- Acute Confusion related to inadequate glucose for cellular brain function evidenced by changes in mentation.
- Ineffective tissue perfusion related to impaired oxygen transport to the brain evidenced by changes in the level of consciousness.
- Deficient knowledge related to inadequate knowledge about hypoglycaemia as evidenced by development of hypoglycaemia and complications.
| Assessment | Nursing Diagnosis | Planning/Outcomes | Intervention | Evaluation |
| Subjective Data: Patient verbalizes irrelevantly Objective Data: -Changes in mentation -Agitation -Restlessness -Alteration in the level of consciousness -Alteration in psychomotor functioning -Misperception -Delirium -Failure to initiate purposeful or goal-directed behavior -Failure to follow commands | Acute Confusion related to inadequate glucose for cellular brain function evidenced by changes in mentation. | 1. Determine additional risk factors for confusion. Review the patient’s risk factors to determine if confusion is related to hypoglycemia or other conditions such as: -Low levels of oxygen (hypoxia) -Metabolic, endocrine, or neurological diseases -Toxins, electrolyte imbalances -Systemic or central nervous system infections -Nutritional deficiencies -Acute psychiatric disorders 2. Assess the patient’s mental status. Changes in mental status can occur abruptly and progress over hours or days. The nurse should closely monitor for subtle changes. 3. Monitor the patient’s blood glucose level. A change in mental status should always alert the nurse to obtain a glucose level. This is an easy and quick way to identify or rule out hypoglycemia. | 1. Manage the underlying condition. Confusion is a symptom of hypoglycemia. It is necessary to manage the underlying issue to resolve the confusion. 2. Review current medications and usage. A review of current medications and usage is important, particularly for diabetic patients. The common cause of hypoglycemia is excessive insulin administration. Ensure the patient understands how and when to administer insulin. 3. Provide safety. Worsening or unrecognized hypoglycemia can cause seizures or inappropriate behavior. It is the nurse’s responsibility to keep the patient safe in the event of a seizure and prevent the risk of injury through fall precautions. 4. Instruct on recognizing symptoms. Educate the patient and family on changes that signal hypoglycemia. These can be individualized for each patient and take time to recognize. A change in personality such as irritability, forgetfulness, slurred speech, drowsiness can be symptoms. 5. Teach how to administer glucose. In the hospital, the nurse can administer D50 IV to quickly treat hypoglycemia when the patient is not alert or oriented. Glucagon may be given IM, and the family can be educated on its administration. If the patient is capable of swallowing safely, juice, milk, or glucose gel can be given. | -Patients will be alert and oriented x4, or at their baseline level of cognition -Patient will verbalize 3 symptoms of confusion and change in cognition to monitor for. -Patient will not display a decrease in consciousness, restlessness, or agitation. |
| Subjective Data: -Increased leg warmth -Edema (Unilateral) -Pain during palpation of a calf muscle -Tenderness Objective Data: -Impaired Skin Integrity | Ineffective tissue perfusion related to impaired oxygen transport to the brain evidenced by changes in the level of consciousness. | To maintain optimal peripheral tissue perfusion in the affected extremity | -Assess the level of consciousness and changes in mentation. -Observe for generalized duskiness and cyanosis in the earlobes, lips, tongue, and buccal membranes. -Keep the head of the bed elevated. -This promotes maximal chest expansion, making it easier to breathe and enhancing physiological and psychological comfort. | Maintained optimal peripheral tissue perfusion in the affected extremity |
| Subjective Data: -Patient verbalizes I am unaware of these information’s Objective Data -Inaccurate follow-through of instructions -Inaccurate statements about a topic -Nonadherence to appointments or medications -Development of pneumonia or other complication | Deficient knowledge related to inadequate knowledge about hypoglycaemia as evidenced by development of hypoglycaemia and complications. | Assess the patient’s age and health literacy. Assess the patient’s willingness to learn. | -Provide accurate information about the disease process, prognosis, and treatment regimen. -Reinforce learning through the provision of repetitive and follow-up sessions -Encourage vaccinations. -Do not smoke or inhale toxins. -Wash hands and wear a mask. -Educate that antibiotics won’t help. -Include family members in patient education sessions. | -Patient will verbalize understanding of the causes of bronchitis and its treatment. -Patients will implement two strategies to prevent the recurrence of bronchitis. |