Unstable blood glucose refers to fluctuations outside the normal range, 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 equate to a diagnosis of diabetes. Various transient conditions such as dehydration or pregnancy can disrupt blood sugar levels, which typically normalize once the underlying cause is addressed.
However, for individuals with diabetes, managing blood glucose instability is a central concern. Uncontrolled blood sugar levels in diabetes can lead to severe long-term complications affecting vital organs, including the heart, kidneys, eyes, and nerves. Therefore, healthcare professionals, particularly nurses, play a vital role in identifying potential causes of unstable glucose and empowering patients and their families with the knowledge and resources necessary for prevention and management.
Risk Factors for Unstable Blood Glucose
Several factors can elevate the risk of unstable blood glucose levels. Recognizing these risk factors is the first step in proactive care. Common risk factors include:
- Denial of Diagnosis: Refusal to accept a diabetes diagnosis can lead to neglecting necessary management strategies.
- Deficient Knowledge: Lack of understanding about diabetes and its treatment can hinder effective self-management.
- Poor Adherence to Diabetes Management: Inconsistent medication intake, glucose monitoring, or dietary practices can destabilize blood sugar.
- Financial Strain: Limited financial resources can restrict access to medications, monitoring supplies, and healthy food options.
- Dietary Intake: Unbalanced diets, inconsistent meal timing, and excessive consumption of sugary or carbohydrate-rich foods can contribute to glucose instability.
- Weight Changes: Significant weight gain or loss can impact insulin sensitivity and glucose control.
- Pregnancy: Hormonal shifts during pregnancy can induce insulin resistance and gestational diabetes.
- Activity Level: Both insufficient physical activity and excessive exercise without proper management can disrupt glucose balance.
- Stress: Physiological stress responses can elevate blood sugar levels.
- Developmental Level: Age-related factors and developmental stages can influence an individual’s ability to manage blood glucose.
Important Note: As a risk diagnosis, “Risk for Unstable Blood Glucose” is identified before the problem occurs. Therefore, there are no existing signs and symptoms to observe. Nursing interventions are strategically focused on preventative measures.
Expected Outcomes
Effective nursing care planning aims to achieve specific, measurable outcomes. For patients at risk of unstable blood glucose, typical goals include:
- The patient will be able to identify personal risk factors that can contribute to unstable blood glucose levels.
- The patient will maintain blood glucose levels within the normal, individualized target range.
- The patient will confidently and accurately demonstrate the correct technique for self-monitoring glucose levels.
Nursing Assessment
A thorough nursing assessment is the foundation of personalized care. It involves gathering subjective and objective data across physical, psychosocial, emotional, and diagnostic domains. When assessing the risk for unstable blood glucose, nurses should focus on the following:
1. Identify Contributing Factors: Explore lifestyle, medical history, and situational factors that increase the risk. This includes:
- Lack of access to prescribed medications or monitoring supplies.
- Irregular eating patterns, including overeating or undereating.
- Obesity or morbid obesity.
- Sedentary lifestyle or excessive exercise without proper management.
- Growth spurts in adolescents.
- Pregnancy.
2. Evaluate Patient’s Diabetes Knowledge: Assess the patient’s understanding of their condition (if diagnosed with diabetes) or risk factors. Engage in open-ended conversations to gauge their knowledge about:
- The mechanism of action of their insulin or oral antidiabetic medications.
- The necessity of medication.
- Proper glucose monitoring procedures.
- Recognition and management of hyperglycemia and hypoglycemia.
This assessment helps identify knowledge deficits and guides tailored education.
3. Assess Adherence to Management Plan: Investigate adherence to prescribed regimens. Ask direct, yet non-judgmental questions about:
- Missed medication doses.
- Consistency of glucose monitoring.
- Dietary adherence.
For example, inquire, “In the past two weeks, how many times have you missed a dose of your insulin?” or “Could you describe what you typically eat in a day?”
4. Medication Review: Scrutinize the patient’s medication list, including prescription, over-the-counter drugs, and supplements. Be aware of medications that can interfere with glucose levels, such as:
- Antidepressants.
- Corticosteroids.
- Oral contraceptives.
- Certain antibiotics.
- Some heart or blood pressure medications.
- Over-the-counter cold remedies.
5. Evaluate Diet and Eating Habits: Assess the consistency and quality of dietary intake.
- Irregular meal schedules can disrupt glucose control.
- Skipping meals can lead to hypoglycemia.
- Diets high in simple carbohydrates and sugars contribute to hyperglycemia.
6. Assess Alcohol Consumption: Inquire about alcohol intake patterns. Alcohol impacts liver function, a key organ in glucose stabilization.
- When the liver prioritizes alcohol metabolism, glucose control can be compromised, potentially causing hypoglycemia.
- This risk is heightened on an empty stomach or when alcohol is consumed with antidiabetic medications.
7. Evaluate Family and Social Support: Determine the level of social support available to the patient. Lack of support can create barriers to:
- Obtaining medications.
- Administering insulin.
- Preparing healthy meals.
8. Monitor Hemoglobin A1C (HbA1c): Review HbA1c results, if available. HbA1c reflects average blood glucose levels over the preceding 2-3 months.
- It provides valuable insights into long-term glucose control and the effectiveness of diabetes management strategies.
- The general target HbA1c for adults with diabetes is typically <7%.
Nursing Interventions
Targeted nursing interventions are crucial in preventing and managing unstable blood glucose. Consider the following interventions for patients at risk:
1. Glucose Monitor Assessment and Training:
- Request the patient to bring their glucose monitor to appointments.
- Verify the monitor’s functionality.
- Observe the patient as they demonstrate their glucose monitoring technique.
- Ensure they perform all steps of the fingerstick procedure correctly, including proper hand hygiene, lancet use, blood application to the test strip, and result interpretation.
2. Insulin Administration Education and Demonstration:
- If the patient uses insulin, have them demonstrate their administration technique.
- Confirm their understanding of insulin dosage preparation (drawing insulin from a vial or using an insulin pen).
- Verify proper subcutaneous injection site rotation techniques to prevent lipohypertrophy.
- Ensure they are cleaning the injection site appropriately before each injection.
3. Glucose Level Logging and Pattern Identification:
- Recommend and facilitate glucose level logging.
- Provide a structured log form or advise the patient to use a notebook.
- Instruct them to record glucose levels daily, along with relevant contextual information like meal times, medication dosages, and activity levels.
- Explain that this log will aid healthcare providers in identifying glucose patterns and making informed treatment adjustments.
4. Dietitian Referral and Nutritional Counseling:
- Refer the patient to a registered dietitian or certified diabetes educator for comprehensive dietary guidance.
- Dietitians can provide personalized meal plans, educate on appropriate food choices, portion control, and carbohydrate counting.
- They can also offer practical resources for healthy eating, grocery shopping, and reading food labels.
5. Hyperglycemia and Hypoglycemia Education: Provide thorough education on recognizing, treating, and preventing extreme glucose fluctuations.
- Hyperglycemia: Educate on signs such as increased thirst, frequent urination, blurred vision, fatigue, and slow-healing sores.
- Hypoglycemia: Educate on signs such as sweating, trembling, dizziness, confusion, rapid heartbeat, and hunger.
- Instruct on immediate management strategies for hypoglycemia, such as consuming fast-acting carbohydrates like juice, glucose tablets, or hard candy.
- Emphasize the importance of exercise and balanced eating habits in maintaining stable glucose levels.
- Stress the need to seek medical attention for frequent or severe episodes of hyper- or hypoglycemia, as medication adjustments may be necessary.
- Clearly define when hypo- or hyperglycemia becomes a medical emergency requiring immediate intervention (e.g., severe confusion, loss of consciousness).
6. Carbohydrate Counting Education:
- Teach the concept of carbohydrate counting as a meal planning tool.
- Explain the different types of carbohydrates (sugars, starches, fiber) and their varying impacts on blood glucose.
- Clarify that carbohydrates are measured in grams, and a standard serving often contains 15 grams of carbohydrates.
- Emphasize that individual carbohydrate needs vary based on caloric intake, weight, activity level, and medication regimen.
7. Promoting Healthy Exercise Habits:
- Discuss the multifaceted benefits of regular exercise, including cardiovascular health, weight management, mental well-being, and improved glycemic control.
- Explain how exercise lowers blood glucose and enhances insulin sensitivity.
- Caution patients about the risk of exercise-induced hypoglycemia, particularly if they are on insulin or certain oral diabetes medications.
- Advise patients to monitor their blood glucose before, during, and after exercise, and to adjust medication or carbohydrate intake as needed to prevent hypoglycemia.
8. Continuous Glucose Monitoring (CGM) Discussion:
- For suitable patients, introduce the option of continuous glucose monitoring systems.
- Explain how CGMs provide real-time glucose readings and trend data, potentially leading to improved glucose control and reduced hypoglycemia.
- Discuss wearable CGM devices like Dexcom or Freestyle Libre.
- Facilitate a discussion with the healthcare provider to determine if a CGM is appropriate and covered by insurance.
9. Diabetes Educator Referral:
- Actively involve certified diabetes educators in patient care.
- Highlight their expertise in diabetes self-management education and support.
- Emphasize their role in motivating behavior change and empowering patients to achieve their health goals.
10. Resource Assistance for Supplies:
- Acknowledge the significant financial burden of diabetes medications and supplies.
- Proactively inquire about patients’ ability to afford insulin, glucose monitoring strips, and other necessities.
- Provide information about available financial assistance programs, pharmaceutical patient assistance programs, and community resources that can help reduce costs and improve access to care.
Nursing Care Plans: Examples
Nursing care plans provide a structured framework for prioritizing assessments and interventions, guiding both short-term and long-term care goals. Here are two example care plans for “Risk for Unstable Blood Glucose”:
Care Plan #1: Risk Related to Pregnancy
Diagnostic Statement:
Risk for unstable blood glucose related to pregnancy-induced hormonal changes.
Expected Outcomes:
- The patient will verbalize understanding that pregnancy increases the risk of unstable glucose levels, including gestational diabetes.
- The patient will maintain blood glucose levels within the following target ranges (individualized ranges to be specified by healthcare provider, e.g.):
- Preprandial (before meals): 90 mg/dL or less
- One hour postprandial (after meals): 140 mg/dL or less
- Two hours postprandial (after meals): 120 mg/dL or less
Assessment:
1. Assess Knowledge of Pregnancy and Diabetes: Evaluate the patient’s current understanding of the relationship between pregnancy and blood sugar.
- Hormonal changes inherent in pregnancy create insulin resistance, increasing the risk of gestational diabetes.
- Assess their understanding of gestational diabetes risk factors and the critical role of nutrition during pregnancy.
2. Obtain Medical and Obstetrical History: Gather comprehensive history to identify risk factors for gestational diabetes.
- A detailed history helps determine the level of risk and guides preventative strategies or early intervention for gestational diabetes.
- Note factors such as previous gestational diabetes, family history of diabetes, obesity, and ethnicity.
3. Monitor Blood Glucose During Gestation: Track blood glucose levels, particularly during the 24th to 28th weeks of gestation.
- Routine glucose screening during this period is crucial for the timely detection of gestational diabetes.
- Screening typically involves a glucose challenge test followed by a diagnostic oral glucose tolerance test if needed.
Interventions:
1. Educate on Hyperglycemia: Ensure the patient understands the symptoms, causes, treatment, and prevention of hyperglycemia, specifically in the context of pregnancy.
- Elevated blood glucose in pregnancy necessitates careful evaluation and management to protect both maternal and fetal health.
2. Promote Physical Activity: Emphasize the importance of regular, moderate-intensity aerobic exercise (at least 150 minutes per week, spread over at least three days).
- Regular physical activity improves insulin sensitivity, aids in blood glucose control, reduces cardiovascular risk, supports healthy weight management, and enhances overall well-being during pregnancy.
3. Prenatal Care Education: Stress the importance of consistent prenatal check-ups.
- Prenatal care is essential for monitoring both maternal and fetal health throughout pregnancy.
- Routine glucose screening is a standard component of prenatal care, enabling early detection and management of gestational diabetes.
- Prompt diagnosis and treatment significantly reduce the risk of maternal and fetal complications.
4. Dietitian Consultation: Arrange for a consultation with a registered dietitian specializing in gestational diabetes or pregnancy nutrition.
- Pregnant women require a balanced diet with a variety of nutrient-rich foods.
- Caloric needs typically increase by approximately 300 calories per day during pregnancy.
- A dietitian can create a personalized meal plan focused on stabilizing blood glucose, preventing both hyperglycemia and hypoglycemia, and meeting the unique nutritional needs of pregnancy.
Care Plan #2: Risk Related to Lack of Acceptance of Diagnosis
Diagnostic Statement:
Risk for unstable blood glucose related to lack of acceptance of diabetes diagnosis and recommended management plan.
Expected Outcomes:
- The patient will verbalize an understanding of their diabetes diagnosis and the corresponding management regimen.
- The patient will actively participate in lifestyle modification activities to stabilize glucose levels.
Assessment:
1. Monitor Blood Glucose Levels: Regularly assess blood glucose levels.
- Glucose monitoring remains a primary assessment to determine risk, guide treatment, and evaluate treatment response.
2. Assess Diabetes Knowledge: Evaluate the patient’s current knowledge and understanding of diabetes.
- Understanding the risks and implications of diabetes is fundamental to motivating patients to engage in necessary lifestyle modifications.
3. Assess Emotional Response to Diagnosis: Explore the patient’s feelings and emotional reactions to the diabetes diagnosis.
- Patients experience a wide range of emotional responses, including fear, anger, depression, disbelief, and denial.
- Negative emotions can significantly hinder adaptation to the disease and adherence to management.
- It’s crucial for the nurse to acknowledge and validate these feelings in a supportive manner.
4. Consider Cultural and Socioeconomic Factors: Note cultural, ethnic, socioeconomic, and religious factors that may influence diabetes recognition and care.
- These factors can significantly impact patients’ perceptions of diabetes, views on seeking and receiving care, dietary practices, and overall ability to manage their condition.
- Care plans must be culturally sensitive and tailored to individual circumstances.
Interventions:
1. Encourage Verbalization of Feelings: Encourage the patient to openly express their feelings and concerns about the diagnosis and required care.
- Verbalizing feelings can be cathartic and reduce emotional distress associated with the diagnosis.
2. Involve Patient and Family in Care Plan: Actively involve the patient and their family members (or significant others) in developing and implementing the care plan.
- Family support is crucial for successful diabetes management.
- Involving family promotes shared understanding, enhances support, and empowers the patient to make informed decisions about their health.
3. Promote Self-Monitoring System: Encourage the patient to develop a consistent system for self-monitoring blood glucose.
- Self-monitoring empowers patients, provides a sense of control over their condition, and allows them to track progress and make informed choices regarding diet, activity, and medication.
4. Refer to Community Resources: Connect the patient with appropriate community resources, such as diabetes educators, support groups, and financial assistance programs.
- Community resources enhance accessibility to healthcare services, education, and support networks.
- Diabetes education programs and support groups can improve adherence to management plans and facilitate positive adaptation to the diabetes diagnosis.
- Financial assistance programs can alleviate the financial burden of medications and supplies, improving access to essential care.
References
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- 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/
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- Understanding A1C | ADA. (n.d.). American Diabetes Association. Retrieved December 10, 2021, from https://www.diabetes.org/a1c
