Last updated on May 16th, 2022 at 04:54 pm
Hyperglycemia Nursing Care Plans Diagnosis and Interventions
Hyperglycemia NCLEX Review and Nursing Care Plans
Hyperglycemia is the medical term used to describe high glucose levels in the bloodstream. High blood sugar occurs when the body has insufficient insulin or cannot utilize insulin adequately.
Furthermore, numerous factors, notably diet and physical activity preferences, comorbidities, non-diabetes maintenance medications, and omitting or not taking enough glucose-lowering medicine can all lead to hyperglycemia, especially in diabetic patients.
Additionally, hyperglycemia must be addressed immediately. If left untreated, it can progress to chronic hyperglycemia which can lead to serious health consequences needing emergency medical care, such as a diabetic induced coma.
Prolonged hyperglycemia can also lead to health issues which may cause damage to the eyes, kidneys, nerves, and heart in the long run.
Causes of Hyperglycemia
Hyperglycemia can result from various causes, including:
- Not receiving the correct insulin or other glucose-lowering medicine dosages.
- Consuming a greater quantity of carbohydrates than usual
- Having a lower level of physical activity than typical
- Disease or infection
- Significant levels of anxiety
- Physical trauma, such as orthopedic injury
- Dawn phenomenon: Increased cortisol and growth hormone hormones cause the dawn phenomenon. These hormones stimulate the liver to produce additional glucose, which gives an individual the energy needed to wake up.
Risk Factors to Hyperglycemia
Numerous factors can trigger hyperglycemia, which include:
- Diabetes Mellitus or a history of diabetes type 2 in the family
- A previous history of gestational diabetes
- For women, medical history of PCOS (Polycystic Ovary Syndrome)
- Obesity or excess weight
- Hyperlipidemia. It is defined as having lipid levels in the blood greater than average.
- Hypertension or High blood pressure
- Inadequate use of insulin or oral diabetes medicine
- Incorrect insulin injection or use of expired insulin
- The patients are not adhering to their diabetes dietary plan.
- Inactive lifestyle
- Having a disease or infection
- Utilization of some drugs, such as steroids
- Physical injury or undergoing surgery
- Emotional stressors such as family discord or professional issues
Disease or stress can induce hyperglycemia because the hormones released to counteract illness or stress might cause the blood sugar to rise.
Even those individuals without diabetes may experience transitory hyperglycemia during severe infection. Patients with diabetes, on the other hand, may need to take more diabetes medicine to keep blood glucose levels close to normal during sickness or tension.
Signs and Symptoms of Hyperglycemia
Symptoms of hyperglycemia do not appear until glucose levels are sufficiently increased — typically beyond 10 to 11.1 millimoles per liter (mmol/L), or 180 to 200 milligrams per deciliter (mg/dL). Hyperglycemia symptoms appear gradually over several days or even weeks.
The more prolonged blood glucose levels remain elevated, the more severe the symptoms develop. Nevertheless, some patients with type 2 diabetes who have had it for an extended time may not have any symptoms while having high blood glucose levels.
Early warning signs and symptoms
Recognizing hyperglycemia’s early signs and symptoms can help manage the illness as soon as possible. Look out for the following signs:
- Polyuria (Urination that occurs frequently)
- Polydipsia (heightened thirst)
- Polyphagia (Excessive hunger)
- Blurry vision
- Exhaustion
- Migraine
Signs and Symptoms that appear later:
If hyperglycemia is not addressed, harmful acids (ketones) can accumulate in the blood and urine (ketoacidosis). Among the signs and symptoms are:
- Sweet-smelling breath
- Vomiting and nausea
- Breathing difficulty
- Mouth dryness
- Ataxia
- Confusion
- Coma
- Pain in the abdomen
Diagnosis of Hyperglycemia
- Monitoring of target blood sugar levels. Below is the suggested target blood sugar levels before meals for many people with diabetes:
- Around 4.4 and 6.7 mmol/L (80 and 120 mg/dL) in adults aged 59 and under without any other significant health issues.
- Around 5.6 and 7.8 mmol/L (100 and 140 mg/dL) for those aged 60 and older, those with other medical disorders such as cardiac, pulmonary, or renal disease, or those with a history of hypoglycemia (low blood sugar) or difficulties identifying hypoglycemia manifestations.
- However, The target blood sugar range may fluctuate, mainly if the patient is pregnant or has diabetes problems. Individuals’ target blood sugar ranges may also shift as they age. Maintaining the target blood sugar range can be challenging at times.
- Regular Blood Sugar Monitoring. Frequent blood sugar monitoring with a glucose meter is the most reliable technique to ensure that the treatment regimen sustains blood sugar levels within the target range. Monitor the patient’s glucose levels as frequently as the doctor suggests.
- Over-the-counter Urine Ketone Test Kits. Use an over-the-counter urine ketones test kit if the blood sugar level is 240 mg/dL (13.3 mmol/L) or higher. If the urine test yields a positive result, it means that the body has begun to undergo the changes that contribute to diabetic ketoacidosis.
- Hb-A1C test for hemoglobin. The doctor may perform an A1C test during a consultation. This blood test determines the average blood sugar level during two to three months. It also calculates the amount of blood glucose bound to the oxygen-carrying polypeptide in red blood cells, known as hemoglobin. Here is the reference range of the diagnostic procedure:
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- An A1C level of 7% or less indicates that the treatment regimen is successful and that the blood sugar levels were regularly within the desired range.
- If the A1C level is greater than 7%, the blood sugar was likely beyond the standard limit. In this scenario, the doctor may suggest altering the diabetes therapeutic approach.
Treatment for Hyperglycemia
- Home Care. Discuss blood sugar management with the doctor and learn how several therapies can help keep the glucose levels within the target range. The health care provider may advise the patient to try the following treatment options:
- Maintain an active lifestyle. Regular exercise is generally an efficient strategy to control blood sugar. Nevertheless, if ketones are detected in the urine, the patient should not exercise. This condition can cause blood sugar to rise considerably further.
- Take the medication exactly as prescribed. If the patient suffers frequent episodes of hyperglycemia, the doctor may change the medication’s dosage or schedule.
- Stick to the diabetes diet plan. It is beneficial to consume smaller meals, avoid sweetened drinks, and snack frequently. If the patient has problems keeping to the food plan, seek advice from the doctor or a nutritionist.
- Monitor the blood sugar levels regularly. The blood glucose levels should be monitored as advised by the doctor. If the patient is sick or worried about severe hyperglycemia or hypoglycemia, check the blood sugar levels more frequently.
- To treat hyperglycemia, adjust the insulin dosage. Adjustments to the insulin protocol or a short-acting insulin injection can help reduce hyperglycemia. A supplement is an additional insulin dosage used to reduce a high blood sugar level temporarily.
- Emergency Treatment for Severe Hyperglycemia. If the patient develops diabetic ketoacidosis or a hyperglycemic hyperosmolar condition, they may be treated in an emergency department or can be hospitalized. Emergency treatment can restore the blood sugar to normal levels. Typical treatment includes:
- Replacement of fluids. The patient will be given fluids — usually intravenously — until rehydration. The fluids replace those lost through excessive urine and dilute unwanted glucose in the bloodstream.
- Replacement of electrolytes. Electrolytes are minerals in the blood that the tissues require to function effectively. The lack of insulin might cause a decrease in the levels of many electrolytes in the blood. Electrolytes will be delivered to the veins to help maintain the heart, muscles, and nerve cells operating normally.
- Insulin administration. Insulin works by reversing the events that cause ketones to accumulate in the blood. The patient will be given insulin therapy, customarily administered intravenously, along with fluids and electrolytes.
Prevention of Hyperglycemia
A few lifestyle modifications could help in avoiding the development of hyperglycemia. Try the following suggestions:
- Regularly test the blood sugar level. Test and record the blood glucose levels daily. At each appointment, bring this information to the doctor’s attention.
- Control the carbohydrate consumption. Keep track of how many carbohydrates are consumed at each meal and snack. Make an effort to keep within the range prescribed by the doctor or nutritionist. Keep this information with the blood glucose level records.
- Be diabetes-aware. Make a plan for what to do if and when the blood glucose levels rise to a certain level. Take the antidiabetic medication as directed, and keep track of the amount and timing of the meals and snacks.
- Alcoholic beverages should be consumed in moderation. Although hypoglycemia is the more common outcome, excessive alcohol consumption might eventually lead to elevated blood glucose levels. Select a beverage that is minimal in refined carbohydrates.
- Wear a medical identifying bracelet. If there is a more significant problem, medical wristbands or necklaces can alert emergency workers to diabetes.
Nursing Diagnosis for Hyperglycemia
Hyperglycemia Nursing Care Plan 1
Risk for Unstable Blood Glucose
Nursing Diagnosis: Risk for Unstable Blood Glucose related to lack of understanding about diabetes treatment or glucose levels control, insufficient monitoring of blood glucose levels, insulin shortage or overproduction, and noncompliance to diabetes treatment programs secondary to hyperglycemia.
As a risk nursing diagnosis, Risk for Unstable Blood Glucose is entirely unrelated to any signs and symptoms since it has not yet developed in the patient, and safety precautions will be initiated instead.
Desired Outcome: After following all the nursing interventions, the patient’s blood glucose level will be less than 180 mg/dL, his fasting blood glucose level will be less than 140 mg/dL, and his hemoglobin A1C level will be 7%.
| Hyperglycemia Nursing Interventions | Rationale |
| Assist the patient in identifying dietary habits that should be changed. | This information serves as the foundation for personalized dietary advice relating to the medical situation that causes glucose levels fluctuations. |
| Give basal and postprandial insulin. | Compliance with the treatment plan enhances tissue perfusion. Maintaining normal glucose levels delays the advancement of complications. |
| Customized diet advice should be sought from a licensed dietitian. | A tailored meal plan is based on the patient’s body, weight, blood sugar levels, exercise habits, and health status. Adjustments to the patient’s diet will help to stabilize blood sugar levels. |
| Administer insulin injections precisely as prescribed. | Insulin is essential to manage blood sugar levels in type 1 diabetes and type 2 diabetic patients. In reaction to the substantial dextrose concentration in the solution, patients who received TPN may require insulin to ensure stable blood sugar levels. |
| Record any blood pressure readings higher than 160 mm Hg (systolic). Take antihypertensive medicine as directed. | Diabetes is frequently connected with hypertension. Controlling blood pressure helps avoid coronary heart disease, hemorrhage, retinopathy, and nephropathy. |
| As advised for the management of hypoglycemia, provide food or other sources of glucose. | To treat hypoglycemia, a quickly digested form of glucose is recommended. These glucose sources may include hard candy or fruit juices consumed orally. An intravenous carbohydrate injection may be suggested if a patient cannot take something orally. |
| Enlighten the patient on the importance of adhering to a meal plan. | A meal plan will assist the patient in maintaining stable blood glucose levels. |
| Educate the patient on how to take prescribed oral hypoglycemic medications correctly. | Diabetes patients must learn how to use insulin or oral hypoglycemic drugs to control their blood sugar levels. |
| Throughout each patient visit, assess advancement toward objectives. | Participation of the patient in the treatment regimen improves compliance with the treatment plan. |
| Discuss the significance of balanced exercise and food consumption. | Exercise helps in balancing glucose levels by enabling glucose absorption into cells. The patient must comprehend the connection between physical activity, dietary patterns, and blood sugar levels. |
Hyperglycemia Nursing Care Plan 2
Risk for Deficient Volume
Nursing Diagnosis: Risk for Deficient Volume related to osmotic diuresis, excessive urination, diarrhea, vomiting,nausea, and perplexity secondary to hyperglycemia.
Desired Outcome: These interventions aim to demonstrate adequate hydration as evidenced by steady vital signs, palpable peripheral pulses, good skin turgidity, capillary refill, individually adequate urinary output, and electrolyte levels within normal limits.
| Hyperglycemia Nursing Interventions | Rationale |
| Patient’s history for information on the period or severity of symptoms such as vomiting or increased urination. | This approach assists in calculating the overall volume depletion. Symptoms could have been present for various lengths of time (hours to days). When an infectious process is present, it causes fever and hypermetabolism, which increases insensible lost fluids. |
| Take note of any changes in orthostatic blood pressure. Hypovolemia can cause hypotension and tachycardia. Hypovolemia intensity can be estimated when a patient’s systolic blood pressure declines over ten mmHg from a recumbent to resting and then a standing position. It should be noted that cardiovascular neuropathy can impair reflexes that typically increase heartbeat. | |
| Examine the pulses, capillary refill, and mucous membranes. | These are markers of fluid balance status and circulating volume sufficiency. |
| Keep track of input and output and the specific gravity of the urine. | This intervention provides a continuous approximate volume replacement necessities, renal function, and therapeutic effectiveness. |
| Monitor the patient’s weight every day. | This method gives the most accurate evaluation of the current hydration balance and fluid replacement sufficiency. |
| When restarting oral consumption, sustain a water intake of at least 2500 mL/day within cardiovascular tolerance. | This intervention retains hydration and volume circulation. |
| Make the patient’s environment more comfortable by covering him or her with soft sheets. | This approach hinders overheating, which could lead to additional loss of fluid. |
| Look into changes in mentation and awareness. | Modifications in mentation can occur due to unusually high or low blood glucose, electrolyte imbalances, acidosis, significantly reduced cerebral perfusion, or the development of hypoxia. Regardless of the circumstances, impaired consciousness can increase the patient’s chances of aspiration. |
| Administer and keep an indwelling urinary catheter in place as needed. | This intervention gives precise continuing urinary output measurement, mainly if autonomic neuropathies cause neurogenic bladder (urinary incontinence or retention). Thus, once the patient becomes stable, the catheter can be removed already. |
Hyperglycemia Nursing Care Plan 3
Risk for Ineffective Therapeutic Regimen
Nursing Diagnosis: Risk for Ineffective Therapeutic Regimen related to poor comprehension about diabetes and its management and a complex treatment regimen secondary to hyperglycemia.
Desired Outcomes:
- The patient will demonstrate an understanding of hyperglycemia self-care measures.
- The patient will verbally express his or her comprehension of the hyperglycemia process and associated complications.
- The patient will carry out the necessary procedures accurately and explain the rationale for his or her actions.
| Hyperglycemia Nursing Interventions | Rationale |
| Examine the patient’s previous attempts to control the hyperglycemia management regimen. | Comprehending a patient’s complications or challenges with his hyperglycemia treatment regimen is one of the best interventions since the patient may feel overwhelmed due to learning to control medications, diet, exercise, self-monitoring of blood glucose, and other preventative measures. |
| Assess the patient’s self-management abilities, including blood glucose monitoring techniques. | Self-management skills determine the amount and type of knowledge required. |
| Determine what circumstances may affect the patient’s ability to stick to the routine. | Limited joint mobility or a pre-existing disability may impede the patient’s ability to prepare and deliver insulin accurately. That is why it is beneficial to determine the factors contributing to an ineffective treatment regimen. |
| Examine the patient’s financial healthcare resources. | Medications and supplies for blood sugar monitoring may be prohibitively expensive for patients with low economic means. |
| Give a brief description of the treatment plan. | Hyperglycemia treatment information can be confusing and difficult to understand for some patients. |
| Provide positive feedback to patients for new self-care activities. | Rather than emphasizing ignored health behaviors, positive reinforcement encourages the patient to stick with the treatment plan. Avoid using fear or scare tactics to change the patient’s health or lifestyle habits. |
| Assess and assure the patient’s understanding of hyperglycemia symptoms, causes, therapy, and prevention. | High blood sugar levels in persons with initially diagnosed diabetes indicate that hyperglycemia management should be reviewed. |
Hyperglycemia Nursing Care Plan 4
Risk for Disturbed Sensory Perception
Nursing Diagnosis: Risk for Disturbed Sensory Perception related to the electrolyte, glucose, or insulin imbalance secondary to hyperglycemia.
Desired Outcome:This intervention aims to keep the usual degree of mentation. It also seeks to acknowledge and counteract pre-existing sensory deficiencies.
| Hyperglycemia Nursing Interventions | Rationale |
| Keep blood sugar levels within the standard limit. | When blood glucose levels are altered due to hypoglycemia, CNS alterations occur. Hypoglycemia is caused by a discrepancy between insulin intake (including patients taking oral hypoglycemic medications), excessive physical activity, and carbohydrate activity. |
| Keep an eye on the patient’s vital indicators and mental state. | This intervention provides a baseline against which anomalous findings can be compared. |
| Assist the patient in ambulation or changing positions. | Promotes patient safety, particularly when the feeling of balance is compromised. |
| When the level of consciousness is impaired, protect the patient by avoiding or minimizing constraints as needed. | Disoriented patients are more vulnerable to injury, particularly at night, and precautions should be taken as needed. Seizure measures must be followed as needed to avoid physical harm, aspiration, and falls. |
| Keep track of the following laboratory values: blood glucose, serum osmolality, Hb/Hct, and BUN/Cr. | Imbalances can impair judgment. It should be noted that if the fluid is restored too quickly, surplus water may penetrate brain cells and induce a change in consciousness (water intoxication). |
Hyperglycemia Nursing Care Plan 5
Deficient Knowledge
Nursing Diagnosis: Deficient Knowledge related to unfamiliarity with normal blood glucose levels, insulin administration, and management of the condition secondary to hyperglycemia as evidenced by lack of comprehension and advancement of the complications.
Desired Outcome: Before discharge, the patient must understand insulin injection, hypoglycemic symptoms and management, and a healthy lifestyle.
| Hyperglycemia Nursing Interventions | Rationale |
| Inform the patient that insulin doses may need to be modified. | While fasting for surgery, not eating, or experiencing hypoglycemia, insulin dosage should be lowered. Sickness or infections may necessitate more insulin. |
| Instruct the patient to alternate the locations of insulin injections. | Lipodystrophy can be avoided by rotating injection sites on a regular basis. |
| Explain why it is critical to inject the syringe perpendicular to the skin. | The optimal insertion angle is a 90-degree angle because it guarantees deep subcutaneous insulin administration. An injection that is too shallow or too superficial may influence the process of insulin absorption. |
| Before beginning an education plan, evaluate the patient’s and family’s willingness to learn. | Patients who have recently been diagnosed with diabetes frequently go through several phases of grief. Reassure the patient and family that their sentiments are typical. |
| Examine the patient’s fears and significant concerns about hyperglycemia. | Encourage the patient to express his or her sentiments and anxieties about hyperglycemia-related complications. Straightforward facts will help dispel any hyperglycemia myths that may be contributing to their concern. |
| Provide the patient with written hyperglycemia management guidelines that he or she can refer to. | This intervention promotes learning and communicates the most relevant data. |
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2018). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
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