welcome to unit 2 diabetes mellitus nursing management part 2. in this presentation we will begin the discussion of acute complications of diabetes mellitus there are two overall classifications of complications in diabetes hypoglycemia and hyperglycemia hypoglycemia is anything technically less than 70 milligrams per deciliter remember our normal blood sugar is 70 to 110 milligrams per deciliter however you can see on this slide that we have the descriptions of mild moderate and severe and that's because when you're describing hypoglycemia it's more in relation to the symptoms the patient is experiencing and someone who does not have diabetes you might experience mild hypoglycemia nervousness um hunger irritability slight irritability with a little bit of mild hypoglycemia so maybe like in the 60s maybe even low 70s but if you have someone who's a diabetic and they live say in the two to three hundreds they might feel those same symptoms those mild symptoms whenever they start dropping into uh more of a normal range so we'll say 120 or 130. so it just depends on where the patient typically lives and then that also how it manifests as symptoms for that specific patient and we're going to talk more about those symptoms here in a second there's also of course hyperglycemia and the two key conditions we're going to talk about in this presentation are the two major acute metabolic decompensation syndromes in relation to both type 1 and type 2. we have diabetic ketoacidosis which occurs in type 1 diabetics and we have hyperglycemic hyperoz molar syndrome hhs also known as honc hypoglycemic hyperosmolar non-ketotic syndrome which occurs in type 2 diabetics and i know some of us especially if you're in the lpn of paramedic track you have seen type 2s flirt with being in diabetic ketoacidosis because their their type 2 diabetes has progressed so far that they they look a lot like a type 1 so basically their beta cells have really really poor function and they might be somewhat acidotic so i will say there is a continuum in between dka and hhs but for the purpose of this class for ctas and for testing diabetic ketoacidosis that comes along with changes in ph of course outside of normal range will relate to a type 1 diabetic and then hyperglycemic hyperas molar syndrome hhs which does not include a condition of acidosis will occur in type 2 diabetics as stated before hypoglycemia is an abnormally low blood glucose level technically below 70 milligrams per deciliter and severe hypoglycemia is less than 40 milligrams per deciliter and in this situation we're talking more about severe hypoglycemia in relation to the the true amount of blood sugar a patient has versus severe hypoglycemia in relation to just symptomatology such as becoming disoriented having seizures even becoming comatose what causes hypoglycemia well there's two major categories so you can have an excess of insulin or oral hypoglycemic agents so too much of a means for the body to use glucose so whether it's direct replacement of insulin or if this patient takes oral hypoglycemic agents so not metformin but specifically sulfonylureas because those specifically act in the beta cells to boost the production of insulin remember metformin does not act on insulin it just basically tells the liver to calm down but release any extra sugar and allows for the cells to use insulin better the other cause of um of hypoglycemia might be excess physical activity because you're just using up so much of that blood sugar your body is demanding so much of it being used the other cause of hypoglycemia or major category is just taking in too little food now this may occur at any time of day or night but it often occurs before meals especially if they're delayed or if snacks are omitted and that becomes important especially in acute care nursing if you have a patient who's on lispro or specifically regular because one of those two and typically regular is used for sliding scale if you give them a injection of insulin and then depending upon which uh insulin you've given them whether it's a lisper or regular if you give it to them in that certain period of time which is ideal before they take their first bite of food which may be anywhere between well 5 to 15 for list bro and 30 to 60 for regular if you give it within that time frame there's always the possibility that dietary may be delayed there might be an order that was lost and so you always have to be concerned about that patient having that first bite of food for sure during that time frame so unfortunately in real world practice we need to be giving that insulin only when we are sure that that patient has their tray in front of them because if that patient becomes hypoglycemic they can become very dangerously hypoglycemic very rapidly and to lower blood sugar is always more rapidly a problem than too high of a blood sugar but then that also brings in the problem of if we are not giving them insulin with enough time for it to get into the body and start taking its effect so when they take the first bite of food they don't have a spike in blood sugar if we're not timing it just right they're gonna have consistent spikes in blood sugar so for example if i take a shot of lisbo and then literally 30 seconds later i start eating my food my blood sugar is going to spike up because it's going to take five to 15 minutes before that lispro to take effect and my my food is already going to be digesting and being released into my bloodstream as sugar so you're going to get this really short spike in blood sugar but if that consistently occurs over time can cause vascular and then ultimately nervous damage the other time that too little food is an issue is when snacks are omitted so maybe a midday snack or more specifically at night especially if a patient's on sliding scale and they have an hs dose of insulin if they meet that requirement per their blood sugar you always give a small snack with hs insulin now of course nothing huge like a bowl of ice cream even though maybe that's what they ask for but something more so like cheese and crackers peanut butter a small glass of milk just something that can carry them through the night with that small amount of insulin that's given to them so they don't become hypoglycemic overnight so what are some of the symptoms of hypoglycemia well there's two branches of symptoms because there's the two different well not only two different but we're talking here about two different branches of the nervous system we've got adrenergic which is more related to sympathetic nervous system or peripheral nervous system and then we also have the cns which is the central nervous system so i'm talking about the brain so adrenergic means that we feel sweating it's peripheral um it's innervations in the skin we might feel tremors innervations in the muscles tachycardia innervations in the heart which is also you know we can also feel palpitations as well just that general nervousness as well as hunger because our we're actually feeling hypoglycemic and our body is telling us so the way we can fix that is by taking in sugar so these are a bit more peripheral types of feelings the nervousness meaning like the uh it goes along with the tremors and the sweating and that sort of um peripheral manifestations of nervousness then if you look at the cns you're going to have an inability to concentrate you might experience a headache confusion memory lapses and altered mental status so if we ask these patients the alert and oriented questions times 4 we won't be getting the answers that we hope to get on an otherwise alert and oriented patient so they might have memory lapses slurred speech poor coordination drowsiness the reason all this happens in hypoglycemia is because our nerves and our muscles heavily depend on a constant and rich supply or appropriate supply of glucose our brains require so much glucose it is really disproportionate the amount of glucose that our brains require versus what the rest of our body requires so that's why when you become hypoglycemic you tend to have a lot of mental status changes because that brain it has to have a constant and steady supply of glucose to function three classifications of hypoglycemia if you'll notice i don't have any numbers listed on this page now i know i talked about before there's hypoglycemia and severe hypoglycemia but that's when you're thinking about the patient who otherwise has normal glucose metabolism they have cell receptivity to insulin they don't have any issues but this right here i want you to think more within the context of someone who has poor glucose metabolism you can have someone who let's say they have a very high hemoglobin a1c their blood glucose tends to run in the 400s all the time so they might feel mild hypoglycemia when their blood sugar dips to only say 200 because their body is used to that level of blood sugar they're used to living in the 400 so when they get down to 200 their cells become a bit confused because they're just used to having so much sugar so they're actually going to feel tremors tachycardia palpitations nervousness hunger sweating with a blood sugar of 200. so let's say you get them down to say 150 then they start to feel confused they have a headache they have poor coordination they've got slurred speech some confusion numbness of the lips and the tongue so they're actually feeling some moderate hypoglycemia at say 150 whereas someone who didn't have diabetes that they wouldn't be feeling that way because their body is used to being within that 60 to 110 whereas this patient with diabetes may be used to living in a much higher level all the time or much higher range of blood sugar all the time so with a moderate hypoglycemia your brain is just beginning to become deprived of the fuel that it needs to function you start to see the beginning of central nervous system issues now if we go down to severe so let's say this same patient lives in the 400s let's say we get them down to 90 which is otherwise normal in a patient who's not a diabetic they might have severe hypoglycemia symptoms such as disorientation combativeness seizures loss of consciousness difficulty arousing them from sleep drowsiness and may even go into a coma and die even though technically their blood sugar is normal for a patient who doesn't have diabetes and that's because your brain like i said before your brain loves that sugar that cns function is so impaired there's so little fuel to function that there has to be another person to help them uh with this treatment of hypoglycemia another thing that's important about this list is that with mild hypoglycemia notice there's no cns changes so we just need to get them some juice we need to get them something um orally and if they're just mildly hypoglycemic they don't have any cns changes they could take in something by mouth whereas with moderate that's a little iffy it just depends on how confused they are um how um how lightheaded are they whether or not they can take something by mouth and then of course with severe they're not taking anything by mouth they're going to have to have some other type of intervention through a different route symptoms of hypoglycemia they may occur suddenly too that's uh one thing to think about with patients that are on uh beta-adrenergic uh blockers such as metoprolol like we talked about uh say if they're on a sulfur urea they become hypoglycemic because sophomore boost insulin production which can make someone hypoglycemia because you're basically providing the blood with the key to the cell that allows the glucose go into the cell and so if you're also taking metoprolol let's say that you become slightly hypoglycemic sulfonate they're new for you or maybe you just don't haven't figured out how to manage how much to eat with your dose just yet and even though you're hypoglycemic your body is not responding with the tremorous palpitations nervousness all those things that your sympathetic nervous system um does to tell you hey i've got a problem here because they're taking that beta adrenergic receptor blocker like metoprolol so they don't feel the symptoms of hypoglycemia so they may go from fine fine fine to coma because they're not getting the alert that their sympathetic nervous system would otherwise give them if they weren't on a beta adrenergic beta blocker such as metoprolol it also very much varies between individuals and not just in between people who are diabetics and people who aren't but between um people who are just normal blood glucose i tend to run hypoglycemic more so than the average person there's a lot of diabetics that they may they may more rapidly experience hypoglycemia and much more pronounced than others and it's just because of their own genetic predisposition to how they relate to glucose and insulin it gets very complex but the bottom line is there's there's typical presentations but you have to appreciate the fact that every diabetic patient every person is very individual and again symptoms are used to categorize hypoglycemic severity rather than blood glucose levels for that reason and here's just that example i talked about before if your blood glucose is typically normal you're going to have symptoms when your blood glucose falls below normal if you tend to live in a very high range or hypoglycemic range you may feel hypoglycemic when your blood levels drop to a normal or almost normal level it just depends on what your body is used to so how do we manage these patients well first of all if the patient is conscious and alert and can also take things by mouth um typically speaking in an otherwise healthy person if they are conscious and alert the first thing we do is give specifically 15 grams of fast acting concentrated carbohydrate orally and 15 grams is specific because if we gave them 50 grams we might send them in the opposite direction we don't want to over treat right in nursing we want to treat but not over treat because if you over treat you can cause a lot of problems so we want to give them just enough to get them into a normal range so we get 15 grams concentrated simple sugars so i'm not giving a turkey sandwich i'm not giving them crackers and cheese i'm not giving them peanut butter i'm not giving them milk at this point i'm giving them maybe just a regular soda which is usually a you know no no for a diabetic but if they're hypoglycemic they need the sugar so they can have a regular soda they can have some kind of juice maybe there's like a gel candy um that they can have just anything that's rapid simple sugars and simple sugars mean there's no fiber there's no fat there's no protein it's just fast sugar think of the stuff that gives you a sugar rush that's what's appropriate right now with your patient who's truly hypoglycemic and there's just some examples right there so you can also give glucose tabs like the glucose gel or like i said about a half a cup of juice or regular soda but not diet soda because remember in diabetic patients we are trying to keep their sugar down we give them diet soda but if right now they're hypoglycemic that's their ticket for a real soda and only half a cup not not a huge 32 ounce one so we need to this the second step then is to retest that blood glucose in 15 minutes if that blood glucose is less than 70 we need to retreat with the supplies from number one so give them another couple of glucose tabs give them another half a cup of juice and then recheck them again in 15 minutes to see if they have come into that normal range for blood sugar and also are they still having symptoms if their blood sugar is less than 70 or if they're a patient who lives in the 400s but they're still feeling very hypoglycemic then you can give them another half cup of juice or just something small to try to slowly bring them back into a normal level then we need to maintain we can't just say well i've fixed your blood sugar you're back to normal but we all know that if we just drink a giant soda our sugar is gonna spike and then we're gonna have a sugar crash so you don't want to do that with anybody but especially with diabetic patients you can give them that fast acting sugar just to get them to feeling better or to normal range but then after that support them so they don't just become hypoglycemic again now is the time to give them peanut butter and crackers cheese and crackers a turkey sandwich something that has protein fats and fiber in it that can maintain them that take much longer to break down now this is in relation to hypoglycemia in an emergency if the patient cannot swallow and or is unconscious now we are not doing anything by mouth do not attempt any source of po glucose because if they can't swallow or they're unconscious and you put something in their mouth they may choke they may aspirate you're going to cause an airway compromise and you're going to make the situation worse so do not put anything in the mouth of a unconscious patient or someone who cannot swallow so your first mode of action is going to be intramuscular glucagon by injection so one milligram and this is if your patient does not have iv access if you are say um in home health or a nursing home or somewhere where we're not in acute care you also do have patients in acute care who have had orders to keep their iv out for whatever reason so if you don't have iv access your first action should be intramuscular glucagon and then while that glucagon might be trying to take its effect because it takes about 20 minutes you can try to start an iv but you're constantly assessing that patient to see are they coming around because remember glucagon is also that hormone released by the alpha cells glucagon then tells the the liver to break down glycogen to then release glucose into the bloodstream to bring up our blood sugar so it's just going to take about 20 minutes for all that to happen and have your patient actually wake up or become conscious again now if there's no response within 20 minutes then you can administer 20 to 25 mil a 50 dextrose or an amp d50 now i i have heard um and i've read a few things about d50 being just too much sugar so it may be an amp of d10 or d5 they may actually be giving less but the bottom line is you're going to be giving something uh by iv if they have iv access now in this situation if they can't swallow they're unconscious and they have iv access we'll skip glucagon just go right to iv access and give them glucose but i will say do not just give them intramuscular glucagon and then leave your patient give them that glucagon make sure they have that response within 20 minutes and if they don't make sure that they're getting an iv during that time frame and that you continue to take care of that patient the reason i bring that up is because i've had several nurses and paramedics tell me that so often in practice they see people give glucagon and oh my job here is done no you have to ensure that you're patient it's that evaluation piece right you've got to close that loop and evaluate to make sure what you did actually worked so glucagon injection this is a video you can watch on how to administer a glucagon injection a key thing about this medication is after the injection you need to place the patient on their side a very common side effect of glucagon injection is feeling nauseated and vomiting so if you don't place them on their side again you're going to cause aspiration because if they vomit and they're laying on their back they're going to suck that into their lungs again it may take as long as 20 minutes to regain consciousness so during that time try to get iv access if you don't have it and be sure that you're carefully watching that patient throughout that time frame and then of course if they recover and they don't need iv glucose you just skip the iv glucose and then you start to treat them once they're conscious and they can swallow with that simple sugar recheck recheck recheck you want to give them some kind of a snack then once they are feeling a little bit better they're within a normal range to then maintain them so they have to have something with protein fats and fiber along with carbs so that they have a much more stable blood glucose so when you have to give iv push dextrose the nice thing about this is effects usually can be seen in minutes or less just depending upon how hypoglycemic this patient is it's a little wild if you haven't seen it they go from comatose and they're just awake very rapidly because all of a sudden the brain is flooded with glucose and so they're suddenly awake but i do have to say you need to assess the patency of that iv because glucose especially if it's d50 is very hyperosmolar glucose is very caustic to the blood vessels as we know and so if you shove a bunch of d50 into someone's vessels it's going to cause irritation of that iv site and you very likely may lose that iv site especially if it's a small peripheral now if it's in a central line you may not but just know that dextrose is very caustic to the veins and you might lose that iv site so how can we help our patients prevent hypoglycemia well of course routine self-monitoring of their blood glucose sm bt so self monitoring of blood glucose help them to understand and be able to recognize and treat signs and symptoms of hypoglycemia so we're talking them through what are you know tremors and nervousness and hunger well that's mild you need to treat yourself before you start to feel you know confused and you have poor coordination and memory lapses like that means that it's already dangerous and the next step past that is you're going to lose consciousness so make sure they understand how to detect hypoglycemia just by feel if if they were to experience that condition but then to routinely check their blood glucose so that they don't even get into hypoglycemia they can manage it before they become symptomatic they could also have an id bracelet or tag especially if there's someone um who is like a brittle diabetic or tend to become dangerously hypoglycemic or again if there's someone who is on some sort of beta adrenergic uh receptor blocker med and so they don't even feel hypoglycemia some kind of tag or something that verifies that they have an issue and that people can take care of them and go get them the care they need tell them to keep a simple sugar source on hand at all times i've had you know friends and patients that have kept little candies now not always hard candies because if you're having any difficulty orally you don't want to have anything that you can aspirate so it's usually like a soft candy or like a gel but they do also have you make some hard candies that they're just feeling kind of hungry um or even like some chews and stuff just to kind of get them through till they can get a more reliable source and a more um complete source of food that has via proteins and fats and and fiber in it however they need to avoid high calorie high fat diets to treat hypoglycemia because that fat like i said it will slow down the absorption of blood sugar so if you think you're going to treat hypoglycemia with cheesecake you're in trouble um yes it's very high calorie and yes it's high sugar but you you're going to have a lot of fat in that dessert and so it's going to prevent that that rapid absorption of sugar and you're not going to get the the rapid replenishment of sugar that you need to get out of that hypoglycemic state so they also have to have a consistent pattern of eating they have to have that consistent pattern of administering their own insulin as well of a consistent pattern of exercising between their meal and or a bedtime snack so like i said before with exercising and administration of insulin and carbs and all that it's got to be very regimented because their pancreas is no longer doing this job for them they have to do that job and it's just easier to be much more consistent so you have a good a good regimen a good plan to prevent hypoglycemia i thought this was really cool to include that there's a lot of people that just get tattoos now uh that say diabetic and this is actually um become more popular especially with type one or uh just an early onset of type two because there's several instances of college students who were found unconscious and people just kind of blew them off as drunk or high or like they had abused some sort of substance but that wasn't true it's because they were diabetic and they were in a hypoglycemic or hyperglycemic state and they were unconscious and they really needed help so i have some sort of identification support your patients have some kind of identification on them so that people can clearly see that they probably need some sort of medical attention and they're not just being blown off for being some sort of substance abuser