Hyperglycemia, commonly known as high blood sugar, is a frequent concern, especially for individuals with diabetes. It occurs when the body doesn’t produce enough insulin or can’t effectively use the insulin it produces, leading to elevated glucose levels in the blood. Understanding the nursing diagnosis for high blood sugar is crucial for effective patient care and management. A blood glucose level exceeding 125 mg/dL when fasting, or above 180 mg/dL after meals, is typically considered hyperglycemic.
Understanding Hyperglycemia: Causes, Complications, and Symptoms
Hyperglycemia can stem from a variety of factors. Diabetes mellitus, both type 1 and type 2, are primary causes. Other contributing conditions include endocrine disorders, pancreatic issues, and even lifestyle factors such as a sedentary lifestyle and stress. Certain medications can also induce hyperglycemia as a side effect.
Diagnosing hyperglycemia involves blood and urine tests. Recognizing the symptoms is also vital for prompt intervention. Common signs of high blood sugar include:
- Excessive thirst (polydipsia)
- Frequent urination (polyuria)
- Increased hunger (polyphagia)
- Headache
- Fatigue
- Blurred vision
If left unmanaged, hyperglycemia can lead to serious health complications. Prolonged high blood sugar damages nerves and blood vessels, increasing the risk of cardiovascular disease, peripheral neuropathy, retinopathy (eye damage), and nephropathy (kidney damage). Furthermore, it can impair the body’s ability to fight infections and slow down the healing process.
The Nursing Process and Hyperglycemia
Nurses play a pivotal role in managing hyperglycemia. The primary nursing goal is to safely reduce blood glucose levels to a healthy range and to empower patients through education to prevent future complications. Nurses are essential in promoting health and providing supportive care for individuals experiencing hyperglycemia.
Nursing care plans are developed once a nursing diagnosis is identified for hyperglycemia. These plans are crucial for prioritizing assessments and interventions, setting both short-term and long-term care objectives. Let’s explore some key nursing diagnoses associated with hyperglycemia and their corresponding care plans.
Decreased Cardiac Output
Uncontrolled hyperglycemia can severely impact the cardiovascular system. The damage to blood vessels caused by high blood sugar can lead to decreased cardiac output.
Nursing Diagnosis: Decreased Cardiac Output
Related to:
- Elevated blood glucose levels
- Compromised myocardial contractility
- Vasoconstriction
- Increased cardiac inflammation
- Reduced cardiac oxygenation
As evidenced by:
- Tachycardia
- Tachypnea
- Dyspnea
- Orthopnea
- Reduced oxygen saturation
- Hypotension
- Fatigue
- Anxiety/Restlessness
- Decreased activity tolerance
- Weak peripheral pulses
- Oliguria
Expected outcomes:
- Patient will demonstrate adequate cardiac output, indicated by:
- Stable vital signs
- Urine output between 0.5 to 1.5 cc/kg/hour
- Absence of arrhythmia
- Patient will commit to lifestyle changes including regular exercise and weight management.
Assessment:
- Monitor vital signs. Unstable vital signs such as tachycardia, hypotension, and tachypnea are common in patients with impaired heart function.
- Review diagnostic results. Echocardiograms and stress tests are important for patients at risk of heart disease or heart failure to monitor cardiac health and function.
- Assess cardiac enzymes. Elevated levels of cardiac enzymes (troponin, CK-MB, BNP) indicate potential damage to cardiac tissue.
Interventions:
- Discuss cholesterol levels. Hyperglycemia elevates the risk of hypercholesterolemia. Counsel the patient on optimal LDL, HDL, and triglyceride levels and ensure they receive recommended screenings.
- Obtain an EKG. An EKG is crucial for detecting dysrhythmias, including STEMI, which require immediate medical intervention.
- Emphasize medication adherence. Patients need to strictly adhere to all prescribed medications, including insulin, antidiabetic drugs, antihypertensives, vasodilators, diuretics, and statins, to minimize cardiac complication risks.
- Educate on heart disease and heart failure symptoms. The patient should be instructed to promptly report any new or worsening symptoms to their healthcare provider.
Deficient Knowledge
Lack of sufficient knowledge about their condition, medication, or necessary lifestyle adjustments can significantly contribute to uncontrolled hyperglycemia.
Nursing Diagnosis: Deficient Knowledge
Related to:
- Misinformation
- Limited access to resources
- Lack of awareness of available resources
- Insufficient information provided
- Low motivation to learn
- Limited involvement in care planning
- Distrust in healthcare professionals
- Misinterpretation of information
As evidenced by:
- Inconsistent adherence to instructions
- Unstable glucose levels
- Inaccurate statements about hyperglycemia
- Development of preventable complications
Expected outcomes:
- Patient will articulate the relationship between glucose and insulin.
- Patient will explain how and when to properly administer insulin.
Assessment:
- Assess learning abilities and motivation. Effective learning requires patient readiness and willingness. Assess learning abilities to tailor teaching methods to their learning style.
- Evaluate current understanding. Before providing education, determine the patient’s existing knowledge of hyperglycemia to avoid redundancy and ensure patient-centered teaching.
Interventions:
- Engage patient and family in learning. Utilize diverse teaching methods suited to the patient’s learning style. Family involvement enhances support and understanding of the health condition.
- Reinforce education through repetition. Consistent and repeated education on glucose management and treatment strategies improves adherence.
- Prioritize vital information. Focus on the most critical aspects of diabetes management, emphasizing that lifestyle changes take time and consistent effort.
- Refer to a registered dietitian. A dietitian can provide essential carbohydrate counting education, a key strategy for effective glycemic control.
Ineffective Health Maintenance
Hyperglycemia can be a consequence of ineffective health maintenance practices, such as poor dietary choices, lack of physical activity, and improper medication management.
Nursing Diagnosis: Ineffective Health Maintenance
Related to:
- Competing life demands
- Insufficient resources
- Conflict between cultural beliefs and health practices
- Conflict between health behaviors and social norms
- Difficulty with decision-making
- Inadequate social support
- Ineffective coping strategies
As evidenced by:
- Failure to engage in preventative health actions
- Inability to assume responsibility for health management
- Lack of commitment to a health action plan
- Limited interest in health improvement
- Insufficient knowledge of basic health practices
- History of poor decision-making regarding health
- Pattern of lacking health-seeking behaviors
Expected outcomes:
- Patient will adopt lifestyle modifications that support effective health maintenance.
- Patient will identify factors that contribute to hyperglycemia.
Assessment:
- Assess beliefs about health management. Personal and cultural beliefs, decision-making preferences, values, and perceptions significantly influence health management behaviors.
- Note desire and ability to meet needs. Evaluate the patient’s motivation to change behaviors and their capacity to make decisions and participate in health maintenance activities.
- Assess resource barriers. Identify potential financial, transportation, and equipment limitations, as well as living arrangements and the need for physical support.
Interventions:
- Develop realistic, achievable goals. Start with small, manageable goals like reducing dessert intake or incorporating short walks into their routine to encourage gradual lifestyle changes.
- Provide strategies for complex medication schedules. Assist patients with medication adherence by developing reminders like alarms, pill organizers, or visual aids.
- Refer to community support programs. Connect patients with home health services, social workers, or skilled nursing facilities as needed to meet their health and safety requirements.
- Teach stress management techniques. Address stress as a barrier to health maintenance, especially for patients with caregiving, parenting, or career responsibilities.
- Build confidence in self-management. Empower patients through education to improve self-management skills, leading to better health outcomes and coping mechanisms.
Ineffective Tissue Perfusion
Chronically elevated blood glucose levels lead to endothelial damage, which can impair oxygenation and result in both microvascular and macrovascular complications, affecting tissue perfusion.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Interruption of blood flow
- Elevated blood glucose level
- Sedentary lifestyle
- Smoking
- Insufficient knowledge of hyperglycemia and management
- Poor management of chronic health conditions
As evidenced by:
- Claudication
- Diminished peripheral pulses
- Capillary refill time exceeding 2 seconds
- Cool, clammy skin
- Abnormal ankle-brachial index
- Altered sensation
- Paresthesia
Expected outcomes:
- Patient will maintain optimal peripheral tissue perfusion, evidenced by:
- Blood pressure within normal limits
- Warm and dry extremities
- Capillary refill time less than 2 seconds
- Palpable peripheral pulses
- Patient will identify two modifiable risk factors to improve tissue perfusion.
Assessment:
- Assess for extremity pain. In arterial insufficiency, pain occurs during activity and is relieved by rest. Venous insufficiency causes aching, cramping, or heaviness in the legs.
- Note skin texture, color, and temperature. Observe for shiny skin on lower legs, pallor, redness, swelling, and coolness, which are indicators of poor circulation.
Interventions:
- Encourage exercise. Activities like biking and walking can improve arterial circulation.
- Instruct on leg elevation. Advise against leg elevation in arterial insufficiency as it reduces circulation, but recommend elevation for venous insufficiency to reduce swelling.
- Promote smoking cessation. Smoking and hyperglycemia significantly increase the risk of peripheral artery disease (PAD) due to endothelial damage and plaque buildup.
- Advise avoiding extreme temperatures. PAD and diabetic neuropathy can impair skin sensation, making patients vulnerable to injury from temperatures that are too hot or cold.
Risk for Unstable Blood Glucose
Individuals with a history of hyperglycemia are at risk for experiencing fluctuations in serum glucose levels, which can compromise their health and lead to further complications if not properly managed.
Nursing Diagnosis: Risk for Unstable Blood Glucose
Related to:
- Diabetes mellitus
- Medication side effects
- Infections
- Pancreatic diseases
- Ineffective health management behaviors
- Ineffective medication management
- Ineffective weight management
- Inadequate glucose monitoring
- Dietary intake
- Pregnancy
- Stress
As evidenced by:
A risk diagnosis is identified by risk factors, not by existing signs and symptoms. Nursing interventions are focused on preventing the problem from developing.
Expected outcomes:
- Patient will adopt behaviors that improve hyperglycemia and maintain blood glucose within the target range.
- Patient will verbalize two strategies to prevent hyperglycemia.
Assessment:
- Assess laboratory values. Monitor blood glucose levels using HbA1C and fingerstick glucose tests. Urinalysis can detect ketones, indicating ketoacidosis, which requires urgent medical attention.
- Assess glucose understanding. Ensure the patient understands their condition and how insulin affects glucose levels.
Interventions:
- Administer medications as prescribed. Administer insulin and other antidiabetic medications to help lower blood glucose levels.
- Educate on glucometer use. Instruct patients on how to accurately check their glucose levels using a glucometer or continuous glucose monitoring devices like Dexcom. Observe their technique for accuracy.
- Monitor for hypoglycemia. Be vigilant for signs of hypoglycemia, which can occur if hyperglycemia is overcorrected. Symptoms include dizziness, shakiness, sweating, headache, pallor, confusion, seizures, and altered mental status.
- Encourage blood glucose logging. Maintaining a blood glucose log helps track treatment effectiveness and identify necessary adjustments.
- Promote lifestyle modifications. Encourage healthy eating habits and regular exercise to help maintain stable glucose levels and prevent hyperglycemia.
References
- ACCN Essentials of Critical Care Nursing. 3rd Edition. Suzanne M. Burns, MSN, RRT, ACNP, CCRN, FAAN, FCCM, FAANP. 2014. McGraw Hill Education.
- Ackley, B.J., Ladwig, G.B.,& Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
- 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. Nursing care plans: Diagnoses, interventions, and Outcomes. (8th ed.). Elsevier.
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