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NURSING PROCESS FOCUS Clients Receiving Oral Hypoglycemic Therapy

Assessment Data

Potential Nursing Diagnoses

Prior to administration:
Obtain a complete health history including allergies, drug history,
and possible drug interactions.
Assess for pain location and level.
Assess knowledge of drug and ability to conduct blood glucose testing.

Injury (hypoglycemia), Risk for, related to adverse effects of drug therapy

Pain (abdominal), related to adverse effects of drug
Knowledge, Deficient, related to drug therapy
Knowledge, Deficient, related to 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 drugs 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
glucose is greater than 300 mg/dl. (Ketones spill into the urine at high blood
glucose levels and provide an early sign of diabetic ketoacidosis.)
Monitor for signs of lactic acidosis if client is receiving a biguanide. (Mitochondrial oxidation of lactic acid is inhibited, and lactic acidosis may result.)
Review lab tests for any abnormalities in liver function. (These drugs are
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
sulfonylurea or biguanide. (These drugs may cause a disulfiram-like reaction.)
Monitor for signs and symptoms of illness or infection. (Illness may increase
blood glucose levels.)
Monitor blood glucose frequently especially at the beginning of therapy, in
elderly clients, and in those taking a beta-blocker. (Early signs of hypoglycemia may not be apparent.)

Teach client how to monitor blood glucose and test urine for ketones,
especially when ill.
Instruct client to report signs of lactic acidosis such as hyperventilation,
muscle pain, fatigue, and increased sleeping.
Instruct client to report the first sign of yellow skin, pale stools, or dark urine.

Advise client to abstain from alcohol and to avoid liquid OTC medications that
may contain alcohol.
Instruct client to report signs of fatigue, muscle weakness, and nausea and to
get adequate rest.

Instruct client:
To monitor blood glucose before breakfast and dinner and not to skip meals.
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
in weight affect the amount of drug needed to control blood glucose.)
Monitor vital signs. (Increased pulse and blood pressure are early signs of
hypoglycemia.)
Monitor skin for rashes and itching. (These are signs of an allergic reaction
to the drug.)
Monitor activity level. (Dose may require adjustment with change in physical
activity.)

Instruct client to weigh self each week, at the same time of day, and report
any significant loss or gain.
Teach client how to take accurate blood pressure, temperature, and pulse.
Advise client of the importance of immediately reporting skin rashes
and itching that is unaccounted for by dry skin.

Advise client to:

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 drugs 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.