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Nursing care in hyperglycemia


Set of activities performed by the nurse to prevent and treat higher than normal blood glucose levels.

Objectives:

– Maintain the patient’s blood glucose levels within normal or acceptable limits. – To teach the patient and family to identify early signs and symptoms of hyperglycemia.

Equipment:

– Trough. – Sharps container. – Equipment necessary to perform the Basal Blood Glucose Test. – Equipment necessary to perform Intravenous Medication Administration. – Equipment necessary for the Peripheral Catheter Insertion Technique.

Material:

– Equipment necessary for the procedure of performing Basal Glycemia. – Tubes for blood analysis. – Material necessary for the administration of intravenous medication. – Material necessary for the Peripheral Catheter Insertion Technique. – Nursing records.

Procedure:

– Perform hand washing. – Prepare the material and move it to the patient’s room. – Preserve the patient’s privacy. – Ask the patient and family to cooperate. – Determine blood glucose levels. – Observe if the patient presents signs and symptoms of hyperglycemia: polyuria, polydipsia, polyphagia, weakness, malaise, lethargy, blurred vision or headaches. – Monitor ketonuria or ketonemia every 4 hours. – Monitor vital signs every 4 hours. – Administer prescribed subcutaneous insulin. -Modify insulin therapy guidelines every 4 hours according to previously established algorithms. – Notify physician if signs and symptoms of hyperglycemia persist or worsen. – Maintain venous line, cannulate peripheral line if the patient does not have one. – Monitor glucose levels until normalization, at the nurse’s discretion or as prescribed by the physician. – Identify the tubes with the patient’s data and send them to the laboratory with the analysis form. – Identify possible causes of hyperglycemia. – Teach the patient and family the signs or symptoms, risk factors and treatment of hyperglycemia. – Follow up and monitor the patient’s diet and therapeutic regimen. – Collect the material. – Perform hand washing. – Record in the nursing documentation: procedure performed, date and time, incidences and patient’s response.

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