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Recognition & Prevention of Hypoglycaemia. & Discharge Planning Caroline Naughton Credentialled Diabetes Educator Royal Melbourne Hospital Hypoglycaemia the facts • BGL of less than 3.5mmol/L • Hypoglycaemia - an excess of insulin relative to carbohydrate intake. • Can’t happen if treatment is diet alone • Can’t happen if only on biguanide • Can happen if on a sulphonylurea or insulin The brain uses glucose as the main energy source • Brain cannot make/store glucose • Making it the most susceptible organ to episodes of hypoglycaemia. Regulation of Blood Glucose • Normally maintained in a very narrow range 4 – 7.6mmol/L • Insulin & glucagon are the hormones responsible for glucose regulation, both are secreted from the pancreas. Normal regulation of blood glucose (cont’) BGL’s • What is Normal? • Depends on the individual • Severity – mild hypoglycaemic episode – severe hypoglycaemic episode Hypo’s S & S • Autonomic – – – – – Sweaty Shaky Tingling Lips Hunger Weakness Palpitations behaviour – Zda – Xds Neurological - Confusion - Headache - Unsteadiness - Blurred vision - Slurred speech - Aggressive - Unconsciousness - Fitting Contributing factors • The presence of autonomic neuropathy or recurrent hypo episodes can lead to “hypoglycaemic unawareness” • Asymptomatic until <2.5mmol • Altered mental status leading to impaired perception/recognition of hypo’s • Decreased Renal function – impaired excretion of medications Contributing factors • Poor or erratic nutritional intake • PEG feeds • Inadequate glucose stores for response to hypo’s (malnutrition) • Polypharmacy/non-compliance with medications • Dependence or isolation Causes of Hypoglycaemia • • • • • • Insufficient carbohydrate Increased activity Excess diabetes medication Excess alcohol Vomiting Diarrhea Role of counter-regulatory mechanisms • Spontaneous recovery of hypoglycaemia will nearly always occur, even if hypoglycaemic episodes are untreated – Role of liver – Hormone responses • Tight glycaemic control; not always appropriate treatment goal • A more realistic goal is to prevent hypo’s and reduce the signs and symptoms of hyperglycaemia Problem solving • Management and prevention – – – – – Review causes of hypoglycaemia Education Exercise planning Carry quickly absorbed carbohydrate Have glucagon available for Type 1 Starting the Discharge Plan • Know your patient –Type of diabetes? How do they usually manage? Testing? What's normal for them? Medications? Why are they in hospital? • What are the obvious gaps from a nursing perspective? • I – soft referral • Diabetes Resource Nurse Preparing for Discharge • Medication Skills- drug knowledge, self administration, need specialized equipment? • What are the patients perceived gaps? • Change of treatment impacts on self management The Patient • Hospitals are not good learning environments • Illness & stress affect learning & recall • Repetition important • Two sessions are more helpful than one for reinforcing messages • Family involvement for support • Control interruptions / setting • Don’t make assumptions / give clear messages Type 1 & Type 2 DM • Have similar educational needs & management guidelines • Require the same medical follow up • Have the same potential for complications • Complications screening recommendations are the same Matthew Type 1 • • • • • • • What is Type 1? Teach Insulin administration Teach BGM / Ketone testing Diet basics Hypoglycaemia recognition & treatment NDSS Sick Day Mx Lena Type 2 • Greek speaking – Interpreter & family • Hx diabetes for 12 years, max OHA’s – Short/Long term insulin? • Not SBGM - Teach blood testing, record results • Hypoglycaemia recognition & management • Target BGL’s Blood glucose monitoring • Ability to make the connection between food, exercise & medications • Self confidence to make change • Ability to recognize & manage high/low BGL • Considering patients financial & physical ability. Knowledge & support • Is powerful • Confidence building • Allows person to make choices • Referrals on discharge – CHC & diabetes educators, GP, Local Podiatrist, Diabetes Australia,