitians can provide guidance on healthy food choices, portion control, and how to interpret food labels.
- **Resource Provision:** Dietitians can offer resources and materials to support dietary changes.5. Education on Hyper/Hypoglycemia: Patient education is key to preventing and managing glucose emergencies.
- **Symptom Recognition:** Educate patients on the signs and symptoms of hyperglycemia (e.g., headache, dry mouth, increased thirst, hunger) and hypoglycemia (e.g., sweating, shakiness, dizziness, lightheadedness).
- **Treatment Strategies:** Instruct patients on immediate actions to take for both conditions. For hypoglycemia, recommend fast-acting glucose sources like juice or hard candy.
- **Lifestyle Modifications:** Emphasize the role of exercise and healthy eating habits in preventing hyperglycemia.
- **Emergency Situations:** Educate patients on when hyper or hypoglycemia becomes a medical emergency requiring immediate medical attention.
- **Medication Adjustment:** Explain that frequent episodes of hyper or hypoglycemia may necessitate medication adjustments by their healthcare provider.6. Carbohydrate Counting Education: Understanding carbohydrates is crucial for glucose control.
- **Types of Carbohydrates:** Explain the different types of carbohydrates (sugars, starches, fiber) and their varying effects on blood glucose.
- **Impact on Glucose and Insulin:** Educate patients on how carbohydrates raise blood glucose levels and influence insulin needs.
- **Serving Sizes and Grams:** Introduce the concept of carbohydrate counting, explaining that 1 serving typically contains 15 grams of carbohydrates.
- **Individualized Needs:** Emphasize that individual carbohydrate needs vary based on calorie intake, weight, and activity level.7. Healthy Exercise Habit Discussion: Physical activity is a cornerstone of diabetes management.
- **Benefits of Exercise:** Discuss the numerous benefits of regular exercise, including cardiovascular health, weight management, mental well-being, and improved glycemic control.
- **Glucose-Lowering Effect:** Explain how exercise lowers blood glucose and increases insulin sensitivity.
- **Hypoglycemia Risk with Exercise:** Caution patients about the risk of exercise-induced hypoglycemia, especially if they don't adjust medication or carbohydrate intake beforehand.
- **Safe Exercise Practices:** Provide guidance on safe exercise practices for individuals with diabetes, including pre- and post-exercise glucose monitoring and carbohydrate adjustments as needed.8. Discussion of Advanced Glucose Monitoring Systems: Continuous glucose monitors (CGMs) can offer enhanced glucose control.
- **CGM Technology:** Introduce the concept of CGMs as wearable devices that continuously track glucose levels.
- **Benefits of CGMs:** Discuss the potential benefits of CGMs, such as real-time glucose readings, trend alerts, and improved glucose management.
- **Dexcom Example:** Mention examples of CGM devices like Dexcom.
- **Provider Consultation:** Advise patients to discuss CGM options with their healthcare provider to determine suitability.9. Diabetes Educator Involvement: Certified Diabetes Care and Education Specialists (CDCES) are invaluable resources.
- **Expert Education and Support:** Recommend consultation with a diabetes educator for specialized education and support in managing diabetes.
- **Behavior Change Motivation:** Highlight their role in motivating patients to adopt and maintain healthy behaviors to achieve their health goals.
- **Comprehensive Diabetes Management:** Diabetes educators can provide guidance on all aspects of diabetes self-management.10. Resource Provision for Supplies: Address financial barriers to diabetes management.
- **Cost Concerns:** Acknowledge the high costs of diabetic medications and supplies.
- **Financial Assistance Programs:** Offer information about available financial assistance programs and resources that can help patients afford insulin and other necessary supplies.
- **Community Resources:** Connect patients with local community resources that may offer support and assistance.Nursing Care Plan Examples for Risk for Unstable Blood Glucose
Nursing care plans provide a structured framework for prioritizing assessments and interventions to achieve both short-term and long-term care goals. Here are two examples of care plans for patients at risk for unstable blood glucose:
Care Plan #1: Risk for Unstable Blood Glucose Related to Pregnancy
Diagnostic Statement:
Risk for unstable blood glucose related to pregnancy.
Expected Outcomes:
- Patient will understand that pregnancy can lead to unstable glucose.
- Patient will maintain the following blood glucose levels:
- Preprandial: 90 mg/dL or less
- One hour postprandial: 130-140 mg/dL or less
- Two hours postprandial: 120 mg/dL or less
Assessment:
1. Evaluate the patient’s current knowledge and understanding of pregnancy and diabetes.
Rationale: Hormonal changes during pregnancy increase the risk of gestational diabetes. Patient education about risk factors and the importance of nutrition during pregnancy is crucial.
2. Obtain a medical and obstetrical history and note factors that heighten the risk for gestational diabetes.
Rationale: A comprehensive history helps identify risk levels and guides preventive strategies and prompt treatment for gestational diabetes. Risk factors can include obesity, family history of diabetes, previous gestational diabetes, and certain ethnicities.
3. Monitor blood glucose levels during the 24th and 28th weeks of gestation.
Rationale: Routine blood glucose screenings during these weeks are standard practice to detect gestational diabetes early in pregnancy, allowing for timely intervention.
Interventions:
1. Ensure that the patient knows the symptoms, causes, treatment, and prevention of hyperglycemia.
Rationale: Elevated blood glucose in pregnant women, especially those with pre-existing diabetes or gestational diabetes, requires careful management to prevent complications for both mother and baby.
2. Teach the importance of at least 150 minutes/week of moderate-intensity aerobic physical activity for at least three days per week, if medically cleared.
Rationale: Regular physical activity is beneficial during pregnancy (if no contraindications exist) and improves blood glucose control, reduces cardiovascular risks, aids in weight management, and enhances overall well-being.
3. Teach the importance of prenatal check-ups.
Rationale: Consistent prenatal care is vital for monitoring both maternal and fetal health. Glucose screening during prenatal visits helps detect gestational diabetes promptly, enabling timely management to prevent maternal and congenital complications.
4. Consult with a registered dietitian about appropriate meal planning for gestational diabetes.
Rationale: Pregnant women with or at risk for gestational diabetes require a balanced diet tailored to their specific needs. A dietitian can create meal plans focused on stabilizing blood glucose levels and preventing episodes of hypo- or hyperglycemia, while meeting nutritional needs of pregnancy. Calorie intake usually needs to be increased by approximately 300 calories per day, with careful attention to macronutrient balance.
Care Plan #2: Risk for Unstable Blood Glucose Related to Lack of Acceptance of Diagnosis
Diagnostic Statement:
Risk for unstable blood glucose related to lack of acceptance of the diagnosis of diabetes.
Expected Outcomes:
- Patient will verbalize an understanding of diabetes and the corresponding regimen.
- Patient will demonstrate lifestyle modification activities to stabilize glucose levels.
Assessment:
1. Obtain blood glucose levels.
Rationale: Monitoring blood glucose is a primary intervention to assess risk, guide treatment, and evaluate treatment response. Baseline and ongoing monitoring are essential.
2. Assess the patient’s current knowledge and understanding of diabetes.
Rationale: Understanding the risks associated with uncontrolled diabetes can motivate patients to engage in necessary lifestyle changes and adhere to treatment plans. Knowledge deficit is a significant barrier to self-management.
3. Assess feelings towards the diagnosis of diabetes.
Rationale: Patients react differently to a diabetes diagnosis. Feelings of fear, anger, depression, disbelief, or other negative emotions can hinder adaptation and self-management. Acknowledging and normalizing these feelings is crucial for therapeutic communication.
4. Note the influence of cultural, ethnic origin, socioeconomic, or religious factors impacting diabetes recognition and care.
Rationale: Cultural, ethnic, socioeconomic, and religious factors significantly influence patients’ perceptions of illness, healthcare seeking behaviors, dietary practices, and adherence to medical recommendations. These factors must be considered for culturally competent and effective care planning.
Interventions:
1. Encourage the verbalization of feelings towards diagnosis and care.
Rationale: Verbalizing feelings can reduce emotional distress and help the patient process the diagnosis. Creating a safe space for open communication is essential.
2. Involve the patient and family in the plan of care.
Rationale: Family involvement and support are crucial for successful diabetes management. Including family members or close individuals in care planning fosters shared understanding and promotes patient adherence and informed decision-making.
3. Encourage the patient to develop a system for self-monitoring and tracking progress.
Rationale: Self-monitoring empowers patients and provides a sense of control over their condition. Tracking progress can be motivating and helps patients make informed choices about their self-care.
4. Refer to appropriate community resources (e.g., diabetes educators or support groups).
Rationale: Community resources enhance accessibility to healthcare services and goods, promote treatment adherence, and assist patients in adapting positively to their diabetes diagnosis. Support groups can also help patients come to terms with their diagnosis by connecting them with others facing similar challenges, reducing feelings of isolation and fostering peer support. Resources can include diabetes education programs, support groups, insulin pump or CGM referrals, and financial assistance programs for supplies.
References
- Ackley, B.J., Ladwig, G.B.,& Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
- Alcohol and Diabetes | ADA. (n.d.). American Diabetes Association. Retrieved December 10, 2021, from https://www.diabetes.org/healthy-living/medication-treatments/alcohol-diabetes
- American Diabetes Association. (2023). Gestational diabetes and a healthy baby? Yes. American Diabetes Association. https://diabetes.org/about-diabetes/gestational-diabetes
- American Diabetes Association. (2023). Prenatal Care. American Diabetes Association. https://diabetes.org/diabetes/gestational-diabetes/prenatal-care
- Blood Sugar and Exercise | ADA. (n.d.). American Diabetes Association. Retrieved December 10, 2021, from https://www.diabetes.org/healthy-living/fitness/getting-started-safely/blood-glucose-and-exercise
- Callahan, A. (2018, March 6). 7 Medications That May Affect Blood Sugar Control in Diabetes. Everyday Health. Retrieved December 10, 2021, from https://www.everydayhealth.com/type-2-diabetes/treatment/medications-may-affect-blood-sugar-control-diabetes/
- Carb Counting. (n.d.). CDC. Retrieved December 10, 2021, from https://www.cdc.gov/diabetes/managing/eat-well/diabetes-and-carbohydrates.html
- Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
- Doenges, M.E., Moorhouse, M.F., & Murr, A.C. (2019). Nursing care plans Guidelines for individualizing client care across the life span (10th ed.). F.A. Davis Company.
- Gulanick, M. & Myers, J.L. (2014). Nursing care plans Diagnoses, interventions, and outcomes (8th ed.). Elsevier.
- Understanding A1C | ADA. (n.d.). American Diabetes Association. Retrieved December 10, 2021, from https://www.diabetes.org/a1c
