Transcript 2009 Blood Glucose Module for Hypoglycemia for Nurses

BLOOD GLUCOSE
CONTROL
HYPOGLYCEMIA
Learning Module
Developed by: Dana Graves RN, MSN, CDE
Diabetes Clinical Nurse Specialist
December 2008
INPATIENT BLOOD
GLUCOSE CONTROL
This learning module is required for orientation to
Diabetes Care and blood glucose control here at
Saint Joseph Health System. This can also be
used for periodic reviews as needed.
The purpose of this module is:
1. To describe the hypoglycemia signs and
symptoms and causes.
2. To discuss inpatient treatment of hypoglycemia.
At the end of this module,
you will take a 17 question post-test.
HYPOGLYCEMIA DEFINITION
So let’s begin with defining hypoglycemia . . . .
Webster’s defines hypoglycemia as “an abnormal decrease of sugar
(glucose) in the blood.”
Therefore, it is when the blood glucose level drops below the normal
level. So what is normal?
Many sources do not agree on a number to identify hypoglycemia. The
American Diabetes Association workgroup on hypoglycemia stated
that “…the glycemic threshold for activation of glucagon and
epinephrine secretion as glucose levels decline is normally 6570mg/dl…” (Diabetes Care, May 2005, Defining and reporting Hypoglycemia,
page 1247)
Thus, the SJH 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 that even though
Hypoglycemia can be serious and
must be treated right away, it rarely
results in any adverse 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?
SAINT JOSEPH HEALTHCARE
HYPOGLYCEMIA PROTOCOLS
Saint Joseph Health System (SJHS) actually has
three hypoglycemia protocols based on weight and
type of individual:
Adult Hypoglycemia Protocol (>100lbs)
Hypoglycemia Protocol for children (<12y.o.) or adults
<100lbs.
Hypoglycemia Protocol for pregnant women
All three protocols are similar with the exceptions of
dose changes. We will look primarily at the Adult
Hypoglycemia Protocol. The next slide shows the
protocol form.
SAINT JOSEPH HEALTH SYSTEMS
HYPOGLYCEMIA PROTOCOL
SAINT JOSEPH HEALTHCARE
BLOOD GLUCOSE TARGET
The SJHS laboratory normal blood glucose is
in the range of 60 to 110mg/dl.
However, to allow for fluctuations that are
common in hospitalized patients, SJHS’s
inpatient target blood glucose for people
with diabetes is:
70 to 180mg/dl for Med/Surg/Tele patients
80 to 140mg/dl. for Critical Care patients
HYPOGLYCEMIA PROTOCOL
Yes, there are 2 different target blood glucose ranges
and that is on purpose!
There is a tighter blood glucose range for Critical
Care patients since research shows that a tighter
control helps to decrease morbidity and mortality
rates for critically ill patients and also since FSBG
can be more closely monitored and controlled.
So, now let’s review the Adult
Hypoglycemia Protocol.
HYPOGLYCEMIA PROTOCOL
This protocol does not need a physician’s order to
implement it. But will need a signature
eventually (so place a red ‘sign here’ flag on the
form).
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 if low treat with this
protocol.
(Remember we already reviewed the signs & symptoms)
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 41 – 69mg/dl IF patient has mental status changes
OR is unconscious; OR NPO; OR when the
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 15-20 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:
If it is not mealtime:
 Give the patient 15-30 grams of carbohydrate using one of the following:
 3 to 4 glucose tablets
 one Glutose 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 – 20 minutes until the
FSBG is >70mg/dl
Tablets or gel are preferred treatment since they are a purer
form of glucose; these are located in the Accudose.
Apple juice is preferred over orange juice since orange juice
may be contraindicated in many patients (as renal or
cardiac patients). However, if the patient does not like
apple juice, then choose tablets, gel, or orange juice.
MILD/MODERATE
HYPOGLYCEMIA TREATMENT
Re-testing the FSBG and treating EVERY 15-20 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,
call the doctor who is managing the patients
blood glucose for further orders.
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 Glutose 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.
Remember this is defined as the following:
FSBG of 41-69mg/dl with mental status changes, or,
Unconscious, or,
FSBG of 40mg/dl or less (whether symptomatic or not)
For any severe hypoglycemia, obtain a STAT lab blood glucose
AND treat the low FSBG!
(You are not to wait for the lab results to start the treatment)
KEY POINT:
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.
5.
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
Notify physician
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.
2.
Give Glucagon IM (1mg) Retest FSBG 15-20
minutes after treatment
Start an IV with D5W, if the patient remains
unconscious
Give one (1) amp D50 slowly
Start D5W at 60ml/hour
Notify physician
3.
4.
5.
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.
Always let the doctor know you’ve had to use Glucagon.
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. Have the hypoglycemia
protocol readily available on your clip board or in the
MAR.
Treat immediately and re-treat!!!
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.
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 and Diabetes Treatment
Center may need to be considered.
HYPOGLYCEMIA
KEY POINTS:
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. . . . . . All located in the SJH intranet (under
Departments, then choose Diabetes Treatment center
(DTC).
And, use the event as a learning experience for yourself;
reassess the cause and how it could have been prevented.
HYPOGLYCEMIA
Example of documenting
hypoglycemia on the
Hypoglycemia MAR
form.
You can document on the
patient’s current MAR
or you can use this form.
This form is located in the
Orders & Forms section
of the SJHS Intranet,
under Endocrinology as
the 2nd page of the Blood
Glucose Control
Protocol.
HYPOGLYCEMIA
Whew, that’s a lot of GOOD information!!!
Well, let’s see if you can now put it to use!
Let’s look at several case studies.
Hang in there! This won’t take too long!!!
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?
Ta da ta duh ta da duh . . . . Well, that’s the
computer version of the Jeopardy music!!
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 15-20 minutes thereafter. You may have to
give an additional one (1) amp of D50 slowly if the
hypoglycemia continues.
Remember after the initial treatment to notify the patient’s
physician who is taking care of the blood glucose for
further orders.
CASE STUDY #2
GOOD JOB!!! Let’s look at the next case
study.
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 is your first
step in treating this hypoglycemia?
A HINT . . .
It is 12noon and the dietary tray cart is on the
unit.
CASE STUDY #2
YES! Feed Mr. Smith. Give him his meal
tray! No need to give an extra carbohydrate
at this point yet.
Then what do you do?
YES! Check his FSBG in 15-20 minutes.
You’ll need to keep checking his FSBG every
15-20 minutes until it is >70mg/dl.
CASE STUDY #2
Please do not assume that eating his meal will
take care of the hypoglycemia. He still
might need a bit more carbohydrate, OR, he
may not.
Do check his FSBG shortly after he has
finished his meal! Observe for potential
other hypoglycemia occurrences.
Remember to document!!!
CASE STUDY #2
One more 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.
Do pay attention to future insulin doses and monitor
for hypoglycemia especially in that 4 to 6 hour
period. Because if it does happen again, then
perhaps the insulin dose or the time it is given,
may need adjustment!
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
1.
2.
3.
4.
Yes, take a deep breath and think
GLUCAGON!!!
Ask the nursing assistant to stay with the
patient.
Call Pharmacy for a STAT Glucagon
injection kit.
Turn the patient on his side and put a
pillow under his head.
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
DOCUMENT
THE FINISH LINE!!!
CONGRATULATIONS!
You have just finished the
HYPOGLYCEMIA
Learning Module
If you have any questions, please contact your
Clinical Educator, your unit’s Diabetes Champion,
or one of the Diabetes Educators.