00179 Unstable Blood Glucose Level

Domain 2: nutrition
Class 4: metabolism
Diagnostic Code: 00179
Nanda label: unstable blood glucose level
Diagnostic focus: glycemia
Approved 2006 • Revised 2013, 2017, 2020 • Level of evidence 3.2

NANDA Nursing Diagnosis Definition

Nanda nursing diagnosis « unstable blood glucose level is defined as: susceptible to variation of serum glucose levels outside normal levels, which can compromise health. P>

Risk factors

  • Excessive stress
  • Excessive weight increase
  • Excessive weight loss
  • Adhesion inadequate to the treatment regime
  • Inadequate personal monitoring of glucose
  • Personal management of inadequate diabetes
  • Inadequate intake dietary habits
  • Inappropriate knowledge of disease management
  • Insufficient knowledge of modifiable factors
  • INEFICA MANAGEMENT OF MEDICATION
  • Sedentary lifestyle

Risk population

  • People who experience a quick growth period
  • People in intensive care units
  • People of African descent
  • People with altered mental state
  • People with a state of committed physical health
  • People with delay in cognitive development
  • People with family history of diabetes mellitus
  • People with a history of autoimmune disorders
  • People with a history of gestational diabetes
  • People with a history of hypoglycemia
  • People with overweight history before pregnancy
  • Infants with low birth weight
  • American native people
  • Pregnant women> 22 years of age
  • Premature infants
  • Women with hormonal changes indicative of normal changes for the vital stage

Associated problems

  • Cardiogenic shock
  • Diabetes mellitus
  • Infections
  • pancreatic diseases
  • Pharmacological preparations
  • Polycystic Ovary Syndrome
  • Preeclampsia
  • Pregnancy induced hypertension
  • Surgical procedures

Suggestions of use

It is recommended to use this diagnosis in those situations in which nursing actions may have a remarkable effect on prevention. When nursing actions basically consist of watching blood glucose and collaborating, it could be better to use the collaboration problem possible complication of (inserting the physiological state: hypoglycemia/hyperglycemia). If glucose concentrations are really abnormal, use hyperglycemia or hypoglycemia

Suggested alternative diagnostics

  • Hyperglycemia
  • Hypoglycemia

NOC Results

  • Diabetes self -control: personal actions aimed at controlling diabetes mellitus, treatment and avoiding the progression of the disease
  • Adhesion behavior: healthy diet: personal actions to monitor and optimize a nutritious and healthy diet
  • Knowledge: Diabetes control: scope of knowledge transmitted by the patient about diabetes mellitus, their treatment and the prevention of complications
  • Weight control: personal actions to achieve and maintain optimal body weight
  • Blood glucose levels: measure in which blood and urine glucose levels remain in normal limits

Evaluation objectives and criteria

  • Stable blood glucose level, as evidenced by blood glucose, glucosylated hemoglobin, urine glucose and urinary ketones (specify from 1 to 5: severe, substantial, moderate, mild or absent deviation in terms of values ??in terms of values normal)
  • Controlled risk factors, manifested by the consistent demonstration of adhesion behavior: healthy diet, diabetes self -control, extensive knowledge: diabetes management, weight control and without deviation in blood glucose levels

    Other examples

    The patient will be able to:

    • Demonstrate the correct procedure to measure blood glucose
    • Follow the prescribed regime to control blood glucose
    • Comply with the recommendations concerning diet and exercise
    • Demonstrate the correct procedures of administering medications
    • Describe the symptoms of hypoglycemia and hyperglycemia

    Note : The objectives of this diagnosis should focus on preventing the instability of blood glucose instead of in the management, in the long term, of diabetes. Therefore, the objectives concerning the care of the feet, ophthalmological examinations, etc.

    are not described here.

    NIC Interventions

    • Teaching: prescribed diet: prepare a patient to correctly follow the prescribed diet
    • Teaching: Individual: Planning, implementation and evaluation of an educational program designed to address the specific needs of a patient
    • Teaching: prescribed medication: prepare a patient to correctly take the prescribed medications and monitor their effects
    • Teaching: disease process: help the patient to understand information related to a specific disease process
    • Hyperglycemia management: Prevent and treat the elevations of blood glucose levels
    • Hypoglycemia management: Prevent and treat blood glucose levels below normal values ??
    • Surveillance: Collection, interpretation and synthesis of patient data, continuous and determined, to make clinical decisions

    Nursing Activities

    Nursing activities in this diagnosis focus on the surveillance of the signs and symptoms of hypoglycemia or hyperglycemia, the reduction of risk factors and the teaching of self -regulation of glucose concentrations. They do not involve the management of diabetes in the long term, so that teachings about feet care (for example) are not included in this section. For the management of the elevation and decrease in glucose concentrations, see the diagnoses of hypoglycemia and hyperglycemia.

    Valuations

    • Evaluate the factors that increase the risk of glucose decompensations
    • Monitor blood glucose concentration (below 60 mg/dl indicates hypoglycemia; above 300 mg/dl, hyperglycemia) according to treatment orders or protocols
    • Control ketones in urine
    • Monitor intake and excretion
    • Monitor the appearance of symptoms and signs of hypoglycemia (for example, blood glucose <60 mg/dl, paleness, tachycardia, diaphoresis, restlessness, blurred vision, irritability, chills, cold sweat, wet skin, confusion)
    • Monitor the appearance of symptoms and signs of hyperglycemia (for example, blood glucose> 300 mg/dl, ketone breath, positive blood ketones, headache, blurred vision, nausea, vomiting, polyuria, polydipsia, polyphia, weakness, weakness, weakness, weakness, weakness, weakness. lethargy, hypotension, tachycardia, kussmaul breathing)
    • Determine the causes of hypoglycemia and hyperglycemia, if they occur

    Patient and family education

    • Give information about diabetes
    • Inform about the usefulness of the diet and exercise to make glucose balancing
    • Give information about medicines used to control diabetes
    • Inform about the management of diabetes during the course of other diseases
    • Provide information on the self -control of glucose concentrations and ketones, if necessary

    Collaboration activities

    • Collaborate with the patient and the diabetes team to modify the pharmacological treatment, if necessary
    • Notify the doctor when signs and symptoms of hypoglycemia or hyperglycemia appear, and cannot be controlled with nursing activities

    Others

    • (NIC) Hippoglycemia Management:
      • Administer simple carbohydrates, if indicated
      • Administer complex carbohydrates and proteins, if indicated
      • Keep via IV, if necessary