Medical Diagnoses: Risk for unstable blood
glucose
Assessment
|
Nursing DX/
Clinical Problem
|
Client Goals/
Desired Outcomes
|
Nursing Interventions/Actions/Orders and Rationale
|
*I
|
Evaluation
|
Goals
|
Interventions
|
Subjective
∙
Husband’s “income is
variable dependent on work”
∙ Client has gestational diabetes
Objective
∙
1 Hour GTT: 145
∙
3 Hour GTT: Fasting- 100 1 Hour-
195 2 Hour- 165 3 Hour- 170
|
Problem
Risk for unstable blood glucose
|
Long Term:
Client
will maintain fasting blood glucose level 105 mg/dL, 1-hour after the meal (pc)
level 155 mg/dL, and 2-hour pc level 130 mg/dL until the EDD (xxxxx)
(Ackley &
Ladwig, 2008).
|
∙
Monitor
blood glucose before meals and at bedtime. (Self-monitoring of blood glucose is
an easy, less intensive way to help reach blood glucose goals)
(Ackley & Ladwig, 2008).
∙
Monitor for signs and symptoms
of hyperglycemia, such as polydipsia, polyuria, and polyphagia. (Being aware of
blood glucose levels outside of normal allows for early detection and treatment
before progressing to ketoacidosis or other more serious conditions)
(Ackley & Ladwig,
2008).
|
|
A goal would be met if the client’s blood glucose levels
are between or below the targeted levels. A goal that is not successfully met would
be shown by glucose levels being above the targeted levels.
|
∙
If the client verbalizes self-monitoring blood glucose levels before meals and at
bedtime then the intervention has been successfully carried out. If the client does
not monitor blood glucose levels before meals and at bedtime the intervention is
not successfully
∙
If the client can verbalize several signs and symptoms of hyperglycemia the intervention
would be successfully carried out. If the client can not, the intervention is not
successfully met.
|
Risk Factors
Pregnancy, stress (Ackley & Ladwig, 2008).
|
Short Term:
Client will verbalize self-care
actions to take if blood glucose is too high or too low a week from the date of
care, xxxxx (Ackley & Ladwig, 2008).
|
∙
Teach client to maintain a blood glucose diary. (Keeping a diary can help clients
realize what symptoms are related to blood glucose readings, as well as guide diabetes
treatment) (Ackley
& Ladwig, 2008).
∙ Teach clients who are treated with insulin that they
may need to eat extra carbohydrates before exercise, depending on how exercise affects
their blood glucose levels. (Taking glucose before exercise can help prevent hypoglycemia)
(Ackley &
Ladwig, 2008).
∙
Teach client that stopping
insulin therapy can lead to hyperglycemic crisis (ketoacidosis or hyperosmolar hyperglycemia).
Ensure client has resources to purchase insulin. (Diabetes can be a particularly
expensive disease to cope with, but it is important to continue therapy)
(Ackley & Ladwig,
2008).
|
|
The goal would be successfully met if the client can verbalize
5 self-care actions to take if blood glucose is too high or too low on xxxxxx. If the client can not verbalize 5 self-care actions the goal would not be
successfully met.
|
∙
If the client either verbalize having kept a blood glucose diary, or can present
a blood glucose diary this intervention would be successful. If not, the intervention
would be unsuccessful.
∙
The intervention would be successful if the client verbalizes having consumed extra
carbs or glucose before exercising. If the client can not do this the intervention
is not successful.
∙
The intervention would be successful if the client verbalizes continuing insulin
therapy. If the client can not do this the intervention is not successful.
|
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