Case Study #99: Hypoglycemia

What would your next action be since BG is still not in the range of what is wanted?

-Give fruit juice, 15 grams - because he is less than 70, follow that 15 grams of simple carbohydrate with a complex carbohydrate and a protein snack such as meat, cheese or peanut butter with crackers, this would be if it is one hour before his next meal, then check BG in 15 minutes- if the BG is still less than 70 after 15 minutes then treat a third time and prepare to transfer the patient to the hospital - after 15 grams it is important to give a complex carb and a protein snack- this is important because it will maintain the BG long-term, the protein and complex carb will maintain it longer

What questions would you ask to find out what precipitated this event?

-Have you eaten recently? - What did you eat? - When was the last time you took your insulin? - How often do you check your blood sugar? - Has this ever happened to you before? - know what type of insulin he took earlier in the day, how much and when did he take it (in red) - Ask what his morning glucose level was (in red)

Based on your knowledge of the types of insulin TR is receiving, when would you expect TR to experience a hypoglycemic reaction?

-He took the Humulin R, the onset is 30 minutes, he should eat within 30 minutes of the fast-acting insulin because it is fast-acting - Regular insulin beaks around 2 to 3 hours after administration so that is another time for concern, may have a reaction mid-morning or around lunchtime, the peak is 2 to 3 hours - Lantus is a peakless insulin, the onset is 1.5 hours and duration is up to 24 hours but has no peak and does not contribute to hypoglycemic reactions

What should you teach TR about alcohol consumption and managing his diabetes?

- Encourage to not drink at all, he should check BG before he drinks, while he drinks, and for up to 24 hours afterward - Check BG before bed, if it is low he needs to eat something before bed to help raise it - If this person drinks then he should drink light beer or wine spritzers with club soda, heavy craft beers have twice the alcohol and calories, if he has mixed drinks then chose calorie free mixers such as club soda

List 4 additional points you would stress in a teaching plan with T.R.

- For the candy, make sure it is a simple carb like lifesavers and not a candy bar - Needs to know when to expect a hypoglycemic reaction based on insulin, need to know onset and peaks - Importance of not delaying his meals - Should receive prescription for glucagon emergency kit and know how to use it - Should carry medical identification such as a bracelet, letting others know he has type 1 diabetes - If he plans to exercise, he should increase food consumption shortly before exercising- this will cover the insulin that he took and also the fact that his muscles are going to use glucose while exercising- he has increased nutritional needs during exercise (emphasized in class)

You tell TR to check his blood glucose at 1230 then eat lunch at the normal time. You determine that he understands your teaching regarding averting hypoglycemia if he states: A."I need to eat within 30 minutes of taking the regular insulin" B. "If I am too sick to eat, I will not take any insulin until I feel better" C. "Only certain kinds of alcoholic drinks will affect my blood glucose levels." D. "I will exercise just before eating and taking insulin so I do not get cramps."

A. "I need to eat within 30 minutes of taking the regular insulin"

If no glucose meter were available, would you treat TR on the assumption he is hyperglycemic or hypoglycemic? Explain your reasoning.

Always treat as if they are hypoglycemic. People can live for many hours if they are hyperglycemic - if they are hypoglycemic it needs to be treated right away and is dangerous- our central nervous system and our brain need a continuous supply of glucose- when it falls below the critical level, patients are in danger of death In the case of T.R. he reported wandering aimlessly, appearing pale and sweaty which are common s/s of hypoglycemia.

At 1045, you recheck TR's glucose and the reading is 64 mg/dL (3.6 mmol/L). His vital signs are 120/72, 18, 92. Has his status improved or not? Defend your response.

BG is now 64 which is still not in the range of what they want, still needs active treatment for hypoglycemia at this time

It is 1025. TR's glucose reading is 50 mg/dI. (2.8 mmol/L). What should your next action be?

Give 15 grams of a simple carbohydrate, 4 ounces of fruit juice or regular soda or 3 glucose tabs

When you enter the room to give the juice, TR is not responsive enough to drink the juice safely. What should you do?

Glucagon can be given SubQ or IV If they are not responsive enough to drink, maintain airway, circulation and breathing, check their vital signs, activate EMS system.

Based on this information, why did TR experience this episode of hypoglycemia?

He did not eat enough to cover 12 units of regular insulin that he took

What do you think is going on with T.R?

He is having a hypoglycemic episode.

What is the first action you would take if you suspect hypoglycemia?

I would have T.R. sit down, while I check his glucose level to determine a course of action.

What further action do you need to take at this time?

Recheck his blood sugar and monitor his status / signs & symptoms of hypoglycemia and make sure it is resolving by ensuring he continues to be alert and oriented X4. Recheck vital signs (in red)

TR. says he had a few similar episodes recently, He treated them by eating a candy bar. He says he is on a 2000-calorie, carbohydrate-controlled diet but has been checking his blood glucose levels every "couple of days" only. What common mistake in previously treated episodes of hypoglycemia did TR. make?

TR should be checking his blood sugars more often. He should check them before meals or snacks and if he experiences any signs or symptoms of hypoglycemia or hyperglycemia. It is good that TR treated the hypoglycemic episode by eating, but he should ideally consume 15g of fast acting carbs and protein. - that 15 grams should be followed by protein and a complex carbohydrate (in red) - problem with candy bar is that if the sweet food contains fat- such as cookies and ice cream- these are poor choices because the fat will slow down absorption of the sugar and delays the response- AVOID FAT like cookies, ice cream and candy bars (in red)

Write a sample documentation note for the encounter with TR.

The patient T.R. was brought into the clinic pale, sweaty, and confused. Patient was diagnosed with hypoglycemia. At 1025, the patient's blood sugar was 50 mg/dL and became unresponsive. TR's breathing rate was 16 and he has a pulse of 112 and regular. 2 mg of subcutaneous glucagon was administered and the patient recovered. At 1045, his blood glucose was 64 mg/dL and vitals were 120/72, 18, 92. Patient was given orange juice and a carbohydrate meal. Blood glucose was redrawn at 1110 and it was 104 mg/dL. TR. says he had a few similar episodes recently, and treated them by eating a candy bar. He says he is on a 2000-calorie, carbohydrate-controlled diet but has been checking his blood glucose levels every "couple of days" only. Patient takes 35 units of glargine insulin (Lantus) and 12 units of regular insulin (Humulin R) and only had an apple to eat this morning. Patient was educated to measure blood glucose after eating lunch and to follow-up with the clinic in one week. - make sure that you have the patient check the BG before eating lunch and that the simple carb is followed by a complex carb and protein (in red)

At 1110, you recheck TR's glucose and the reading is 104 mg/dL (5.8 mmol/L). What should you do now?

This is a normal blood glucose level, so what you would do now is; follow the hypoglycemia protocol per facility guidelines & most importantly educate TR on how to prevent this from happening again. - you will need to make sure to check BG before lunch and that he eats a lunch within dietary parameters *(in red)*

TR's breathing rate is 16 and he has a pulse of 112 and regular. Because outpatient resources vary, describe your next actions if (1) your clinic is well equipped for emergencies or (2) your clinic has no emergency supplies.

Well Equipped = for the IV fluids, if you were in a well-equipped clinic, IV fluids started would be Normal Saline and they would administer ampule of 50% dextrose IV push No Emergency Supplies = If you did not have NS or dextrose, they would start an IV of 5 % or 10% dextrose until paramedics arrive

Which assessment findings would support the premise that TR is experiencing a hypoglycemic reaction? a. Extreme thirst and nausea b. Nervousness and tachycardia c. Hypertension with bounding pulses d. Fruity breath with deep, rapid respirations

b. Nervousness and Tachycardia