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BLOOD GLUCOSE
CONTROL
HYPOGLYCEMIA
Learning Module
A NIMALASURIYA MD
HIGH RISK PATIENTS
• RENAL DIEASE
– HIGH DOSE SLIDING SCALE
•
•
•
•
•
PAST HISTORY OF HYPOGLYCEMIA
GASTROPARESIS
HYPOGLYCEMIC UNWARENESS
PATIENTS ON VENTILATORS
CONFUSED PATIENTS
HIGH RISK PATIENTS(CONT)
• ADDISONS DISEASE
• PATIENT OFF HIGH DOSE STEROIDS
• HYPOPITUITARISM
INPATIENT BLOOD GLUCOSE CONTROL
The purpose of this module is:
1. To describe the hypoglycemia signs and symptoms
and causes.
2. To discuss inpatient treatment of hypoglycemia.
3. Discuss the prevention of hypoglycemia
At the end of this module,
you will take the post-test.
HYPOGLYCEMIA DEFINITION
Hypoglycemia protocol now defines
hypoglycemia as <70mg/dl.
HYPOGLYCEMIA
SIGNS AND SYMPTOMS
Hypoglycemia signs and symptoms can be
categorized as mild, moderate, or severe.
MILD HYPOGLYCEMIA SYMPTOMS =
Hunger
Tired
Headache
Sweating Dizzy
Nervous
Shakiness Light headed
Blurred vision
Fast/pounding heart beat
Numbness/tingling around mouth or lips
If this goes untreated it can lead to moderate
hypoglycemia.
HYPOGLYCEMIA
SIGNS AND SYMPTOMS
MODERATE HYPOGLYCEMIA SYMPTOMS =
Personality change
Poor coordination
Irritability
Difficulty in concentration
Confusion
Slurred/slowed speech
If this goes untreated and the blood glucose
continues to drop then severe hypoglycemia can
occur.
HYPOGLYCEMIA
SIGNS AND SYMPTOMS
SEVERE HYPOGLYCEMIA SYMPTOMS =
Mental status changes
Unconsciousness
Coma.
This could lead to convulsions or death if not
taken care of immediately!
Whew! We don’t want that to happen!!!
HYPOGLYCEMIA
Keep in mind Hypoglycemia serious and
must be treated right away, because it
can cause cardiac arrhythmia and
precipate cardiac and brain ischemia
and known to have pro inflammatory
effects
CAUSES OF HYPOGLYCEMIA
Generally, there are 3 main causes:
 When the body’s glucose is used up too
rapidly, or,
 When glucose is released into the blood
stream too slowly, or,
 When too much insulin is released into the
bloodstream
CAUSES OF HYPOGLYCEMIA
More specifically, hypoglycemia can be caused by:
 Too much insulin
 Oral anti-diabetes medications (as sulfonylureas or
insulin secretagogues)
 Skipped or delayed meals
 Renal insufficiency
 Liver disease
 Gastroparesis
 Menstrual Cycles
 When TPN or TF is stopped and NPO or low PO intake
So, what can we do about hypoglycemia?
HYPOGLYCEMIA TREATMENT
Of course prevention is the best intervention.
But when hypoglycemia happens, eating or drinking a form of
simple carbohydrate that contains glucose is the main
treatment.
The KEY and challenge to treatment is to
not overtreat.
Overtreating hypoglycemia causes posttreatment hyperglycemia.
Thus potentially putting the patient on a ‘roller-coaster’ of
trying to treat high and low swings in blood glucose.
And boy that does not feel good!!!
So how do we treat hypoglycemia for our patients?
BLOOD GLUCOSE TARGET
inpatient target blood glucose for people with
diabetes is:
Prepradial < 140mg/dl and random <180
for Med/Surg/Tele patients
140-180 mg/dl. for Critical Care patients
HYPOGLYCEMIA PROTOCOL
This protocol does not need a physician’s order to
implement it.
The hypoglycemia protocols are based on the FSBG
(finger stick blood glucose) number and the
signs/symptoms the patient may be experiencing!
For any suspected hypoglycemia, do a FSBG
immediately AND treat
HYPOGLYCEMIA PROTOCOL
This protocol has the following definitions:
Mild/Moderate Hypoglycemia is defined as:
FSBG 41 – 69mg/dl whether symptomatic or not
Severe Hypoglycemia is defined as:
FSBG is 40mg/dl or less
OK first let’s discuss mild/moderate treatment in relation to
if the patient is eating or not.
MILD/MODERATE HYPOGLYCEMIA TREATMENT
Treatment for patients who are eating:
If the mealtime tray is available:
 Feed the patient immediately
 Check FSBG in 15 minutes
 Continue to check FSBG and treat with 15-30 grams carbohydrate
while FSBG remains <70mg/dl every 15-20 minutes
Use your good nursing assessment as to whether you use
15grams (for mild hypoglycemia) or 30grams (for moderate
hypoglycemia).
Also, don’t assume that the meal will correct the
hypoglycemia. . . . . . . it may not!
KEY POINT: Do not add sugar to the juice!!! That is considered
overtreating.
MILD/MODERATE HYPOGLYCEMIA TREATMENT
Treatment for patients who are eating:
 Give the patient 15-30 grams of carbohydrate using one of the following:
 3 to 4 glucose tablets
 one Glucose gel tube (squeeze tube contents into patient’s mouth and have
them swallow)
 one-half cup juice (Do Not add extra sugar)
 Again keep treating the hypoglycemia every 15 minutes until the FSBG is
>70-80mg/dl
Gel are preferred treatment since they are a purer form of
glucose and exact dose of glucose is given and
documented in the MAR
Apple juice is preferred over orange juice since orange juice
may be contraindicated in many patients (as renal or
cardiac patients).
MILD/MODERATE HYPOGLYCEMIA TREATMENT
Re-testing the FSBG and treating EVERY 15 minutes with 15
to 30 grams carbohydrate is very important!
When you do this you must also document all FSBG and
treatment and response to treatment as well!
Then the LAST STEP is:
Once the hypoglycemia is resolved AND if it is more than an
hour before next meal, give one of the following:




6 crackers and 1ounce cheese, OR,
6 crackers and 2 Tbsp. peanut butter, OR,
1 slice bread and 1 ounce meat/cheese, OR,
1 carton of skim milk with 1 box (serving) of cereal
MILD/MODERATE
HYPOGLYCEMIA TREATMENT
If after 45 minutes of treatment and
hypoglycemia is not resolved,
Consider iv glucose glucagon or octeotride.
Special notes:
 If the patient is being treated with Acarbose (Precose) or
Miglitol (Glyset) treat with only tablets or gel (a purer form
of glucose has to be used since these drugs effect the digestive
system).
 Avoid use of Glucose e gel if patient has a decreased
swallowing reflex (on aspiration precautions).
 Intubated patients should be treated intravenously.
SEVERE
HYPOGLYCEMIA TREATMENT
Now let’s discuss Severe Hypoglycemia treatment.
Definition:
FSBG of 41-69mg/dl with mental status changes, or,
Unconscious, or,
FSBG of 40mg/dl or less (whether symptomatic or not)
Patients who are NPO and have hypoglycemia will be treated as if in severe
hypoglycemia if FSBG is less than 70mg/dl.
Now, let’s look at IV available versus IV not available.
SEVERE
HYPOGLYCEMIA TREATMENT
1.
2.
3.
4.
If an IV is available, follow these steps:
Give one (1) amp of D50 (50ml)
Retest FSBG 15-20 minutes after treatment
If adult remains unconscious, give additional
one (1) amp (50ml) of D50 slowly
When patient is conscious, follow up with a
snack (as discussed earlier)
SEVERE
HYPOGLYCEMIA TREATMENT
If an IV is not available: (or if the patient is not willing or
able to swallow)
1. Give Glucagon IM (1mg) Retest FSBG 15-20
minutes after treatment
2. Give one (1) amp D50 slowly
3. Start D5W at 100ml/hour
4. Notify physician
KEY POINT:
Glucagon comes in a kit from the Pharmacy. It has to be
reconstituted by the nurse right before giving it.
SEVERE
HYPOGLYCEMIA TREATMENT
Glucagon was the first step if the IV is not available. Do you
know what it is and how to use glucagon?
Glucagon is an important hormone in carbohydrate metabolism.
It is released from the Alpha cells of the pancreas. It helps
maintain the level of glucose in the blood by causing the liver
to release its stored glucose.
Glucagon is given for severe hypoglycemia as an IM injection
which helps to quickly raise the blood glucose.
When Glucagon is used, place the unconscious patient on
his/her side, supporting the head, give the IM injection, and
closely observe the patient. The patient may wake up
vomiting and/or feeling sick.
SEVERE
HYPOGLYCEMIA TREATMENT
REMINDER: Implement seizure precautions (observe for
seizures) when patient is experiencing severe
hypoglycemia.
KEY POINTS:
Plan ahead!!! For any patient on insulin, always keep a
watch out for hypoglycemia. Treat immediately and retreat!!!
Teach!!!
Document, document, document!!!
HYPOGLYCEMIA
OTHER POINTS OF INTEREST:
Some patients may have ‘hypoglycemia unawareness’. This
is when the patient loses the ability to feel the symptoms
of low blood glucose.
Frequent monitoring helps to identify that condition and
treatment is initiated sooner. This helps the body to
recognize the low blood glucose sooner.
KEY POINT:
It is important to treat the FSBG number whether
symptomatic or not.
Another point of interest is the timing of FSBGs, Insulin
Administration and meals.
HYPOGLYCEMIA
DETERMINE CAUSE AND MAKE CHANGES:
1. SLIDING SCALE INSULIN
2. INADEQUATE INTAKE
3. NPO STATUS AND DIABETES AGENTS NOT
DISCONTINUED
4. INSULIN AND MEAL NOT SYNCHRONOUS
5. WRONG TYPE ISULIN 70/30
6. GLIPIZIDE NOT DISCONTINUED
TIMING OF FSBG, INSULIN, AND MEALS
The timing of checking a patient’s blood glucose is
important in relation to the meal. It’s important to
check it right before the meal (which is why the order
needs to be ac & hs).
Then it can be determined whether insulin is needed or
not. And depending on the type of insulin, it may be
given right before the meal (as Novolog or Humalog insulin) or
up to about 30 minutes before the meal (as Regular
insulin).
TIMING OF FSBG, INSULIN, AND MEALS
Therefore, we often need to encourage the patient
to eat especially if he/she is receiving insulin.
Sometimes if the patient does not eat enough and
insulin is given, then low blood glucose could
occur.
Monitoring, recognizing hypoglycemia symptoms,
and providing replacement foods will help to
prevent it!!!
A consult to the Dietitian may need to be
considered.
HYPOGLYCEMIA
KEY POINTS: FOR NURSES
Physicians base medication changes on how much hypoglycemia
or hyperglycemia is occurring.
So the Physician won’t know that unless it is accurately
documented.
DOCUMENT the result, time, and treatment on the MAR; &
DOCUMENT the following in the blood glucose section of the
patient care flow sheet:






FSBG
Time of hypoglycemia occurrence
If patient is symptomatic or not
Treatment (and if no treatment)
Response to treatment
If Physician was called and why
HYPOGLYCEMIA
KEY POINTS cont’d:
When a patient experiences hypoglycemia, use this time as a
teachable moment.
Discuss the signs and symptoms, how to treat and when to
call the doctor.
If the patient has Type 1 diabetes, verify with the patient and
family if someone knows how to give glucagon. If not,
once again, a teachable moment has occurred.
Use your resources! Remember all the forms, protocols,
standing orders, and teaching materials are at your
fingertips. . . . .
And, use the event as a learning experience for yourself;
reassess the cause and how it could have been prevented.
HYPOGLYCEMIA
Well, let’s see if you can now put it to use!
Let’s look at several case studies.
CASE STUDY #1
Your patient, Mrs. Smith is going for surgery
later today. She is NPO and you have just
started an IV. She calls out and says she feels
light headed. What do you do?
CASE STUDY #1
Obviously, the first step is to check her
FSBG.
When you do, you find that it is
52mg/dl.
What is your next step?
CASE STUDY #1
Yes, one amp of D50 is the correct answer!
Remember if the patient is NPO & FSBG is less than 70mg, the
hypoglycemia is to be treated as if it is severe. And of
course Mrs. Smith had an IV available.
Then retest the FSBG 15-20 minutes after initial treatment and
every 1 minutes thereafter. You may have to give an
additional one (1) amp of D50 slowly if the hypoglycemia
continues.
CASE STUDY #2
.
You gave Mr. Jones 70/30 insulin about 0715 this
morning. It is now 12noon. You go to check
on Mr. Jones and notice he is sweating and
seems irritable when you ask how he feels.
What should you do?
CASE STUDY #2
Of course, the first step is to check his FSBG.
OK, his FSBG is 63mg/dl. WHAT MAY HAVE
CAUSED IT
CASE STUDY #2
One point of interest with Mr. Jones’ case. Remember
he had his scheduled 70/30 insulin about 4 to 5
hours prior to the hypoglycemia occurrence.
70/30 insulin has regular insulin in it which has a peak
effect of around 4 to 6 hours.
FIXED DOSE COMBINATION INSULINS ARE NOT
APPROPRIATE IN THE INPATIENT SETTING
CASE STUDY #3
Your patient Ms. Torres says she feels like her
blood sugar is low and would like something
to eat. She has no other symptoms of
hypoglycemia other than she is hungry.
Her FSBG is 74mg/dl.
What are you going to do?
(Yes, this could be a trick question . . . . :-)
CASE STUDY #3
Let’s think this through . . . . . . . .
The in-hospital blood glucose range is 70 –
180mg/dl.
The hypoglycemia protocol says to start
treatment when the FSBG is less than
70mg/dl. regardless of symptoms or not.
Her FSBG is 74mg/dl.
She wants something to eat. HHhhmmmm.
CASE STUDY #3
Well, if her diet allows it, give her something to
eat!
Technically, you are not ‘treating a low blood
glucose’. You are just giving her something to
eat because she asked for it.
However, pay attention to future FSBG’s and
other symptoms (just in case she actually does
become hypoglycemic).
CASE STUDY #4
OK, let’s do one more case study.
You are one of those lucky nurses who has a
nursing assistant do all the FSBG’s.
She comes to you and says that Mr. Johnson is
disoriented (this is a change in his mental status),
sleepy, and his FSBG is 44mg/dl.
What do you do?
CASE STUDY #4
On your way back to his room, you get a cup of
apple juice.
When you get to his room, you find Mr. Johnson
laying in his bed having pulled out his only IV
(he was a hard stick).
You try to give the juice but he is not swallowing
well and he chokes a bit.
What are you going to do?
CASE STUDY #4
Yes, take a deep breath and think GLUCAGON!!!
1. Ask the nursing assistant to stay with the
patient.
2. Call Pharmacy for a STAT Glucagon injection
kit.
3. Turn the patient on his side and put a pillow
under his head.
4. Give the IM injection in his hip.
CASE STUDY #4
Now, comes the hard part. . . . . wait, observe,
and support.
Remember after glucagon injection, the patient
could get sick and throw up. So be prepared
for this.
Also get prepared to start another IV as soon as
possible.
After 15-20 minutes, check his FSBG again.
CASE STUDY #4
OK, let’s say he arouses and is now becoming
oriented.
You check his FSBG and it is 65mg/dl.
He is able to swallow now. Give him either a ½
cup juice, or 4 glucose tablets, or one Glutose
gel tube.
Keep checking the FSBG every 15-20minutes
until it has stabilized above 70mg/dl. and treat
as needed.
KEY POINTERS
It can not be repeated enough . . . . .
When treating hypoglycemia, give 15 to 30
grams of carbohydrate every 15-20 minutes
until the FSBG is above 70mg/dl.
Do not over treat!!!
Follow the protocol.
Observe for future hypoglycemia once the
patient has one occurrence.
HYPOGLYCEMIA
Just remember the following four steps when hypoglycemia
occurs:
PLAN
TREAT
TEACH
PREVENT
DOCUMENT
HYPOGLYCEMIA
Just remember the following when hypoglycemia occurs:
PREVENT
PREVENT!
Determine cause
Make Changes
THE FINISH LINE
CONGRATULATIONS!
You have just finished the
HYPOGLYCEMIA
Learning Module