Risk for unstable blood glucose level nursing diagnosis: risk factors and interventions

Risk factors that push glucose down, up, or both ways at once

NANDA-I is the source taxonomy for this label. In plain terms it flags a patient whose blood glucose may drift outside the normal range in either direction. That two-way risk is what separates it from a simple hypoglycemia or hyperglycemia focus, and the table below pairs each risk factor with the chart cue that reveals it.

Notice that several patients carry risk factors pointing in opposite directions. A man on insulin who is barely eating and has just started a steroid can run high at 4 pm and low at 3 am. That is the situation this diagnosis was built for.

Writing the statement when there is nothing to observe yet

Hypothetical patient for practice: a 67-year-old woman with type 2 diabetes admitted with pneumonia. She takes a sulfonylurea and evening basal insulin at home, has chronic kidney disease, was started on a corticosteroid today, and ate about 25 percent of her breakfast and lunch. Her glucose readings so far are 132 and 188 mg/dL.

Statement: Risk for unstable blood glucose level related to sulfonylurea and insulin use with reduced oral intake, chronic kidney disease, acute infection and a newly started corticosteroid. There is no as evidenced by clause. A risk diagnosis describes something that has not happened, so there are no defining signs to report, only risk factors. Some programs ask you to write the risk factors after the phrase as evidenced by; check which format your instructor uses, but never list symptoms of hypoglycemia that the patient does not have.

Goals need a number and a date. Examples: glucose stays at or above 70 mg/dL on every check during the stay; the patient names three warning signs of low glucose and the first thing to do before discharge. Use the target range in the provider's order for the upper limit rather than inventing one.

Interventions built around catching the swing early

Monitoring comes first because a risk diagnosis is only useful if it lets you see a trend before it becomes an event. Match checks to meals and insulin timing, add an overnight check when the patient is on basal insulin with poor intake, and compare each reading with the last two rather than reading it alone. The skills of a correct fingerstick are covered on the blood glucose monitoring page.

Teaching is the second pillar. The CDC describes the early signs of a low: fast heartbeat, shaking, sweating, nervousness, irritability, dizziness and hunger. MSD adds the brain signs that follow: headache, blurred vision, confusion, seizures and coma. NIDDK teaches 15 to 20 grams of glucose or carbohydrate, then a recheck after 15 minutes. Patients with long-standing diabetes or frequent lows may lose the warning signs altogether, which MSD and NIDDK call hypoglycemia unawareness, so for them the meter replaces symptoms as the alarm.

Coordination is the third. Tell the prescriber when intake falls, when a steroid starts or stops, or when kidney function worsens, because each one changes how much glucose-lowering medicine is safe. Adjusting doses is a medical order; noticing the change and reporting it is the nursing action.

When the risk label is no longer the right one

Students often keep this diagnosis after the event has happened. If the patient now reads 52 mg/dL and is sweating and confused, the risk has become a real problem. MSD classes a reading below 54 mg/dL as level 2 hypoglycemia. Treat it, notify the provider, and change the care plan to an actual problem; a risk label paired with a low reading tells the grader you did not reassess.

The other mix-up is with deficient knowledge or ineffective health self-management. Those fit when the root cause is that the patient cannot or does not manage the disease at home. Risk for unstable blood glucose fits when the danger comes from the current situation, such as illness, new drugs or not eating. A newly diagnosed patient with an infection can need both, written as separate statements.

Practice question, hypothetical: which client most clearly needs this diagnosis? A client with type 2 diabetes controlled by diet, eating well, with a glucose of 140 mg/dL; or a client on insulin who is NPO for surgery and receiving a steroid. The second has risk factors pulling in both directions. The first has diabetes but no current trigger, and the label is not justified by the medical diagnosis alone.

Sources and further reading

Hypoglycemia - Endocrine and Metabolic Disorders - MSD Manual Professional Edition. Hypoglycemia below 70 mg/dL with level 1, 2 (below 54 mg/dL) and 3 definitions; causes including insulin, sulfonylureas, alcohol, renal failure and cirrhosis; headache, blurred vision, confusion, seizures and coma; hypoglycemia unawareness.

Low Blood Sugar (Hypoglycemia) | Diabetes | CDC. Low glucose defined as below 70 mg/dL; common symptoms such as fast heartbeat, shaking, sweating and dizziness; triggers including insulin, too little carbohydrate, physical activity and alcohol.

Low Blood Glucose (Hypoglycemia) - NIDDK. Treatment with 15 to 20 grams of glucose or carbohydrate and recheck after 15 minutes; causes including insulin, sulfonylureas, skipped meals, activity and alcohol without food; glucagon for severe lows; hypoglycemia unawareness.

High blood sugar - self-care: MedlinePlus Medical Encyclopedia. High blood sugar can occur temporarily from stress of surgery, infection, trauma or medicines; symptoms of high glucose; when to check ketones.