Nursing diagnosis: Risk for Unstable Bood Glucose Level
Risk factors may include
Decreased insulin production, increased glucagon release
Physical health status, stress
Possibly evidenced by
(Not applicable; presence of signs and symptoms establishes an actual diagnosis)
Desired Outcomes/Evaluation Criteria—Client Will
Maintain glucose in satisfactory range.
Nursing intervention with rationale:
1. Note signs of increased thirst and urination or changes in mentation and visual acuity.
Rationale: May warn of developing hyperglycemia associated with increased release of glucagon (damage to alpha cells) or decreased release of insulin (damage to beta cells).
2. Perform and monitor results of bedside fingerstick glucose testing and dipstick testing of urine for sugar and acetone (ketones).
Rationale: Early detection of inadequate glucose utilization may prevent development of hyperglycemic crisis. IV insulin may be required to control serum glucose within normal ranges.
3. Monitor serum glucose, as indicated.
Rationale: Indicator of insulin needs because hyperglycemia is frequently present, although not usually in levels high enough to produce ketoacidosis.
4. Provide insulin, as appropriate.
Rationale: Corrects persistent hyperglycemia caused by injury to cells and increased release of glucocorticoids. Insulin therapy is usually short-term unless permanent damage to pancreas occurs.
5. Advance diet as tolerated and based on specific nutritional needs.
Rationale: Loss of pancreatic function or reduced insulin production may require initiation of a diabetic diet.