Nursing Care Plan on Hyperglycemia

Hyperglycaemia, a condition that is often associated with diabetes, means high blood glucose. This condition occurs when the body is not able to use insulin properly.

A blood glucose level over 125 mg/dL may be considered hyperglycemic while fasting, and over 180 mg/dL after eating. 

Causes and Complications

Hyperglycemia may be caused by various conditions including type 1 and 2 diabetes, endocrine disorders, pancreatic disorders, a sedentary lifestyle, stress, and medication side effects. 

Hyperglycemia is found through blood and urine tests. Symptoms of hyperglycemia include:

• Increased thirst (polydipsia)
• Frequent urination (polyuria)
• Increased hunger (polyphagia)
• Headache
• Fatigue
• Blurry vision

Uncontrolled hyperglycemia damages nerves and blood vessels and can cause complications such as cardiovascular disease, peripheral neuropathy, retinopathy, and nephropathy, as well as an increase in infections and decreased ability to heal.

Nursing Process

The primary goal for the management of hyperglycemia is to lower the blood glucose to the acceptable range and to promote patient education in the prevention of complications. The nurse plays an important role in health promotion and supportive care for patients with hyperglycemia.

Nursing Assessment

Proper assessment is the foundation of effective nursing care for hyperglycemia. Nurses should perform thorough evaluations to identify signs and symptoms, understand the underlying causes, and develop appropriate care plans.

1. Patient History

Gathering a comprehensive patient history is vital in understanding the context of hyperglycemia. This includes:

• Reviewing past medical history, including diabetes diagnosis and management
• Identifying medications, including insulin and oral hypoglycemics
• Assessing lifestyle factors such as diet, physical activity, and stress levels
• Noting recent illnesses, infections, or surgeries

2. Physical Examination

A detailed physical examination helps identify clinical signs of hyperglycemia, such as:

• Increased thirst (polydipsia)
• Frequent urination (polyuria)
• Unexplained weight loss
• Fatigue and weakness
• Blurred vision
• Fruity-smelling breath

3. Laboratory Tests

Laboratory tests are essential for diagnosing and monitoring hyperglycemia. Key tests include:

• Blood glucose levels (fasting, random, and postprandial)
• Hemoglobin A1c for long-term glucose control
• Urine tests for glucose and ketones
• Electrolyte levels to assess for imbalances

4. Continuous Glucose Monitoring

For patients with diabetes, continuous glucose monitoring (CGM) provides real-time data on glucose levels, helping to identify trends and make informed decisions about treatment.

Nursing Intervention

Effective intervention strategies are crucial for managing hyperglycemia and preventing complications. Nurses play a vital role in implementing these strategies through patient education, medication management, and lifestyle modifications.

1. Medication Administration

Medications are often necessary to control blood glucose levels. Nurses should ensure:

• Accurate administration of insulin or oral hypoglycemics
• Monitoring for side effects and adverse reactions
• Adjusting dosages based on blood glucose readings and physician orders

2. Nutritional Counselling

Diet plays a significant role in managing hyperglycemia. Nurses should provide guidance on:

• Maintaining a balanced diet with appropriate carbohydrate intake
• Understanding the impact of different foods on blood glucose levels
• Meal planning and portion control
• Avoiding sugary beverages and excessive fats

3. Physical Activity

Regular physical activity helps regulate blood glucose levels. Nurses should:

• Encourage patients to engage in moderate exercise, such as walking or swimming
• Educate on the benefits of physical activity for glucose control
• Advise on safe exercise practices and potential risks

4. Monitoring for Complications

Hyperglycemia can lead to serious complications if not managed properly. Nurses should be vigilant in:

• Monitoring for signs of diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS)
• Assessing for long-term complications such as neuropathy, retinopathy, and nephropathy
• Referring patients to specialists as needed for comprehensive care

5. Patient Education and Support

Educating patients and their families about hyperglycemia is crucial for effective management. Nurses should:

• Provide information on the causes and symptoms of hyperglycemia
• Teach self-monitoring techniques for blood glucose levels
• Discuss the importance of medication adherence and lifestyle modifications
• Address any concerns or anxieties the patient may have about their condition

Nursing Care Plans

Once the nurse identifies nursing diagnoses for hyperglycemia, 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 hyperglycemia.

Decreased Cardiac Output

Uncontrolled hyperglycemia can damage blood vessels leading to reduced cardiac output.

Nursing Diagnosis: Decreased Cardiac Output

Related to:

• Elevated blood glucose levels
• Alterations in myocardial contractility
• Vasoconstriction
• Increased cardiac inflammation
• Reduced cardiac oxygenation

As evidenced by:

• Tachycardia
• Tachypnea
• Dyspnoea
• Orthopnea
• Reduced oxygen saturation
• Hypotension
• Fatigue
• Anxiety/Restlessness
• Decreased activity tolerance
• Weak peripheral pulses
• Oliguria

Expected outcomes:

• Patient will manifest adequate cardiac output as evidenced by the following:
  • Stable vital signs
  • Urine output 0.5 to 1.5 cc/kg/hour
  • Absence of arrhythmia
• Patient will adhere to lifestyle modifications of exercise and weight loss.

Assessment:

1. Monitor vital signs.
Patients with decompensating heart function experience unstable vital signs such as tachycardia, hypotension, and tachypnea.

2. Review diagnostic results.
Patients at risk for heart disease or heart failure should receive echocardiograms or stress tests to monitor the heart and its function.

3. Assess cardiac enzymes.
Elevated cardiac enzymes (troponin, CK-MB, BNP) indicate cardiac tissue damage.

Interventions:

1. Discuss cholesterol numbers.
Hyperglycemia increases the risk of hypercholesterolemia. Discuss optimal LDL, HDL, and triglyceride levels with the patient and ensure patients receive screenings as instructed.

2. Obtain an EKG.
An EKG can detect dysrhythmias like STEMI that require immediate intervention.

3. Advise on adherence to all medications.
Along with insulin and antidiabetic drugs, patients must strictly adhere to their regimen of antihypertensives, vasodilators, diuretics, and statins to reduce the risk of cardiac complications.

4. Educate on symptoms of heart disease or heart failure.
The patient should address new or worsening symptoms with their healthcare provider:

• Chest pain
• Dyspnea
• Dizziness
• Syncope
• Edema
• Activity intolerance

Deficient Knowledge

A lack of knowledge or understanding of an underlying health condition, medication regimen, diet, and more can result in hyperglycemia.

Nursing Diagnosis: Deficient Knowledge

Related to:

• Misinformation
• Inadequate access to resources 
• Inadequate awareness of resources 
• Inadequate information 
• Inadequate interest in learning
• Inadequate participation in care planning 
• Inadequate trust in healthcare professionals
• Misinterpretation of information

As evidenced by:

• Inaccurate follow-through of instructions 
• Uncontrolled glucose levels
• Inaccurate statements about hyperglycemia 
• Development of preventable complications

Expected outcomes:

• Patient will verbalize the relationship between glucose and insulin.
• Patient will verbalize how and when to administer insulin.

Assessment:

1. Assess the patient’s learning abilities and motivation to learn.
Learning is only effective when the patient is ready and willing to learn. The patient’s ability to learn may be an obstacle but the learning process can be adjusted and use appropriate learning techniques to meet the patient’s learning style.

2. Assess current understanding.
A patient’s lack of follow-through may be mistaken for deficient knowledge. Before providing education, discuss what the patient currently understands about hyperglycemia so as not to patronize or offend them.

Interventions:

1. Encourage the patient and family members to take part in the learning process.
A combination of teaching methods adapted to the patient’s learning styles shows efficient outcomes. Involving family members in the learning process encourages support and allows both the patient and family members to better understand the health condition.

2. Reinforce patient education through frequent repetition.
Repeated and continuous education sessions about glucose management and treatment support follow-through.

3. Begin with the most vital information.
Managing diseases such as diabetes requires a life-long commitment. Determine what is most critical and remind the patient that change doesn’t happen overnight, but with consistent behavior change.

4. Refer the patient to a dietician.
A dietician can provide the patient with appropriate carbohydrate counting instructions. Monitoring carbohydrate intake is a key strategy in effectively achieving glycemic control.

Ineffective Health Maintenance

Hyperglycemia can occur due to unhealthy practices like a diet high in carbohydrates, a sedentary lifestyle, and failure to take insulin medications correctly.

Nursing Diagnosis: Ineffective Health Maintenance

Related to:

• Competing demands 
• Insufficient resources 
• Conflict between cultural beliefs and health practices 
• Conflict between health behaviors and social norms
• Difficulty with decision-making 
• Inadequate social support
• Ineffective coping strategies

As evidenced by:

• Failure to take action that prevents health problems 
• Inability to take responsibility for health actions
• Inadequate commitment to a plan of action
• Inadequate interest in improving health 
• Inadequate knowledge of basic health practices 
• History of poor decision-making 
• A pattern of lack of health-seeking behavior

Expected outcomes:

• Patient will demonstrate lifestyle changes that promote effective health maintenance.
• Patient will verbalize factors that contribute to hyperglycemia.

Assessment:

1. Assess the patient’s beliefs about proper health management.
Personal and cultural beliefs along with decision control preferences, values, and perceptions can affect the patient’s decision-making regarding health management behaviors.

2. Note desire and ability to meet needs.
Assess the patient’s motivation to change behaviors as well as their ability to make decisions and perform/participate in health maintenance.

3. Assess resource barriers.
Assess for possible financial, transportation, and equipment barriers as well as the patient’s living arrangements and need for physical support.

Interventions:

1. Develop realistic goals.
Patients may be unwilling to change their lifestyles but developing small goals that can be met such as cutting back on desserts or walking twice a week can be a compromise.

2. Teach the patient ways to manage complex medication schedules.
If the patient displays difficulty adhering to their medication schedule, help them develop reminders such as alarms, pill boxes, signage, etc., that supports adherence.

3. Refer to community support programs.
The patient may require home health support, social worker assistance, or even skilled nursing services in order to meet their health and safety requirements.

4. Teach the patient ways to manage stress.
Stress can be a major factor in managing health maintenance behaviors. If the patient is burdened by other roles such as caregiving, parenting, or career responsibilities, their health may not be a priority.

5. Assist the patient to develop confidence in managing the health condition.
Self-management education improves physiological outcomes, effective healthcare use, and enhanced coping techniques.

Ineffective Tissue Perfusion

Consistent elevation of blood glucose levels causes endothelial damage that leads to impaired oxygenation and microvascular and macrovascular changes.

Nursing Diagnosis: Ineffective Tissue Perfusion

Related to:

• Interruption in blood flow
• Elevated blood glucose level
• Sedentary lifestyle
• Smoking
• Insufficient knowledge of hyperglycemia and its management
• Poor control of chronic health conditions

As evidenced by:

• Claudication
• Decreased peripheral pulses
• Capillary refill time >2 seconds
• Cool, clammy skin
• Ankle-brachial index < 0.9
• Alteration in sensation
• Paresthesia

Expected outcomes:

• Patient will maintain optimal peripheral tissue perfusion as evidenced by the following:
  • BP within normal limits
  • Warm and dry extremities
  • Capillary refill time of <2 secs
  • Palpable pulses
• Patient will verbalize two modifiable risk factors they can improve upon to increase tissue perfusion.

Assessment:

1. Assess for pain in the extremities.
In patients with arterial insufficiency, pain is experienced while walking that is relieved by rest. Venous insufficiency causes aching, cramping, or heaviness in the legs.

2. Note skin texture, color, and temperature.
The nurse may observe shiny skin to the lower legs, pallor, rubor, swelling, and coolness, which signals poor circulation.

Interventions:

1. Encourage exercise.
Bike riding and walking can improve arterial insufficiency.

2. Instruct on when to elevate legs.
Legs should not be elevated with arterial insufficiency as this decreases circulation to the legs, but legs should be elevated with venous insufficiency to reduce swelling.

3. Encourage to stop smoking.
Smoking and hyperglycemia create a synergistic yet preventable factor in increasing the risk for the development of peripheral artery disease (PAD). Cigarette smoke induces pathological changes such as endothelial damage and plaque buildup, reducing perfusion.

4. Inform the client to avoid exposure to extreme temperatures.
PAD and diabetic neuropathy alter skin sensation. The patient may not recognize if the temperature is too hot or cold, which can lead to injury.

Risk for Unstable Blood Glucose

Patients who experience hyperglycemia are known to be susceptible to variations in serum levels of glucose. If left untreated, this condition could compromise the patient’s health and result in further complications.

Nursing Diagnosis: Risk for Unstable Blood Glucose

Related to:

• Diabetes mellitus
• Medication side effects
• Infections
• Pancreatic diseases 
• Ineffective health management behaviors
• Ineffective medication management
• Ineffective weight management 
• Inadequate glucose monitoring
• Dietary intake
• Pregnancy
• Stress

As evidenced by:

A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet and nursing interventions are directed at the prevention of symptoms.

Expected outcomes:

• Patient will demonstrate behaviors that improve hyperglycemia and maintain blood glucose levels within normal range.
• Patient will verbalize two strategies to prevent hyperglycemia.

Assessment:

1. Assess laboratory values.
Blood glucose levels are monitored through laboratory tests like HbA1C and fingerstick glucose tests. Alterations in these laboratory values can indicate an underlying condition like diabetes. Urinalysis can check for high ketone levels which indicates ketoacidosis and requires immediate medical attention.

2. Assess the patient’s understanding of glucose.
Ensure the patient understands their disease process and how glucose is affected by insulin.

Interventions:

1. Administer medications as indicated.
Insulin and other antidiabetic agents may be administered to help lower blood glucose levels.

2. Instruct on the use of glucometers or other equipment.
To properly assess and manage hyperglycemia, the patient must understand how to check their glucose levels. Observe them using their glucometer for accuracy. Some patients may benefit from a Dexcom which is a wearable continuous glucose monitoring device.

3. Monitor for any signs of hypoglycemia.
Blood glucose levels can fluctuate and hypoglycemia may occur if hyperglycemia is overcorrected. Signs and symptoms of hypoglycemia include dizziness, shakiness, sweating, headache, pallor, confusion, seizures, and mental status changes.

4. Encourage the patient to maintain a blood glucose log.
A blood glucose log can help track the patient’s responses to the treatment regimen and determine if those treatments are effective or need alteration.

5. Encourage lifestyle modifications.
Lifestyle modifications including healthy eating habits and exercise can maintain normal glucose levels and prevent hyperglycaemia.

Nursing Diagnoses and Rationales for Hyperglycaemia

1. Risk for Unstable Blood Glucose Levels

Rationale: Hyperglycemia can result from inadequate insulin production or action, excessive carbohydrate intake, or stress. Monitoring blood glucose levels regularly and educating patients on the importance of medication adherence, dietary modifications, and stress management can help maintain stable blood glucose levels.

2. Deficient Knowledge

Rationale: Patients may lack understanding of hyperglycemia, its causes, symptoms, and management. Providing education on the importance of lifestyle changes, medication adherence, blood glucose monitoring, and recognizing signs of hyperglycemia can empower patients to manage their condition effectively.

3. Risk for Fluid Volume Deficit

Rationale: Hyperglycemia can lead to osmotic diuresis, causing excessive fluid loss. Patients may experience increased thirst and dehydration. Monitoring fluid balance, encouraging adequate fluid intake, and assessing for signs of dehydration (e.g., dry mucous membranes, decreased urine output) are essential for maintaining hydration.

4. Imbalanced Nutrition: More Than Body Requirements

Rationale: Poor dietary choices and excessive carbohydrate intake can contribute to hyperglycemia. Assessing the patient’s dietary habits and providing nutritional education on balanced meals, portion control, and the impact of carbohydrates on blood glucose levels can promote better nutritional management.

5. Risk for Infection

Rationale: Hyperglycemia can impair immune function, increasing the risk of infections such as urinary tract infections and skin infections. Educating patients on maintaining proper hygiene, monitoring for signs of infection, and seeking prompt medical attention for any signs of infection can help prevent complications.

6. Fatigue

Rationale: Hyperglycemia can cause fatigue due to the body’s inability to effectively use glucose for energy. Assessing the patient’s energy levels, encouraging regular physical activity, and providing strategies for managing fatigue can help improve the patient’s overall well-being.

7. Risk for Electrolyte Imbalance

Rationale: Osmotic diuresis caused by hyperglycemia can lead to the loss of electrolytes such as sodium and potassium. Monitoring electrolyte levels and ensuring appropriate supplementation when necessary can help maintain electrolyte balance and prevent complications.

8. Ineffective Coping

Rationale: The chronic nature of hyperglycemia and the need for continuous self-management can be overwhelming for patients. Assessing the patient’s coping mechanisms, providing emotional support, and connecting patients with support groups or counseling services can enhance their ability to manage their condition effectively.

9. Risk for Impaired Skin Integrity

Rationale: Hyperglycemia can lead to poor wound healing and increased susceptibility to skin infections. Regularly assessing the patient’s skin, educating on proper skin care, and encouraging prompt treatment of any skin issues can help maintain skin integrity.

10. Risk for Complications

Rationale: Chronic hyperglycemia is associated with long-term complications such as cardiovascular disease, neuropathy, nephropathy, and retinopathy. Educating patients about the importance of regular follow-up appointments, adherence to prescribed treatments, and lifestyle modifications can help prevent and manage these complications.

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