Risk for Unstable Blood Glucose Levels (Hyperglycemia & Hypoglycemia) Nursing Diagnosis & Care Plan

Unstable glucose shows up on every unit, not just endocrine. Your job is to catch the swing before it turns into a code: treat hypoglycemia fast, bring down the dangerous highs, watch for DKA and HHS, and teach the self-care that keeps the patient out of the ER. This guide covers the assessment, diagnoses, goals, and interventions that matter at the bedside.

What Is Unstable Blood Glucose?

Unstable blood glucose means the patient cannot hold a steady glucose level. It swings out of the controlled range into hyperglycemia (high) or hypoglycemia (low).

Glucose is the body's primary fuel. Other sugars, like fructose from fruit and lactose from milk, are converted to glucose, and starches break down into glucose as well. Glucose travels from the intestines and liver through the bloodstream and enters cells with the help of insulin, which the beta cells in the islets of Langerhans secrete when glucose rises. When glucose drops, the alpha cells release glucagon.

Hyperglycemia

Hyperglycemia is glucose greater than 125 mg/dL fasting or greater than 180 mg/dL 2 hours postprandial. Diabetes mellitus is the most common cause, but some drugs raise glucose as a side effect. The drivers are reduced insulin secretion, decreased glucose utilization, and increased glucose production.

Diabetic Ketoacidosis (DKA)

DKA is an acute, life-threatening complication marked by hyperglycemia, ketoacidosis, and ketonuria. When absolute or relative insulin deficiency keeps glucose out of cells, the liver breaks fat down into ketones for fuel. Ketones accumulate in blood and urine and turn the blood acidic.

Hyperosmolar Hyperglycemic State (HHS)

HHS is the other major metabolic emergency in diabetes. It is less common than DKA but carries a much higher mortality rate. It is marked by hyperglycemia, hyperosmolality, and dehydration without significant ketoacidosis. Enough insulin remains to suppress lipolysis and ketogenesis but not enough to control glucose.

Hypoglycemia

Hypoglycemia most often results from excess insulin in a patient with diabetes. It also occurs with heavy alcohol intake, prolonged fasting, starvation, adrenal insufficiency, and eating disorders such as anorexia nervosa. Low glucose after meals can follow gastric bypass surgery or heavy intake of refined carbohydrates, both driving excess insulin production. The symptomatic threshold varies, but a plasma glucose below 50 mg/dL is generally considered the cutoff.

Diagnosis requires the Whipple triad: documented low glucose, symptoms, and reversal of those symptoms once glucose is restored.

Maintaining a healthy weight through diet and exercise is central to keeping glucose stable.

Common Causes

Factors that put a patient at risk for unstable glucose:

• Lack of knowledge of diabetes or glucose management
• Developmental level
• Imbalance of activity
• Inadequate glucose monitoring
• Insulin deficiency or excess
• Nonadherence to the diabetes regimen
• Obesity or overweight (more than 20% over desired body weight)
• Family history of type 2 diabetes

Nursing Care Plans and Management

Care plans let you tailor monitoring and interventions to the individual. Build the plan from the patient's history, current status, lifestyle, and risk factors, and spell out the monitoring parameters: glucose, vital signs, and other relevant indicators.

Nursing Problem Priorities

1. Risk for hypoglycemia. Hypoglycemia kills if untreated. Prevent episodes through regular monitoring, timely insulin or oral agents, and teaching the patient and family the signs and symptoms.
2. Risk for hyperglycemia. Hyperglycemia leads to DKA or HHS. Monitor closely, give medications on schedule, and teach diet and medication adherence.
3. Ineffective self-management. Address the barriers and give the patient the support and resources to control their own glucose.
4. Inadequate nutrition. Help the patient build a meal plan and work with the dietitian.
5. Foot complications. Uncontrolled glucose drives neuropathy and vascular disease, raising the risk of ulcers and infection. Do regular foot assessments and teach foot care.

Nursing Assessment

A thorough assessment identifies what is driving the instability so interventions hit the right target.

Assess for the following subjective and objective data:

Hypoglycemia

• Sweating
• Tremors
• Tachycardia
• Palpitation
• Nervousness
• Hunger
• Inability to concentrate
• Headache or lightheadedness
• Confusion, memory lapses
• Numbness of lips and tongue
• Slurred speech
• Impaired coordination
• Emotional changes
• Irrational or combative behavior
• Double vision
• Drowsiness
• Disoriented behavior
• Seizures, difficulty arousing from sleep
• Loss of consciousness

Hyperglycemia

• Polyuria
• Polydipsia
• Weight loss
• Lethargy
• Focal neurologic deficits
• Altered mental status
• Nausea and vomiting
• Abdominal pain
• Fruity odor to the breath
• Rapid, shallow respirations
• Hypotension
• Tachycardia
• Dry mucous membranes

Nursing Diagnosis

After assessment, the diagnosis names the specific problem based on your clinical judgment. The label matters less than the judgment behind it. Common examples:

• Risk for Unstable Blood Glucose related to inadequate adherence to the therapeutic regimen
• Risk for Unstable Blood Glucose related to decreased coping mechanisms

Nursing Goals

Common goals and expected outcomes:

• The patient maintains glucose below 180 mg/dL, fasting glucose below 140 mg/dL, and an A1C below 7%.
• The patient identifies factors that destabilize glucose.
• The patient verbalizes understanding of body and energy needs.
• The patient verbalizes a plan to prevent or minimize complications.

Nursing Interventions and Actions

1. Monitoring and Assessing Unstable Blood Glucose Levels

Beyond the diagnostic workup, patients with known diabetes need ongoing specialized assessment, and newly diagnosed patients need evaluation for complications.

Assessing for hypoglycemia

Assess for signs of hypoglycemia. Presentation is consistent within the same patient. Signs come from increased adrenergic activity and decreased glucose to the brain: tachycardia, diaphoresis, tremors, dizziness, headache, fatigue, hunger, and visual changes.

Watch closely in new-onset diabetes. Consider new medications, activity changes, and infection. Early in non-insulin-dependent diabetes, patients may go hypoglycemic several hours after meals. The symptoms are usually brief and resolve on their own.

Assess for anxiety, tremors, and slurred speech. CNS signs appear with moderate hypoglycemia as the brain loses fuel: trouble concentrating, headache, lightheadedness, confusion, irrational behavior. Tremors come earlier with mild hypoglycemia as the sympathetic nervous system fires.

Monitor serum insulin levels. Hyperinsulinemia appears early in type 2 diabetes. Obesity and insulin receptor dysfunction drive insulin secretion. Insulinomas and some extrapancreatic tumors raise insulin and cause hypoglycemia.

Watch for altered mental status. In severe hypoglycemia, CNS function is impaired enough that the patient needs another person to treat it. Look for disoriented behavior, seizures, difficulty arousing from sleep, or loss of consciousness.

Correlate glucose with symptoms. Check the glucose and match it to the symptoms. If glucose is low but the patient has no symptoms, recheck to confirm the reading. A blunted hormonal response can mask symptoms.

Tie symptoms to meal times. Timing relative to meals is key. Fasting hypoglycemia typically hits in the morning before eating and during the day, especially in the afternoon when meals are missed or delayed.

Watch for postprandial hypoglycemia. It occurs 2 to 4 hours after eating, especially after meals high in simple carbohydrates, from reactive causes. About 4 to 6 hours after eating, plasma glucose runs 80 to 90 mg/dL, with glucose use and production around 2 mg/kg/minute.

Assess pregnant patients strictly. Maternal hypoglycemia is more common in women younger than 25 years and those with preexisting conditions.

Assess skin and HEENT. The skin may be diaphoretic and warm or show poor turgor from dehydration. HEENT exam may show blurred vision, pupils normal to fixed and dilated, icterus, and parotid pain from endocrine causes.

Rule out infection. A concurrent occult infection can trigger a new hypoglycemic episode. Work it up with a full physical, chest radiography, urinalysis, and blood cultures.

Perform an oral glucose tolerance test if reactive hypoglycemia is suspected. Run the test for 5 hours, testing glucose and insulin together. A glucose below 50 mg/dL during the test with typical symptoms confirms it.

Monitor lab results. Check liver function, serum insulin, cortisol, and thyroid levels. Proinsulin is normally less than 20% of total immunoreactive insulin; in islet-cell tumors it can reach 70%.

Assessing for hyperglycemia

Assess for signs of hyperglycemia. With too little insulin for the glucose load, excess blood glucose creates an osmotic effect: increased thirst (polydipsia), hunger (polyphagia), and urination (polyuria). Patients may also report fatigue, tingling or numbness in the hands and feet, and blurred vision.

Obtain glucose by the diagnostic criteria for diabetes. An abnormally high glucose is the basic criterion. The criteria:

• Symptoms of diabetes (polyuria, polydipsia, unexplained weight loss) plus a casual plasma glucose (any time of day, regardless of last meal) of 200 mg/dL (11.1 mmol/L) or greater.
• Fasting (no caloric intake for at least 8 hours) plasma glucose of 126 mg/dL (7.0 mmol/L) or greater.
• Two-hour post-load glucose of 200 mg/dL (11.1 mmol/L) or greater during an oral glucose tolerance test.
• A1C greater than 6.5% (48 mmol/mol).

Monitor vital signs. Relative tachycardia is typical of autonomic neuropathy and often precedes orthostatic hypotension. A respiratory pattern suggesting Kussmaul respiration means consider DKA immediately.

Assess for morning hyperglycemia. A high glucose on waking comes from insufficient insulin.

Monitor urine output. To clear excess glucose, the kidneys excrete it with water and electrolytes. This osmotic diuresis (polyuria) drives dehydration and marked electrolyte loss.

Assess knowledge of the prescribed diet. Meal planning, like the food exchange system, can be hard to learn, whether from intellectual limits or emotional issues such as difficulty accepting the diagnosis.

Assess eating patterns. Nonadherence drives glucose swings. Start nutritional teaching with a thorough dietary history covering habits, lifestyle, and cultural eating patterns.

Assess the feet for temperature, pulses, color, and sensation. This tracks perfusion and neuropathy. Atherosclerosis in the lower extremities raises the incidence of occlusive peripheral arterial disease in diabetes. Watch for diminished pulses and intermittent claudication (pain in the buttock, thigh, or calf with walking).

Assess for orthostatic hypotension. Patients with autonomic neuropathy or marked volume depletion may drop systolic pressure 20 mm Hg or more from lying to standing. Orthostatic vital signs help gauge volume status and flag autonomic neuropathy.

Watch the breathing for a fruity odor and hyperventilation. Ketosis and acidosis in DKA cause acetone or fruity breath with elevated ketones. Kussmaul respirations, deep but not labored, are the body's attempt to blow off acid and counter the ketone load.

Monitor ABGs. Ketoacidosis shows as low serum bicarbonate (0 to 15 mEq/L) and low pH (6.8 to 7.3). A low PCO2 (10 to 30 mm Hg) reflects respiratory compensation for the metabolic acidosis.

Perform a fundoscopic exam as appropriate. Because type 2 diagnosis is often delayed, 20% of patients already have some retinopathy at diagnosis. Visual acuity may seem normal unless the macula is involved. Refer any suspected macular edema to ophthalmology.

Check the feet regularly. Palpate the dorsalis pedis and posterior tibialis pulses and note them. Poor lower-extremity flow delays healing and raises amputation risk. Decreased sensation limits the patient's ability to protect the feet.

Screen pregnant patients. Screen high-risk women at the first prenatal visit: marked obesity, prior gestational diabetes, glycosuria, or a strong family history. High-risk and average-risk women get an oral glucose tolerance test (OGTT) or a glucose challenge test (GCT) followed by OGTT if they exceed the glucose threshold of 140 mg/dL (7.8 mmol/L).

Self-monitoring of blood glucose

Assess equipment preference. Most self-monitoring of blood glucose (SMBG) methods use a fingertip drop of blood on a reagent strip read for a set time. Meters vary in features like monthly averages, event tracking, and downloading.

Assess the patient's ability to self-monitor. Match the method to skill and physical ability. Visual acuity, fine motor coordination, cognition, comfort with technology, and cost all affect performance. Some meters have audio components for patients with visual impairment.

Re-check technique every 6 to 12 months. Have experienced patients compare their meter result against a simultaneous lab glucose in the clinic and have their technique observed.

Check meter and strip accuracy. Verify with control solutions specific to that meter whenever a new vial of strips is opened or a reading looks doubtful.

Identify candidates for self-monitoring. SMBG helps everyone with diabetes. For patients not on insulin, it tracks the effect of exercise, diet, and oral agents. In type 2 diabetes, use it during suspected highs or lows and when medication or dose changes. Also recommended for:

• Patients with unstable diabetes who swing from very high to very low within a 24-hour day
• Patients prone to severe ketosis or hypoglycemia
• Patients with hypoglycemia unawareness

Identify risk factors and potential causes

Obtain family history. Patients inherit a genetic predisposition to type 1 diabetes, not the disease itself, linked to certain human leukocyte antigen types.

Weigh the patient at each visit. Type 2 diabetes is common in patients older than 30 years with obesity. The BMI at which weight raises diabetes risk varies by racial group. About 90% of patients with type 2 diabetes are overweight or have obesity.

Monitor fasting and postprandial glucose. Normal fasting glucose for an adult is 70 to 105 mg/dL. Critical values: hypoglycemia below 40 to 50 mg/dL, hyperglycemia above 400 mg/dL. Patients on total parenteral nutrition (TPN) may run higher because the solution contains up to 50% dextrose. Reactive hypoglycemia shows a below-normal glucose after eating.

Assess glucose before meals and at bedtime. Target 140 to 180 mg/dL. Hold non-ICU patients at premeal levels below 140 mg/dL. Timing of checks, meals, and insulin doses all matter for control and avoiding hypoglycemia.

Review the medication list. Many drugs swing glucose. Beta-blockers, corticosteroids, thiazide diuretics, estrogen, isoniazid, lithium, and phenytoin can cause hyperglycemia. Salicylates, disopyramide, insulin, sulfonylureas, and pentamidine can cause hypoglycemia. If control is poor or complications are preventable, dig into why the regimen is failing.

Assess physical activity. Activity lowers glucose and cuts cardiovascular risk and is core to diabetes management. Patients with glucose above 250 mg/dL (14 mmol/L) and ketones in the urine should not exercise until the urine clears of ketones and glucose nears normal. Exercising with high glucose raises glucagon, the liver dumps more glucose, and the level climbs further.

Assess alcohol intake. Heavy alcohol without food blocks glycogen release from the liver and causes hypoglycemia. Alcohol is absorbed before other nutrients and needs no insulin; large amounts convert to fat and raise DKA risk.

Ask about mental health history. Depression is a significant risk factor for type 2 diabetes, and antidepressant use may itself raise risk by altering glucose homeostasis or promoting weight gain. Schizophrenia is also linked to type 2 diabetes through acquired protein kinase defects that impair glucose regulation.

Monitor pregnant patients for preeclampsia. Diabetes with preeclampsia is significantly more common, and the risk climbs further with preeclampsia or gestational hypertension plus gestational diabetes. Gestational diabetes is any glucose intolerance with onset in pregnancy, driven by placental hormones that cause insulin resistance.

2. Decreasing Blood Glucose (Hyperglycemia)

The goal is to clear hyperglycemic symptoms and cut long-term complications.

Report a systolic BP above 160 mm Hg. Hypertension commonly rides with diabetes. Controlling BP prevents coronary artery disease, stroke, retinopathy, and nephropathy.

Use a continuous glucose monitoring system. A CGMS sensor on a subcutaneous abdominal infusion set connects to a device worn on the patient. Use it to judge whether treatment holds over a 24-hour period.

Test glycated hemoglobin. A1C reflects glucose control over the past 3 months. When glucose is high, glucose attaches to hemoglobin in RBCs. Normal values run 4% to 6%, indicating consistently near-normal glucose.

Test for ketones. Ketones are fat-breakdown byproducts that build up in blood and urine. Ketonuria signals insulin deficiency and deteriorating type 1 control. Use a urine dipstick whenever a type 1 patient has glycosuria or persistent hyperglycemia, during illness, in pregnancy with preexisting diabetes, and in gestational diabetes.

Push lifestyle management for weight loss. Advise all overweight and obese patients of the benefits and enroll them in intensive lifestyle management. In one randomized trial, 5,145 overweight or obese patients with type 2 diabetes went through an intensive program of energy restriction with meal replacements and increased activity versus standard education. Weight loss was 6% at the end of the study.

Promote regular activity. Aerobic exercise, resistance training, or both can reduce HbA1C by about 6.6 mmol/mol. Use caution with CVD, uncontrolled retinopathy or nephropathy, and severe neuropathy. Leisure activities (walking, swimming, gardening, jogging, tai chi, yoga) all help.

Administer antihypertensives as prescribed. The ADA recommends a BP target below 130/80 mm Hg for patients at high cardiovascular risk. Use ACE inhibitors (ACEI) or angiotensin II receptor blockers (ARBs) in patients with albuminuria to slow kidney disease, regardless of BP.

Administer oral antidiabetic agents as indicated. These work for type 2 patients who cannot be controlled with exercise and medical nutritional therapy (MNT) alone. They add to, not replace, MNT and exercise.

Refer to diabetes educators. Certified diabetes educators specialize in diabetes teaching, but every nurse identifies patients, assesses self-care, gives basic education, reinforces the specialist's teaching, and arranges followup care.

Insulin therapy

Prepare the appropriate insulin. Preparations vary by time course, species, and manufacturer.

• Rapid-acting insulin. Faster onset and shorter duration than regular. Have the patient eat 5 to 15 minutes after injection.
• Short-acting (regular) insulin. Marked R, a clear solution, given 15 minutes before a meal, alone or with longer-acting insulin.
• Intermediate-acting (NPH) insulin. Neutral protamine Hagedorn, also called Lente, white and cloudy. The patient should eat around onset and peak but does not have to eat before injecting.
• Very long-acting "peakless" basal insulin. Absorbed slowly over 24 hours, given once a day at the same time to prevent overlap.

Let the patient choose the regimen with provider supervision. The patient should weigh the benefits and costs of each option. Teach the approaches.

• Conventional regimen. One or more daily injections of mixed short- and intermediate-acting insulin, with consistent meals and activity. Best for terminally ill patients, older adults with limited self-care, or patients unwilling or unable to self-manage.
• Intensive regimen. More flexible dosing day to day with eating, activity, stress, and illness. Requires 3 or 4 injections a day and raises hypoglycemia risk three-fold.

Administer basal and preprandial insulin. Keeping glucose in range slows microvascular disease. Basal insulin (long- or intermediate-acting) holds glucose between meals; preprandial insulin (rapid- or short-acting) covers meals.

Administer insulin as directed. Insulin is required in type 1 and in many type 2 patients. Patients on TPN may need insulin to offset the high dextrose load. In type 1, exogenous insulin is for life because the body cannot make it. In type 2, insulin may be needed long-term when meal planning and oral agents fail or insulin deficiency develops.

3. Improving Blood Glucose (Hypoglycemia)

Patients with hypoglycemic episodes need teaching on nutrition, home glucose checks, and early warning signs. Catching symptoms early is the key to self-treatment.

Give a rapid source of glucose. Use hard candy or fruit juice by mouth. For a patient who cannot take anything orally, give IV glucose. If none of the recommended foods are available, the patient should eat any food, preferably carbohydrate.

Do not add sugar to food or drinks. Juice already has enough carbohydrate to raise glucose, even when labeled unsweetened. Added table sugar can spike glucose and cause hours of hyperglycemia after treatment.

Avoid high-calorie, high-fat foods for treatment. Cookies, cakes, ice cream, and doughnuts slow glucose absorption and delay symptom resolution because of their fat content.

Restrict carbohydrates in reactive hypoglycemia. Avoid simple sugars, eat more often, and eat smaller meals. The patient may need 6 small meals and 2 to 3 snacks a day with added protein and fiber.

Avoid intense activity in fasting hypoglycemia. Exercise burns carbohydrate and raises insulin sensitivity. A routine program is fine as tolerated, and some patients with reactive hypoglycemia improve with it.

Obtain C-peptide levels as appropriate. Check C-peptide any time insulin is elevated. Exogenous hyperinsulinemia from injected insulin gives low C-peptide.

Treat hypoglycemia with 50% dextrose. For a patient who cannot swallow or is unconscious, give 25 to 50 mL of dextrose 50% in water (D50W) IV. Effect shows within minutes. Warn of headache and injection-site pain. Ensure IV patency, because hypertonic dextrose is irritating to veins.

Administer glucagon subcutaneously as indicated. For an unconscious adult who cannot swallow, give glucagon 1 mg subcutaneously. Glucagon, an alpha-cell hormone, drives the liver to break down stored glycogen. The patient may take as long as 20 minutes to wake. Turn them on their side, because glucagon can cause nausea and aspiration.

Administer insulin-secretion inhibitors as prescribed. These raise glucose by reducing peripheral glucose metabolism. Diazoxide increases hepatic glucose output by inhibiting pancreatic insulin release. Octreotide inhibits insulin and growth hormone secretion and also blocks glucagon.

4. Managing Complications of Hyperglycemia (DKA and HHS)

Goals: maintain fluid and electrolyte balance, build self-care knowledge, reduce anxiety, and avoid further complications.

Monitor glucose and ketones. Glucose may run between 300 and 800 mg/dL (16.6 and 44.4 mmol/L). Ketone buildup shows in blood and urine.

Monitor serum potassium closely. The initial potassium may be low, normal, or high, but usually trends high. Rehydration increases urinary potassium loss, and insulin drives potassium from the extracellular fluid into cells.

Review "sick day rules." To prevent DKA in illness, stress that the patient never skips insulin when nauseated or vomiting. Take the usual dose, eat small frequent carbohydrate portions, and drink fluids every hour to prevent dehydration. Check glucose and urine ketones every 3 to 4 hours.

Encourage oral fluids. In DKA or HHS, oral fluids help correct the dehydration and electrolyte loss from osmotic diuresis.

Measure intake and output. Hyperglycemia causes osmotic diuresis with loss of water and electrolytes, shifting water from the intracellular to the extracellular space. Watch too for fluid overload from rapid, large-volume replacement.

Teach when to call the provider. If the patient cannot keep fluids down, or glucose or ketones stay elevated, contact the provider. The patient must know how to reach them 24 hours a day.

Administer IV fluids as indicated. Rehydration maintains perfusion and helps the kidneys clear glucose. Start 0.9% sodium chloride at a rapid rate, usually 0.5 to 1 L per hour for 2 to 3 hours. Half-strength saline (0.45%) is used for hypertension, hypernatremia, or heart-failure risk. When glucose reaches 300 mg/dL or less, switch to dextrose 5% in water.

Administer potassium replacement cautiously. Timely potassium replacement prevents the dysrhythmias of hypokalemia. As much as 40 mEq per hour may be needed for several hours. Because extracellular potassium falls during DKA treatment, infuse potassium even when the plasma level is normal.

Administer regular insulin IV. Insulin runs as a slow continuous IV infusion. Switch to a higher-glucose solution, such as NS, when glucose reaches 250 to 300 mg/dL. Keep insulin infusing until subcutaneous dosing resumes to avoid ketone reaccumulation and worsening acidosis.

5. Promoting Nutritional Therapy

Nutrition, meal planning, weight control, and activity are the foundation of diabetes management. The main dietary goals: control total calories to reach a reasonable weight, control glucose, and normalize lipids and BP to prevent heart disease.

Identify eating patterns to modify. Build instruction around what the patient already eats. Work with the patient and dietitian on a plan within their financial reach and cultural background.

Build the meal plan with the patient. Account for food preferences, lifestyle, usual eating times, and cultural background. Insulin-dependent patients should keep meals consistent. Patients who master insulin-to-carbohydrate counting earn a more flexible lifestyle with predictable control.

Pace intake through the day. For obese patients, cutting total calories matters more than timing, but do not skip meals. Pace them through the day to ease demand on the pancreas.

Set calories by need. Calculate energy needs from age, gender, height, and weight, then distribute into carbohydrate, protein, and fat.

• Carbohydrates. The ADA and the Academy of Nutrition and Dietetics recommend 50% to 60% of calories from carbohydrate at all calorie levels. This includes sugars (sucrose) and starches like rice, bread, and pasta, eaten in moderation to limit postprandial spikes.
• Fats. Keep fat below 30% of total calories and saturated fat at 10%. Limit dietary cholesterol to less than 300 mg/day.
• Protein. The remaining 10% to 20%. Include non-animal sources like legumes and whole grains to cut saturated fat and cholesterol.
• Fiber. More fiber improves glucose, lowers exogenous insulin needs, and reduces total and LDL cholesterol. Soluble fiber (legumes, oats, some fruits) does most of the work; insoluble fiber is in whole-grain breads, cereals, and some vegetables.

Use the exchange list. Six main lists organize food: bread/starch, vegetable, milk, meat, fruit, and fat. Foods in a group carry roughly equal calories and grams of protein, fat, and carbohydrate. Plans set a number of choices from each list.

Teach carbohydrate counting. Carbohydrates are the main driver of glucose, so counting them gives flexible food choices and more accurate control with multiple daily injections, and is simpler than the exchange list.

Measure servings. Used more in type 2 diabetes, this emphasizes portion control of total carbohydrate servings at meals and snacks. One carbohydrate serving equals 15 g, for example an apple 2 inches across or one slice of bread.

Use the MyPlate guide. Good for type 2 patients who struggle with a calorie-controlled diet. Five major groups (grains, vegetables, fruits, dairy, protein) plus fats and oils. Build the diet on the lowest-calorie, highest-fiber foods (grains, fruit, vegetables).

Build a personal glycemic index. The glycemic index describes how much a food raises glucose versus an equal amount of glucose. The patient can build their own by checking glucose after eating a given food, improving control through individualized diet changes.

Advise on alcohol. The main danger is hypoglycemia, especially in patients on insulin secretagogues, because alcohol blunts the body's glucose production. Eating with alcohol lowers that risk but can raise glucose. Recommend moderation.

Promote non-nutritive sweeteners. Non-nutritive sweeteners have few or no calories and are FDA-listed as safe for diabetes. Use in moderation.

Refer to a registered dietitian. The individualized plan depends on body weight, glucose values, activity, and clinical conditions. Communicate clearly with the dietitian and reinforce the patient's understanding.

6. Providing Patient and Family Education

Teaching covers basic skills plus prevention of long-term complications. Depth depends on the patient's interest and ability.

Teach the prescribed meal plan. Cover consistent eating, the food-insulin relationship, and the individualized plan. Followup teaching adds skills like eating out, reading food labels, and adjusting for exercise, illness, and special occasions.

Teach correct medication use. The patient learns to take insulin or oral hypoglycemics. Insulin is self-injected into subcutaneous tissue with insulin syringes. Cover the equipment, the insulins, the syringes, and mixing when needed.

Review progress at each visit. Patient involvement improves adherence. Even patients with excellent control and no complications should see their provider at least twice a year for evaluation and nutrition updates.

Teach how to raise glucose in hypoglycemia. Food works in most cases. The usual recommendation is 15 g of a fast-acting concentrated carbohydrate.

Balance exercise with food. The patient must understand the link between exercise, food, and glucose. Cover the insulin peak with a snack and add food when activity increases.

Teach capillary glucose monitoring. Once the patient picks a meter, review the manufacturer's guidelines so readings are accurate. Patients who are comfortable checking and interpreting their glucose make better self-care decisions.

Teach medical alert identification. Because unexpected hypoglycemia happens, every patient on insulin should wear an identification bracelet or tag stating they have diabetes.

Refer for specific exercise instruction. An exercise physiologist, physical therapist, or cardiac rehabilitation nurse can prescribe exercise around the patient's limits. Patients should clear an exercise program with their provider and get a medical evaluation first.

Teach the family the warning signs. The patient, family, and coworkers must recognize hypoglycemia. Family should know that any subtle, unusual behavior change may signal a low, and that hypoglycemia can cause irrational behavior from low brain glucose.

Flag glucose-masking medications. Beta-blockers like propranolol for hypertension or dysrhythmias can mask hypoglycemia symptoms. Patients on them must check glucose frequently. Oral sulfonylureas can also cause hypoglycemia, especially in older adults.

Carry simple sugar at all times. Patients on insulin especially should carry a simple sugar. Commercial glucose tablets and gels are convenient. If none of the recommended foods are available during a reaction, eat any carbohydrate food.

Allow occasional desserts. Patients who feel restricted may treat lows as a reward with dessert. Working occasional desserts into the plan makes it easier to limit low-treatment to simple, low-calorie carbohydrate like juice or glucose tablets.

Self-monitoring of blood glucose levels

Teach the SMBG procedure. SMBG lets patients individualize treatment and catch highs and lows early.

• Prepare the equipment. Read the manufacturer's instructions before using the meter and strips. A new meter may need calibration.
• Perform hand hygiene.
• Choose a puncture site, preferably the side of an adult's finger. Avoid sites over bone. Hold the finger dependent to increase blood flow.
• Clean the site with an antiseptic swab and let it dry completely.
• Place the injector against the site and release the lancet perpendicular to the skin.
• Without an injector, prick the site with a lancet or needle using a darting motion.
• Gently squeeze without touching the site until a drop forms. Check the manufacturer's instructions for the drop size needed.
• Hold the reagent strip under the site until blood covers the indicator square. Do not smear it.
• Apply pressure with a 2×2 gauze for hemostasis.
• Follow the meter's timing.
• Some meters take the strip before the specimen, others after.
• After the set time, most meters display the reading automatically.
• Turn off the meter and discard the strip and gauze appropriately.
• Perform hand hygiene.
• Stress record keeping: log every reading to show the provider.

Teach the risks of SMBG. Erroneous values come from incorrect technique: improper blood application, reagent strips damaged by heat or humidity, outdated strips, and poor meter maintenance.

Teach SMBG frequency. Recommended two to four times daily, usually before meals and at bedtime. Patients on premeal insulin need at least three checks a day before meals to set each dose. Patients not on insulin may check at least two or three times a week, including a 2-hour postprandial test.

Self-administering insulin

Let the patient choose the delivery method with supervision. Options include traditional subcutaneous injection, insulin pens, jet injectors, and insulin pumps.

• Insulin pens. Prefilled cartridges load into a pen holder with a disposable needle. Dose by dialing or pushing for each 1- or 2-unit increment.
• Jet injectors. Deliver insulin through the skin under pressure in a fine stream. More expensive, needing thorough training. Absorption, peak activity, and insulin levels may differ from injection.
• Insulin pumps. Continuous subcutaneous infusion from a small worn device that mimics the pancreas. A 3-mL syringe connects through thin tubing to a needle or Teflon catheter inserted in the abdomen and taped. Change the needle or catheter at least every 3 days.

Teach insulin storage. Refrigerate vials and pens not in use, including spares. Avoid temperature extremes: do not freeze insulin or leave it in direct sun or a hot car. Keep the in-use vial at room temperature to reduce injection-site irritation. A vial used within one month may stay at room temperature.

Check contents and expiration before preparing. Inspect intermediate-acting insulin for flocculation, a frosted whitish coating from temperature extremes. Check the expiration date on any insulin.

Teach syringe selection. Match the syringe to the insulin concentration. Three U-100 sizes exist: 1-mL with 100-unit capacity, 0.5-mL with 50-unit capacity, and 0.3-mL with 30-unit capacity. Smaller syringes let patients draw small amounts accurately and are marked in 1-unit increments, easier for visual deficits and small doses.

Teach mixing insulins. When rapid- or short-acting insulin is given with longer-acting insulin, mix them in one syringe; mix the longer-acting insulin thoroughly before drawing. The ADA recommends drawing up regular insulin first. Never inject one insulin into the vial of clear insulin and contaminate it.

Teach withdrawing insulin. Inject air into the vial equal to the units to be withdrawn to prevent a vacuum that makes accurate withdrawal difficult.

Rotate injection sites. The four main areas are the abdomen, posterior upper arms, anterior thighs, and hips. Rotate systematically within one area to prevent lipodystrophy, and use all sites within an area before moving to another for consistent absorption. Absorption is fastest in the abdomen.

Teach skin prep. Alcohol is unnecessary, but patients who use it should let the skin dry first so alcohol is not carried into the tissue, causing redness and burning.

Teach needle insertion. Insulin must reach subcutaneous tissue; too deep or too shallow alters absorption. A 90-degree angle is best for a normal or overweight patient. Dispose of the used pen, syringe, needle, or lancet properly. During self-administration, instruct the patient to:

• Stabilize the skin by spreading it or pinching up a large area.
• Hold the syringe like a pencil and insert the needle straight into the skin.
• Push the plunger all the way in.
• Pull the needle straight out and press a cotton ball over the site for several seconds.
• Use a disposable syringe once, then discard it into a hard, puncture-proof plastic container.