Unstable blood glucose is a deviation from normal blood glucose levels that results in either hyperglycemia or hypoglycemia. Unstable blood glucose does not necessarily mean the patient is diabetic. For example, in temporary situations such as dehydration or pregnancy, blood sugar levels may return to normal when the source is resolved.
That being said, unstable glucose levels are a common problem for those with diabetes. Controlling glucose levels is important as untreated diabetes can result in long-term complications that affect almost every part of the body, such as the heart, kidneys, eyes, and nerves. Nurses should investigate the potential causes of unstable glucose levels and provide education and resources to patients and families to prevent the occurrence.
In this article:
- Risk Factors (Related to)
- Expected Outcomes
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- References
Risk Factors (Related to)
The following are common risk factors for unstable blood glucose:
- Denial of diagnosis
- Deficient knowledge of diabetes or treatment
- Poor adherence to diabetes management
- Financial strain
- Dietary intake
- Weight gain or loss
- Pregnancy
- Activity level
- Stress
- Developmental level
Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are aimed at prevention.
Expected Outcomes
The following are common nursing care planning goals and expected outcomes for risk for unstable blood glucose:
- Patient will identify factors that may contribute to unstable glucose.
- Patient will maintain blood glucose level within normal limits.
- Patient will demonstrate proper technique for monitoring glucose levels.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In the following section, we will cover subjective and objective data related to risk for unstable blood glucose.
1. Determine factors that increase the risk of unstable glucose.
Lack of access to medications, over or undereating, morbid obesity, lack of exercise or overexercising, growth spurts in adolescence, and pregnancy are common causes of unstable glucose.
2. Assess the patient’s understanding of their disease.
Allow time for open-ended questions and discussion to assess the patient’s knowledge of diabetes. Ask them how their insulin (or oral antidiabetic) works, why it is needed, how they should monitor their glucose, and how to recognize hyperglycemia or hypoglycemia. This allows the nurse to assess for a knowledge deficit and educate accordingly.
3. Assess for nonadherence.
Assess for missed doses of medications, inconsistent glucose monitoring, and poor diet adherence. Ask questions such as “How many doses of insulin have you missed in the last 2 weeks” or “What do you eat on an average day?”
4. Review all medications.
Review for other medications taken that could interfere with glucose levels. Some medications that may contribute to unstable blood sugars include, antidepressants, corticosteroids, oral contraceptives, antibiotics, some heart or blood pressure medications, and over-the-counter cold medicines.
5. Assess diet and eating patterns.
Inconsistent eating patterns can cause poor glucose control. Missed meals can lead to hypoglycemia, while diets high in carbohydrates and sugar cause hyperglycemia.
6. Assess alcohol intake.
Alcohol use impacts liver function, which is the organ that stabilizes glucose levels. If the liver is metabolizing alcohol, it may not control glucose levels, which can cause hypoglycemia, especially on an empty stomach or if taken with antidiabetic medications.
7. Assess family support.
Assess for a lack of support that may be causing issues with obtaining medications, administering insulin, or preparing food.
8. Monitor A1C.
Hemoglobin A1C results show average glucose levels over three months. It can be useful in monitoring how diabetes treatment is working over time. The goal for adults with diabetes is < 7%. An A1C higher than this points to poor glucose control.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient with a risk for unstable blood glucose.
1. Have patient bring glucose monitor and demonstrate use.
Ensure the monitor is working properly, and then observe the patient checking their glucose. Ensure they are performing all steps of the fingerstick correctly.
2. Have patient demonstrate insulin administration.
Ensure the patient understands how to draw up their insulin (or use the dial on an insulin pen) and that they are rotating subcutaneous fat sites and cleaning the site before injection.
3. Recommend keeping a glucose level log.
Provide the patient with a form or instruction to use a notebook and write down their glucose levels daily. This will help the provider understand any patterns and the need for any treatment changes.
4. Refer to a dietician.
Dieticians can instruct on specific dietary changes and provide resources on which foods to eat, what to limit, and how to read food labels.
5. Educate on signs of hyper/hypoglycemia and how to treat.
Provide education on signs of hyperglycemia: headache, dry mouth, increased thirst or hunger, and hypoglycemia: sweating/chills, shakiness, feeling lightheaded or dizzy. Tighter control of high blood sugar occurs with exercise and better eating habits. If hypoglycemic, eat a fast-acting glucose snack like juice or hard candy. Frequent episodes of hyper/hypoglycemia may need medication adjustment. It is also important to educate the patient about when hypo or hyperglycemia can become a medical emergency. Frequent episodes of hyper/hypoglycemia may need medication adjustment.
6. Teach ‘carb-counting’.
Instruct on different types of carbohydrates (sugars, starches, and fiber) and the effect of carbohydrates on blood glucose and insulin levels. Carbohydrates are measured in grams and 1 serving = 15 g of carbs. Each person will require an individualized amount of carbohydrates depending on their caloric intake, weight, and activity level.
7. Discuss healthy exercise habits.
Everyone should exercise to maintain cardiovascular health, control weight, improve mental health, and maintain glycemic control. Exercise lowers glucose and makes the body more sensitive to insulin. This is a good thing but can cause hypoglycemia if the patient does not monitor their medication and carbohydrate intake prior to physical activity.
8. Discuss other glucose monitoring systems.
For some patients a continuous monitor may allow for improved blood sugar control. The nurse can discuss with the provider whether they may be eligible for new technological devices such as Dexcom, a wearable continuous glucose device.
9. Involve a diabetes educator.
Most hospitals employ diabetes educators to educate diabetics on managing their disease. They can be powerful motivators to help them with behavior change to meet their health goals.
10. Offer resources for supplies.
Diabetic medications and supplies can be very costly. If a patient is at risk for unstable glucose due to a lack of ability to afford their insulin or supplies, there are financial resources and programs available they may be eligible for.
Nursing Care Plans
Nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for risk for unstable blood glucose.
Care Plan #1
Diagnostic statement:
Risk for unstable blood glucose related to pregnancy.
Expected outcomes:
- Patient will understand that pregnancy can lead to unstable glucose.
- Patient will maintain the following blood glucose levels:
- Preprandial: <95 mg/dl
- One hour postprandial: <140 mg/dl
- Two hours postprandial: <120 mg/dl
Assessment:
1. Evaluate the patient’s current knowledge and understanding of pregnancy and diabetes.
Hormonal changes during pregnancy increase their risk of developing diabetes. The patient should understand the risk factors for gestational diabetes and the importance of nutrition during pregnancy.
2. Obtain a medical and obstetrical history and note factors that heighten the risk for gestational diabetes.
Having a comprehensive medical and obstetrics history will help identify the level of risk of developing gestational diabetes and determine appropriate strategies to prevent or provide prompt treatment to address gestational diabetes.
3. Monitor blood glucose levels on the 24th and 28th week age of gestation.
Blood glucose screenings done on the 24th and 28th weeks of gestation will help prompt the detection of gestational diabetes.
Interventions:
1. Ensure that the patient knows the symptoms, causes, treatment, and prevention of hyperglycemia.
Elevated blood glucose levels in patients with previously-diagnosed diabetes indicate the need to evaluate diabetes management.
2. Teach the importance of at least 150 minutes/week of moderate-intensity aerobic physical activity for at least three days per week.
Regular physical activity improves the control of blood glucose levels, lowers cardiovascular risk factors, promotes weight loss, and enhances well-being.
3. Teach the importance of prenatal check-ups.
Prenatal care is essential to monitor both the mother and baby’s health. Glucose screening is done on the 24th or 28th week of gestation to detect gestational diabetes. Prompt diagnosis will help prevent maternal and congenital disabilities.
4. Consult with the dietitian about the appropriate meals for the patient.
Pregnant women are required to eat a balanced diet with various foods. They need to increase their calorie intake by around 300 more calories each day. Meal plans should focus on stabilizing blood glucose levels or preventing episodes of hypoglycemia or hyperglycemia.
Care Plan #2
Diagnostic statement:
Risk for unstable blood glucose related to lack of acceptance of the diagnosis.
Expected outcomes:
- Patient will verbalize an understanding of diabetes and the corresponding regimen.
- Patient will demonstrate lifestyle modification activities to stabilize glucose levels.
Assessment:
1. Obtain blood glucose levels.
Monitoring blood glucose levels remains one of the priority interventions to determine the risk, appropriate treatment, and treatment response.
2. Assess the patient’s current knowledge and understanding of diabetes.
Understanding the risk will help patients to engage in lifestyle modification behaviors to prevent diabetes.
3. Assess feelings towards the diagnosis of diabetes.
Patients have different reactions to the diagnosis of the disease. They may experience fear, anger, depression, disbelief, or other negative emotions that could hinder their adaptation to the disease. It is important for the nurse to acknowledge and normalize these feelings.
4. Note the influence of cultural, ethnic origin, socioeconomic, or religious factors impacting diabetes recognition and care (e.g., perceptions on diabetes, views of seeking and receiving care, dietary practices, etc.)
These factors influence patients’ ability to manage their condition and must be considered when planning care.
Interventions:
1. Encourage the verbalization of feelings towards diagnosis and care.
Verbalization of feelings may reduce distress to the patient.
2. Involve the patient and family in the plan of care.
Family members or others who are close to the patient may be able to help support the patient to make informed decisions for their health.
3. Encourage the patient to develop a system for self-monitoring.
This strategy will provide a sense of control and enable the patient to follow their progress and assist with making choices.
4. Refer to appropriate community resources (e.g., diabetic educators or support groups) for lifestyle modification, medical management, referral for an insulin pump or glucose monitor, financial assistance for supplies, and so forth.
Community resources increase accessibility to healthcare services and goods, promote compliance, and assist patients to adapt positively to their diabetes diagnosis. The groups may also help the patient come to terms with their diagnosis in the presence of others.
References
- Ackley, B.J., Ladwig, G.B.,& Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
- 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/
- Carb Counting. (n.d.). CDC. Retrieved December 10, 2021, from https://www.cdc.gov/diabetes/managing/eat-well/diabetes-and-carbohydrates.html
- 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. (2014). Nursing care plans Diagnoses, interventions, and outcomes (8th ed.). Elsevier.
- Understanding A1C | ADA. (n.d.). American Diabetes Association. Retrieved December 10, 2021, from https://www.diabetes.org/a1c
