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NURSING PROCESS FOCUS Clients Receiving Oral Hypoglycemic Therapy

Assessment Data Potential Nursing Diagnoses
Prior to administration: ■ Injury (hypoglycemia), Risk for, related to adverse effects of drug therapy
■Obtain a complete health history including allergies, drug history, ■ Pain (abdominal), related to adverse effects of drug
and possible drug interactions. ■ Knowledge, Deficient, related to drug therapy
■Assess for pain location and level. ■ Knowledge, Deficient, related to blood glucose testing
■Assess knowledge of drug and ability to conduct blood glucose testing.
Planning: Client Goals and Expected Outcomes
The client will:
■Describe signs and symptoms that should be reported immediately, including nausea, diarrhea, jaundice, rash, headache, anorexia, abdominal pain, tachycardia,
seizures, and confusion.
■Demonstrate an ability to accurately self-monitor blood glucose.
■Demonstrate an understanding of the drug’s action by accurately describing drug side effects and precautions.
■Maintain blood glucose within a normal range.
Implementation
Interventions and (Rationales) Client Education/Discharge Planning
■ Monitor blood glucose at least daily and monitor urinary ketones if blood ■ Teach client how to monitor blood glucose and test urine for ketones,
glucose is greater than 300 mg/dl. (Ketones spill into the urine at high blood especially when ill.
glucose levels and provide an early sign of diabetic ketoacidosis.)
■ Monitor for signs of lactic acidosis if client is receiving a biguanide. (Mitochon- ■ Instruct client to report signs of lactic acidosis such as hyperventilation,
drial oxidation of lactic acid is inhibited, and lactic acidosis may result.) muscle pain, fatigue, and increased sleeping.
■ Review lab tests for any abnormalities in liver function. (These drugs are ■ Instruct client to report the first sign of yellow skin, pale stools, or dark urine.
metabolized in the liver and may cause elevations in AST and LDH. Metformin
decreases absorption of vitamin B12 and folic acid.)
■ Obtain accurate history of alcohol use, especially if client is receiving a ■ Advise client to abstain from alcohol and to avoid liquid OTC medications that
sulfonylurea or biguanide. (These drugs may cause a disulfiram-like reaction.) may contain alcohol.
■ Monitor for signs and symptoms of illness or infection. (Illness may increase ■ Instruct client to report signs of fatigue, muscle weakness, and nausea and to
blood glucose levels.) get adequate rest.
■ Monitor blood glucose frequently especially at the beginning of therapy, in Instruct client:
elderly clients, and in those taking a beta-blocker. (Early signs of hypo- ■ To monitor blood glucose before breakfast and dinner and not to skip meals.
glycemia may not be apparent.) ■ To monitor signs and symptoms of hypoglycemia and, if present, eat a simple
sugar; if symptoms do not improve, call 911.
■ Not to skip meals and to follow a diet specified by the healthcare provider.
■ Monitor weight, weighing at the same time of day each time. (Changes ■ Instruct client to weigh self each week, at the same time of day, and report
in weight affect the amount of drug needed to control blood glucose.) any significant loss or gain.
■ Monitor vital signs. (Increased pulse and blood pressure are early signs of ■ Teach client how to take accurate blood pressure, temperature, and pulse.
hypoglycemia.)
■ Monitor skin for rashes and itching. (These are signs of an allergic reaction ■ Advise client of the importance of immediately reporting skin rashes
to the drug.) and itching that is unaccounted for by dry skin.
■ Monitor activity level. (Dose may require adjustment with change in physical Advise client to:
activity.) ■Increase activity level to help lower blood glucose.
■Closely monitor blood glucose when involved in vigorous physical activity.
Evaluation of Outcome Criteria
Evaluate the effectiveness of drug therapy by confirming that client goals and expected outcomes have been met (see “Planning”).
■The client accurately describes signs and symptoms that should be reported immediately, including nausea, diarrhea, jaundice, rash, headache, anorexia,
abdominal pain, tachycardia, seizures, and confusion.
■The client demonstrates an ability to accurately self-monitor blood glucose.
■The client demonstrates an understanding of the drug’s action by accurately describing drug side effects and precautions.
■The client maintains blood glucose within a normal range.
See Table 44.2 for a list of drugs to which these nursing actions apply.