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 unstable blood glucose isn’t exclusive to individuals with diabetes. Transient conditions such as dehydration or pregnancy can also disrupt blood glucose balance, typically resolving once the underlying cause is addressed.
However, for individuals with diabetes mellitus, managing blood glucose levels is paramount. Uncontrolled diabetes can lead to severe long-term complications impacting vital organs including the heart, kidneys, eyes, and nerves. Therefore, nurses play a vital role in identifying the root causes of unstable blood glucose and empowering patients and their families with the knowledge and resources necessary for prevention and management.
Important Note: It’s essential to be aware that the nursing diagnosis “Risk for Unstable Blood Glucose” has been updated and renamed by NANDA International to “Risk for Ineffective Blood Glucose Pattern Self-Management.” While this article acknowledges this change, it will continue to use the term “Risk for Unstable Blood Glucose” to ensure clarity and familiarity for students and nurses who may still be transitioning to the newer terminology.
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: Lack of acceptance of a diabetes diagnosis can significantly hinder adherence to necessary management plans.
- Deficient Knowledge: Inadequate understanding of diabetes, its management, and treatment regimens is a major risk factor.
- Poor Adherence to Diabetes Management: This encompasses inconsistent medication intake, irregular blood glucose monitoring, and neglecting dietary recommendations.
- Financial Strain: Limited financial resources can restrict access to essential medications, monitoring supplies, and healthy food options.
- Dietary Intake: Unhealthy eating habits, including excessive carbohydrate intake, inconsistent meal timings, and poor portion control, contribute to glucose instability.
- Weight Fluctuations: Significant weight gain or loss can impact insulin sensitivity and glucose metabolism.
- Pregnancy: Hormonal changes during pregnancy can lead to insulin resistance and gestational diabetes.
- Activity Level: Both sedentary lifestyles and excessive exercise without proper management can disrupt blood glucose levels.
- Stress: Physiological and psychological stress can trigger hormonal responses that elevate blood glucose.
- Developmental Level: Age-related factors, particularly in children and adolescents experiencing growth spurts, can influence glucose regulation.
Note: As a risk diagnosis, “Risk for Unstable Blood Glucose” is identified before the problem occurs. Nursing interventions are therefore proactively focused on prevention.
Expected Outcomes for Nursing Care
Establishing clear goals and expected outcomes is crucial for effective nursing care planning. For patients at risk of unstable blood glucose, common goals include:
- Patient Education: The patient will be able to identify personal risk factors that contribute to unstable blood glucose levels.
- Blood Glucose Control: The patient will maintain blood glucose levels within the target normal range as recommended by healthcare providers.
- Self-Monitoring Skills: The patient will confidently and accurately demonstrate the correct technique for monitoring blood glucose levels using appropriate equipment.
Nursing Assessment for Unstable Blood Glucose Risk
A thorough nursing assessment is fundamental to identify individuals at risk and guide appropriate interventions. This assessment involves gathering both subjective and objective data, encompassing physical, psychosocial, and emotional aspects.
1. Identify Risk-Enhancing Factors:
- Explore lifestyle factors that increase the likelihood of unstable glucose. This includes:
- Medication Access: Assess for any barriers to obtaining prescribed medications.
- Eating Habits: Evaluate for overeating, undereating, and mealtime inconsistencies.
- Obesity: Assess for morbid obesity as a contributing factor.
- Exercise Patterns: Inquire about levels of physical activity, considering both lack of exercise and excessive exercise.
- Life Stages: Recognize growth spurts in adolescents and pregnancy as periods of increased risk.
2. Evaluate Disease Understanding:
- Assess the patient’s knowledge of diabetes and blood glucose management.
- Utilize open-ended questions to encourage discussion and gauge their understanding of:
- Medication Action: How their insulin or oral antidiabetic medications work.
- Medication Necessity: Why medication is required for glucose control.
- Glucose Monitoring: How to properly monitor blood glucose levels and interpret results.
- Hyperglycemia and Hypoglycemia Recognition: Ability to identify the signs and symptoms of both high and low blood sugar.
- This assessment helps pinpoint knowledge deficits and tailor patient education effectively.
3. Assess Medication and Diet Adherence:
- Investigate potential nonadherence to prescribed regimens.
- Ask direct but non-judgmental questions about:
- Missed Doses: Frequency of missed medication doses (e.g., “How many insulin doses have you missed in the past two weeks?”).
- Monitoring Consistency: Regularity of blood glucose monitoring.
- Dietary Adherence: Typical daily dietary intake (e.g., “What do you usually eat in a day?”).
4. Medication Review:
- Conduct a comprehensive review of all medications, including prescription, over-the-counter, and herbal supplements.
- Identify medications that may potentially interfere with glucose levels. Common culprits include:
- Antidepressants
- Corticosteroids
- Oral Contraceptives
- Antibiotics
- Certain Cardiovascular Medications (blood pressure and heart medications)
- Over-the-counter Cold Remedies
5. Diet and Eating Pattern Evaluation:
- Analyze dietary habits and eating patterns for consistency and balance.
- Recognize that irregular eating patterns significantly impact glucose control.
- Missed Meals: Can lead to hypoglycemia.
- High-Carbohydrate/Sugar Diets: Contribute to hyperglycemia.
6. Alcohol Intake Assessment:
- Inquire about alcohol consumption habits.
- Understand alcohol’s impact on liver function, which plays a vital role in glucose stabilization.
- Alcohol metabolism by the liver can impair glucose control, particularly leading to hypoglycemia, especially on an empty stomach or when combined with antidiabetic medications.
7. Family Support System Evaluation:
- Assess the patient’s access to family and social support networks.
- Identify any lack of support that may hinder medication access, insulin administration, or meal preparation.
8. Monitor Hemoglobin A1c (HbA1c):
- Review HbA1c results as an indicator of average blood glucose levels over the preceding 2-3 months.
- HbA1c is a valuable tool for assessing long-term glycemic control and the effectiveness of diabetes management strategies.
- Typical A1c goal for adults with diabetes is generally <7%, but individual targets may vary.
Nursing Interventions for Unstable Blood Glucose Risk
Nursing interventions are crucial for preventing and managing unstable blood glucose. These interventions are focused on education, skill-building, and resource provision.
1. Glucose Monitor Skills Check:
- Request the patient to bring their personal glucose monitor to appointments.
- Observe the patient demonstrate their technique for blood glucose monitoring.
- Verify that the monitor is functioning correctly.
- Ensure the patient performs all steps of the fingerstick procedure accurately.
2. Insulin Administration Technique Review:
- If the patient uses insulin, have them demonstrate their administration technique.
- Confirm their understanding of:
- Insulin Dose Preparation: Correctly drawing up insulin from a vial or using an insulin pen dial.
- Injection Site Rotation: Rotating subcutaneous fat injection sites to prevent lipohypertrophy.
- Site Preparation: Cleaning the injection site with an alcohol swab before injection.
3. Glucose Level Logging Recommendation:
- Advise patients to maintain a blood glucose level log.
- Provide a structured form or instruct them to use a notebook.
- Encourage daily recording of blood glucose readings, along with meal times, medication doses, and exercise.
- Explain that this log aids healthcare providers in identifying patterns and making informed treatment adjustments.
4. Dietitian Referral:
- Refer patients to a registered dietitian for specialized dietary guidance.
- Dietitians can provide tailored education on:
- Food Choices: Identifying appropriate food types and portion sizes.
- Food Label Reading: Interpreting nutritional information on food labels.
- Dietary Modifications: Developing individualized meal plans to stabilize blood glucose.
5. Hyperglycemia and Hypoglycemia Education:
- Educate patients comprehensively about the signs, symptoms, and management of both hyperglycemia and hypoglycemia.
- Hyperglycemia Signs: Headache, dry mouth, increased thirst, increased hunger.
- Hypoglycemia Signs: Sweating/chills, shakiness, lightheadedness, dizziness.
- Management Strategies:
- Lifestyle Modifications: Emphasize the role of exercise and healthy eating habits in blood glucose control.
- Hypoglycemia Treatment: Instruct on immediate treatment of hypoglycemia with fast-acting glucose sources like juice or hard candy.
- Medical Follow-up: Advise patients that frequent episodes of hypo- or hyperglycemia may necessitate medication adjustments and require medical consultation.
- Emergency Awareness: Educate patients about when hypo- or hyperglycemia becomes a medical emergency requiring immediate attention.
6. Carbohydrate Counting Education:
- Teach the principles of carbohydrate counting.
- Explain the different types of carbohydrates (sugars, starches, and fiber) and their impact on blood glucose and insulin levels.
- Clarify that carbohydrates are measured in grams and that a standard serving typically contains 15 grams of carbohydrates.
- Emphasize that individual carbohydrate needs vary based on caloric intake, weight, and activity level, necessitating personalized guidance.
7. Healthy Exercise Habit Promotion:
- Discuss the importance of regular exercise for overall health and glycemic control.
- Highlight the benefits of exercise: cardiovascular health, weight management, mental well-being, and improved insulin sensitivity.
- Explain that exercise lowers blood glucose and enhances insulin sensitivity.
- Caution about potential hypoglycemia during exercise, particularly if medication and carbohydrate intake are not appropriately adjusted prior to physical activity.
8. Continuous Glucose Monitoring (CGM) Discussion:
- For suitable patients, discuss the potential benefits of continuous glucose monitoring (CGM) systems.
- Explain that CGM devices can provide real-time glucose readings and trend data, potentially improving blood sugar management.
- Discuss the availability of wearable CGM devices like Dexcom and the process for determining eligibility with their healthcare provider.
9. Diabetes Educator Referral:
- Refer patients to certified diabetes educators (CDEs) or diabetes education programs.
- CDEs are specialized healthcare professionals who provide comprehensive diabetes self-management education and support.
- Emphasize their role in empowering patients to make positive behavior changes and achieve their health goals.
10. Resource Provision for Supplies:
- Acknowledge the financial burden of diabetes medications and supplies.
- Offer information about available financial assistance programs and resources to help patients access affordable medications and monitoring supplies.
Nursing Care Plans for Risk for Unstable Blood Glucose
Nursing care plans provide a structured framework for prioritizing assessments and interventions, guiding both short-term and long-term care goals. Here are examples of nursing care plans for “Risk for Unstable Blood Glucose” addressing different related factors:
Care Plan #1: Unstable Blood Glucose Risk Related to Pregnancy
Diagnostic Statement: Risk for unstable blood glucose related to physiological changes of pregnancy.
Expected Outcomes:
- Patient will understand the increased risk of unstable glucose during pregnancy.
- Patient will maintain blood glucose levels within the following target ranges:
- Preprandial (Before Meals): 70-95 mg/dL
- One Hour Postprandial (After Meals): <140 mg/dL
- Two Hours Postprandial (After Meals): <120 mg/dL
Assessment:
- Knowledge Assessment: Evaluate the patient’s current understanding of pregnancy and diabetes, including the increased risk of gestational diabetes due to hormonal changes and the importance of nutrition during pregnancy.
- Risk Factor Identification: Obtain a detailed medical and obstetrical history to identify factors that elevate the risk for gestational diabetes. This informs risk stratification and appropriate preventative or early intervention strategies.
- Gestational Diabetes Screening: Monitor blood glucose levels during the 24th to 28th weeks of gestation, as recommended for routine gestational diabetes screening.
Interventions:
- Hyperglycemia Education: Ensure the patient understands the symptoms, causes, treatment, and prevention of hyperglycemia, particularly relevant in managing pre-existing diabetes during pregnancy or gestational diabetes.
- Physical Activity Promotion: Teach the importance of at least 150 minutes of moderate-intensity aerobic activity per week, spread over at least three days, unless contraindicated. Regular exercise improves glucose control, reduces cardiovascular risks, supports healthy weight management, and enhances overall well-being during pregnancy.
- Prenatal Care Emphasis: Educate the patient about the critical importance of regular prenatal check-ups for monitoring both maternal and fetal health. Reinforce that glucose screening during prenatal care facilitates early detection and management of gestational diabetes, preventing potential complications.
- Dietary Consultation: Consult with a registered dietitian to develop an appropriate meal plan tailored to pregnancy needs and blood glucose management. Pregnant women require balanced nutrition and increased caloric intake (approximately 300 extra calories daily). Meal plans should prioritize blood glucose stabilization and prevent hypo- or hyperglycemic episodes.
Care Plan #2: Unstable Blood Glucose Risk Related to Lack of Acceptance of Diagnosis
Diagnostic Statement: Risk for unstable blood glucose related to psychological denial and non-acceptance of diabetes diagnosis.
Expected Outcomes:
- Patient will verbalize understanding of diabetes and the prescribed management regimen.
- Patient will demonstrate active participation in lifestyle modifications to stabilize glucose levels.
Assessment:
- Blood Glucose Monitoring: Regularly monitor blood glucose levels to establish baseline data and track treatment response.
- Diabetes Knowledge Assessment: Assess the patient’s current knowledge and understanding of diabetes, its implications, and management strategies to identify knowledge gaps.
- Emotional Response Assessment: Evaluate the patient’s feelings and emotional reactions towards the diabetes diagnosis. Recognize that denial, fear, anger, depression, or disbelief are common and can impede adaptation and self-management.
- Cultural and Socioeconomic Factors: Note the influence of cultural, ethnic, socioeconomic, or religious factors that may impact diabetes recognition, care-seeking behavior, dietary practices, and overall disease management.
Interventions:
- Emotional Expression Encouragement: Encourage the patient to verbalize their feelings and concerns related to the diagnosis and required care. Open communication can reduce emotional distress and facilitate acceptance.
- Collaborative Care Planning: Involve the patient and family members in developing the care plan. Collaborative planning empowers patients, promotes informed decision-making, and enhances support systems.
- Self-Monitoring System Development: Encourage the patient to develop a consistent system for self-monitoring blood glucose. This promotes a sense of control, allows for progress tracking, and supports informed self-management choices.
- Community Resource Referral: Refer the patient to appropriate community resources, such as diabetes educators, support groups, and financial assistance programs. Community resources enhance access to healthcare services, promote treatment adherence, facilitate positive adaptation to the diagnosis, and provide peer support.
Care Plan #3: Unstable Blood Glucose Risk Related to Medication Nonadherence
Diagnostic Statement: Risk for unstable blood glucose related to nonadherence with prescribed medication management.
Expected Outcomes:
- Patient will maintain a Hemoglobin A1c (HbA1c) level within the target range (individualized per provider).
- Patient will maintain preprandial blood glucose levels between 70 and 130 mg/dL (unless otherwise specified).
Assessment:
- Nonadherence Factor Identification: Determine the underlying factors contributing to medication nonadherence. Understanding these factors is crucial for developing individualized and effective intervention strategies.
- Hyperglycemia Symptom Monitoring: Monitor for signs and symptoms of hyperglycemia as indicators of inadequate glucose control and medication nonadherence.
- HbA1c Level Evaluation: Evaluate HbA1c levels to assess overall glycemic control over the past 2-3 months, reflecting long-term medication adherence and treatment effectiveness.
Interventions:
- Emotional Expression Support: Allow the patient to express any negative feelings toward diabetes care, such as frustration, sadness, or fear. Addressing emotional barriers can foster a trusting relationship with the healthcare provider and improve treatment engagement.
- Diabetes Education Enhancement: Provide comprehensive education about diabetes, its management, potential complications, and the importance of medication adherence. Knowledge empowers patients to make informed decisions and engage in better self-care behaviors.
- Blood Glucose Log Promotion: Teach the patient to maintain a detailed blood glucose log. This tool helps patients track medication adherence, monitor their response to treatment, and identify patterns that may inform necessary adjustments.
- Community Resource Utilization Encouragement: Encourage patients to utilize available community resources based on their individual needs, such as financial assistance programs, medication assistance, and diabetes support services. Community resources can significantly improve adherence to treatment regimens by addressing practical and socioeconomic barriers.
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.
- Herdman, T. H., Kamitsuru, S., & Lopes, C. (Eds.). (2024). NANDA-I International Nursing Diagnoses: Definitions and Classification, 2024-2026. Thieme. 10.1055/b000000928
- Understanding A1C | ADA. (n.d.). American Diabetes Association. Retrieved December 10, 2021, from https://www.diabetes.org/a1c
