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Unstable Blood Glucose Level | Nursing Care Plan for Diabetes Mellitus

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Nursing diagnosis: unstable blood Glucose Level related to Lack of diabetes management or adherence to diabetes action plan; inadequate blood glucose monitoring or medication management, Insulin deficiency—decreased uptake or utilization of glucose by the tissues resulting in increased protein and fat metabolism, Weight gain or loss, Rapid growth periods or pregnancy, Change in physical health status
Hypermetabolic state—release of stress hormones, such as epinephrine, cortisol, and growth hormone, Infectious process

Possibly evidenced by
Increased urinary output, dilute urine
Reported inadequate food intake, lack of interest in food
Weakness, fatigue, poor muscle tone
Altered level of consciousness (LOC)
Increased ketones

Desired Outcomes/Evaluation Criteria—Client Will
Blood Glucose Level
Maintain glucose in satisfactory range.
Diabetes Self-Management
Acknowledge factors that lead to unstable glucose and DKA.
Verbalize understanding of body and energy needs.
Verbalize plan for modifying factors to prevent or minimize complications.

Nursing intervention with rationale:
1. Determine individual factors that may have contributed to current situation. Note client’s age, developmental level, and awareness of needs.
Rationale: Occasionally client with unknown diabetes will present with DKA, especially a young person with some type of precipitating infection. However, many times DKA is precipitated by failure of diabetes management, possibly related to dietary factors, activity, or medications. Because DKA presents more frequently in the young client with type 1 diabetes, there may be a failure to account for developmental changes, such as an adolescent growth spurt or pregnancy.

2. Perform fingerstick glucose testing. Ascertain whether client and SO(s) are adept at blood glucose monitoring and are testing according to plan.
Rationale: All available glucose monitors will provide satisfactory readings if properly used and maintained and routinely calibrated. Note: Unstable blood glucose is often associated with failure to perform testing on a regular schedule.

3. For client on insulin: Review type(s) of insulin used, such as rapid, short-acting, intermediate, long-acting, premixed, and the delivery method—subcutaneous, inhaled, or pump. Note times when short-acting and long-acting insulins are administered.
Rationale: These factors affect timing of effects and provide clues to potential timing of glucose instability.

4. Review client’s dietary program and usual pattern; compare with recent intake.
Rationale: Identifies deficits and deviations from therapeutic plan, which may precipitate unstable glucose and uncontrolled hyperglycemia.

5. Weigh daily or as indicated.
Rationale: Assesses adequacy of nutritional intake—both absorption and utilization. Note: Eating disorders are a contributing factor in 20% of recurrent DKA in young clients.

6. Auscultate bowel sounds. Note reports of abdominal pain and bloating, nausea, or vomiting. Maintain nothing by mouth (NPO) status, as indicated.
Rationale: Hyperglycemia and fluid and electrolyte disturbances decrease gastric motility and function resulting in gastroparesis, affecting choice of interventions. Note: Long-term difficulties with gastroparesis and poor intestinal motility suggest autonomic neuropathies affecting the GI tract and requiring symptomatic treatment.

7. Provide liquids containing nutrients and electrolytes as soon as client can tolerate oral fluids; progress to more solid food as tolerated.
Rationale: Oral route is preferred when client is alert and bowel function is restored.

8. Identify food preferences, including ethnic and cultural needs.
Rationale: Incorporating as many of the client’s food preferences into the meal plan as possible increases cooperation with dietary guidelines after discharge.

9. Include SO in meal planning, as indicated.
Rationale: Promotes sense of involvement; provides information for SO to understand nutritional needs of client. Note: Various methods available for dietary planning include carbohydrate counting, exchange list, point system, or preselected menus.

10. Observe for signs of hypoglycemia—changes in LOC, cool and clammy skin, rapid pulse, hunger, irritability, anxiety, headache, lightheadedness, and shakiness.
Rationale: Once carbohydrate metabolism resumes, blood glucose level will fall, and as insulin is being adjusted, hypoglycemia may occur. If client is comatose, hypoglycemia may occur without notable change in LOC. This potentially lifethreatening emergency should be assessed and treated quickly per protocol. Note: Type 1 diabetics of long standing may not display usual signs of hypoglycemia because normal response to low blood sugar may be diminished.
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