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Difficulty: EasyPhysiological Adaptation

A nurse finds a conscious client who has diabetes mellitus profusely sweating and reporting tremors and palpitations. Arrange the following nursing actions in the priority order they should be performed.

  1. 1Check the client's capillary blood glucose level.
  2. 2Administer 15 grams of a fast-acting carbohydrate.
  3. 3Wait 15 minutes to allow the carbohydrate to absorb.
  4. 4Recheck the capillary blood glucose level.
  5. 5Provide a snack containing protein and a complex carbohydrate.

Answer

First, check the blood glucose level. Second, administer 15 grams of a fast-acting carbohydrate. Third, wait 15 minutes. Fourth, recheck the blood glucose level. Finally, provide a snack containing protein and a complex carbohydrate.
The sequence follows the standard '15-15 rule' for hypoglycemia management. The nursing process dictates assessment first (checking the blood glucose) to confirm the condition. Once confirmed, immediate treatment with a fast-acting carbohydrate is provided. The nurse must wait 15 minutes for absorption before rechecking the glucose level. Finally, a complex carbohydrate and protein snack is given to maintain blood glucose stability and prevent a secondary drop.

Step-by-Step Solution

1
Assess the client's current glycemic status.
The capillary blood glucose level is checked.
Symptoms of hypoglycemia can mimic other acute conditions. Assessment must precede intervention to confirm the diagnosis.
2
Administer immediate treatment for hypoglycemia.
15 grams of a fast-acting carbohydrate is given.
A simple carbohydrate rapidly absorbs into the bloodstream to quickly elevate the blood glucose level.
3
Allow time for the intervention to work.
The nurse waits 15 minutes.
It takes approximately 15 minutes for the simple carbohydrate to take effect and accurately reflect in the blood.
4
Evaluate the effectiveness of the intervention.
The capillary blood glucose level is rechecked.
The nurse must verify that the blood glucose has risen above 70 mg/dL (3.9 mmol/L). If it has not, the previous treatment steps are repeated.
5
Prevent recurrence of hypoglycemia.
A snack with protein and a complex carbohydrate is provided.
Simple carbohydrates have a short duration of action. Protein and complex carbohydrates provide sustained glucose release to prevent a subsequent drop.

Key Concept

Management of acute hypoglycemia using the 15-15 rule
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Topics

Physiological Adaptation

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