1. Ms. M. complained of feeling dizzy, tingling lips, feeling shaky and fast heartbeat. Her vital signs, which are: Temperature 98.8 degrees F, Pulse: 122 bpm, Respiration: 18 breaths/min, BP: 134/84 mmHg. Ms. M. is diabetic. Her blood glucose is 55 mg/dL.  What should the nurse do?

1. Anna is a known diabetic. She came to the ER complaining of having a virus for 3 days and feeling very weak. Her blood glucose was 837 mg/dL.  What should the nurse do?

ANSWER

Nursing Actions for Clients with Altered Blood Glucose Levels

When encountering clients with altered blood glucose levels, such as in the cases of Ms. M. and Anna, who both have diabetes, nurses must promptly assess the situation and take appropriate actions to ensure the safety and well-being of the clients. Let’s discuss the actions that the nurse should take in each scenario.

Scenario 1: Ms. M. with Low Blood Glucose (55 mg/dL)

Assessment

Ms. M. is experiencing symptoms of hypoglycemia, including dizziness, tingling lips, shakiness, and a fast heartbeat.
Her vital signs reveal a rapid pulse (122 bpm), but her blood pressure is within the normal range.
Her blood glucose level is notably low (55 mg/dL).

Nursing Actions

1. Immediate Assessment: Begin by ensuring Ms. M.’s safety. If she is conscious and able to swallow, provide her with a source of fast-acting carbohydrate, such as fruit juice, glucose gel, or glucose tablets. Reassure her that help is available.

2. Repeat Blood Glucose Check: After administering the carbohydrate, repeat the blood glucose check in approximately 15 minutes to ensure it has risen to a safe level.

3. Continuous Monitoring: Continue to monitor Ms. M.’s vital signs, blood glucose levels, and her overall condition closely. Observe for any signs of improvement or worsening of symptoms.

4. Review Medications: Determine if Ms. M. has taken her diabetic medications or insulin as prescribed. Adjustments may be needed to prevent future hypoglycemic episodes.

5. Education: Provide education to Ms. M. on the importance of regular monitoring, recognizing hypoglycemia symptoms, and appropriate interventions. Stress the significance of carrying a source of fast-acting carbohydrates.

Scenario 2: Anna with High Blood Glucose (837 mg/dL)

Assessment

Anna presents with severe hyperglycemia, with a blood glucose level of 837 mg/dL.
She complains of having a virus for three days and feeling extremely weak.

Nursing Actions

1. Immediate Intervention: In the case of such extreme hyperglycemia, the nurse should prioritize immediate intervention to lower Anna’s blood glucose levels.

2. IV Fluids: Initiate intravenous (IV) access to administer fluids. Normal saline is often used to help rehydrate the patient and dilute the excess glucose in the bloodstream.

3. Insulin Administration: Administer regular insulin via an IV infusion or subcutaneous injection, as prescribed by the healthcare provider. The goal is to lower the blood glucose levels gradually to prevent hypoglycemia.

4. Frequent Monitoring: Monitor Anna’s blood glucose levels frequently to assess the response to treatment. Continuously assess her vital signs and overall clinical status.

5. Assess for Complications: Be vigilant for signs of diabetic ketoacidosis (DKA) or hyperosmolar hyperglycemic state (HHS), which may require additional interventions.

6. Collaboration: Collaborate with the healthcare provider and other members of the healthcare team to determine the underlying cause of Anna’s hyperglycemia and adjust her treatment plan accordingly.

7. Patient Education: Once Anna’s condition stabilizes, provide her with education on diabetes management, including medication adherence, diet, and lifestyle modifications to prevent future hyperglycemic episodes.

In both scenarios, timely and appropriate nursing interventions are crucial to address the immediate blood glucose issue and prevent potential complications associated with hypo- or hyperglycemia. Effective patient education and collaboration with the healthcare team are essential components of comprehensive diabetes care.