Question

Med Surge Ch50

4. Differentiate between acute hypoglycemia and diabetic ketoacidosis.
5. Describe the treatment of a patient experiencing acute hypoglycemia or diabetic ketoacidosis.
6. Identify nursing interventions for a patient diagnosed with diabetes mellitus or hypoglycemia.
7. Assist in developing a nursing care plan for patients with diabetes mellitus hypoglycemia or ketoacidosis .

Answer 1

4. )

Hypoglycemia is a condition where the blood glucose levels are too low. The most common cause for hypoglycemia is diabetes medication. This is because too much insulin or medication to reduce blood sugar may drop levels too far, causing hypoglycemia.

Diabetic ketoacidosis is a serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones.

Hypoglycemia symptoms	Diabetic ketoacidosis symptoms
excess sweating, excessive hunger,	· High ketone levels in your urine
fainting, fatigue, light-headedness, or shakiness	· Excessive thirst
nausea or vomiting	· Frequent urination
mental confusion or unresponsiveness	· Nausea and vomiting
dryness or tingling lips	· Stomach pain
Anxiety, blurred vision, headache, irritability	· Weakness or fatigue
pallor, palpitations, sensation of pins and needles.	· Shortness of breath
sleepiness, slurred speech	· Fruity-scented breath
tremor, or unsteadiness	· Confusion

5.)

Treatment of Hypoglycaemia

· Eat or drink 15 to 20 grams of fast-acting carbohydrates. These are sugary foods without protein or fat that are easily converted to sugar in the body. Try glucose tablets or gel, fruit juice, regular — not diet — soft drinks, honey, and sugary candy.

· Recheck blood sugar levels 15 minutes after treatment. If blood sugar levels are still under 70 mg/dL (3.9 mmol/L), eat or drink another 15 to 20 grams of fast-acting carbohydrate, and recheck the blood sugar level again in 15 minutes. Repeat these steps until the blood sugar is above 70 mg/dL (3.9 mmol/L).

· Have a snack or meal. Once your blood sugar is normal, eating a snack or meal can help stabilize it.

Treatment of Diabetic ketoacidosis
*   Fluid replacement

At the hospital, your physician will likely give you fluids. If possible, they can give them orally, but you may have to receive fluids through an IV. Fluid replacement helps treat dehydration, which can cause even higher blood sugar levels.

Insulin therapy

Insulin will likely be administered to you intravenously until your blood sugar level falls below 240 mg/dL. When your blood sugar level is within an acceptable range, your doctor will work with you to help you avoid DKA in the future.

Electrolyte replacement

When your insulin levels are too low, your body’s electrolytes can also become abnormally low. Electrolytes are electrically charged minerals that help your body, including the heart and nerves, function properly. Electrolyte replacement is also commonly done through an IV.

6.)

Nursing Intervention

Advice patient about the importance of an individualized meal plan in meeting weekly weight loss goals and assist with compliance.

Assess patients for cognitive or sensory impairments, which may interfere with the ability to accurately administer insulin.

Demonstrate and explain thoroughly the procedure for insulin self-injection. Help patient to achieve mastery of technique by taking step by step approach.

Review dosage and time of injections in relation to meals, activity, and bedtime based on patients individualized insulin regimen.

Instruct patient in the importance of accuracy of insulin preparation and meal timing to avoid hypoglycaemia.

Explain the importance of exercise in maintaining or reducing weight.

Advise patient to assess blood glucose level before strenuous activity and to eat carbohydrate snack before exercising to avoid hypoglycaemia.

Assess feet and legs for skin temperature, sensation, soft tissues injuries, corns, calluses, dryness, hair distribution, pulses and deep tendon reflexes.

Maintain skin integrity by protecting feet from breakdown.

Advice patient who smokes to stop smoking or reduce if possible, to reduce vasoconstriction and enhance peripheral flow.

Nursing Intervention

• Assess causative or contributing factors by identifying the factors present.
• Assess the degree of impairment.
• Check the current blood glucose.
  • For conscious patients with blood glucose is below 60mg/dl give at least 10-15g of fast-acting simple carbohydrates such as 1 tablespoon of honey, 6 pcs of crackers, half glass of juice, or soda.
  • For unconscious patients and patients unable to swallow administer dextrose 50% 50ml bolus per IV as prescribed.
• Repeat the patient’s blood glucose level after 1 hour.
• Monitors patient’s vital signs.
• Draw blood for baseline electrolytes.
• Obtain a complete patient history including the last alcohol intake and medications.

7.)Nursing Interventions  diabetes mellitus hypoglycemia or ketoacidosis .

1. Administer basal and prandial insulin.
Adherence to the therapeutic regimen promotes tissue perfusion. Keeping glucose in the normal range slows the progression of microvascular disease.

2. Watch out for signs of morning hyperglycemia.
Morning hyperglycemia, as the name suggests, is an elevated blood glucose level arising in the morning due to insufficient level of insulin.

3. Teach patient how to perform home glucose monitoring.
Blood glucose is monitored before meals and at bedtime. Glucose values are used to adjust insulin doses.

4. Report BP of more than 160 mm Hg (systolic). Administer hypertensive as prescribed.
Hypertension is commonly associated with diabetes. Control of BP prevents coronary artery disease, stroke, retinopathy, and nephropathy.

5. Instruct patient to avoid heating pads and always to wear shoes when walking.
Patients have decreased sensation in the extremities due to peripheral neuropathy.

6. Instruct patient to take oral hypoglycemic medications as directed:

· Sulfonylureas: glipizide (Glucotrol), glyburide (DiaBeta), glimepiride (Amaryl)
Sulfonylureas stimulate insulin secretion by the pancreas, used mostly in type 2 diabetes to control blood glucose levels. They also enhance cell receptor sensitivity to insulin and decrease the liver synthesis of glucose from amino acids and stored glycogen.

· Meglitinides: repaglinide (Prandin)
Stimulates insulin secretion by the pancreas.

· Biguanides: metformin (Glucophage)
These drugs decrease the amount of glucose produced by the liver and improve insulin sensitivity. They enhance muscle cell receptor sensitivity to insulin.

· Phenylalanine derivatives: nateglinide (Starlix)
Stimulates rapid insulin secretion to reduce the increases in blood glucose that occur soon after eating.

· Alpha-glucosidase inhibitors: acarbose (Precose), miglitol (Glyset).
Inhibits the production of glucose by the liver and increases the body’s sensitivity to insulin. Used in controlling blood glucose levels in type 2 diabetes.

· Thiazolidinediones: pioglitazone (Actos), rosiglitazone (Avandia)
Sensitizes body tissues to insulin and stimulates insulin receptor sites to lower blood glucose and improve the action of insulin.

· Incretin modifiers: sitagliptin phosphate (Januvia), vildagliptin (Galvus)
Increases and prolongs the action of incretin which increases insulin secretion and decreases glucagon levels.

7. Instruct patient to take insulin as directed:

· Rapid-acting insulin analogs: lispro insulin (Humalog), insulin aspart
Has a clear appearance. Have an onset of action within 15 minutes of administration. The duration of action is 2 to 3 hours for Humalog and 3 to 5 hours for aspart. Patient must eat immediately after injection to prevent hypoglycemia.

· Short-acting insulin (regular insulin): regular, Humulin R
Short-acting insulins have a clear appearance, has an onset of action within 30 minutes of administration, duration of action is 4-8 hours. Regular insulin is the only insulin approved for IV use.

· Intermediate-acting insulin (NPH insulin): neutral protamine Hagedorn (NPH), insulin zinc suspension (Lente)
They appear cloudy and have either protamine or zinc added to delay their action. Onset of action for the intermediate-acting is one hour after administration; duration of action is 18 to 26 hours. This type of insulin should be inspected for flocculation, a frosted-whitish coating inside the bottle. If frosted, it should not be used.

· Long-acting insulin: Ultralente, insulin glargine (Lantus)
Have a clear appearance and do not need to be injected with a meal. Long-acting insulins have an onset of one hour after administration, and have no peak action because insulin is released into the bloodstream at a relatively constant rate. Duration of action is 36 hours for Ultralente is 36 hours and glargine is at least 24 hours. They cannot be mixed with other insulin because they are in a suspension with a pH of 4, doing so will cause precipitation.

· Intermediate and rapid: 70% NPH/30% regular
Premixed concentration has an onset of action similar to that of a rapid-acting insulin and a duration of action similar to that of intermediate-acting insulin.

8. Instruct patient on the proper injection of insulin. The absorption of insulin is more consistent when insulin is always injected in the same anatomical site. Absorption if fastest in the abdomen, followed by the arms, thighs, and buttocks. It is recommended by the American Diabetes Association to administer insulin into the subcutaneous tissue of the abdomen using insulin syringes.

9. Educate patient on the correct rotation of injection sites when administering insulin.
Injection of insulin in the same site over time will result in lipoatrophy and lipohypertrophy with reduced insulin absorption. Repeated use of an injection site can cause the development of fatty masses called lipohypertrophy which can impair in the absorption of insulin when used again.

10. Instruct patient on the proper storage of insulin.
Insulins should be refrigerated, should not be allowed to freeze, should avoid extremes of temperatures, and avoid exposure to direct sunlight. To prevent irritation from “cold insulin,” vials may be stored at temperatures of 15º to 30ºC (59º to 86ºF) for 1 month. Opened vials are to be discarded after that time while unopened vials may be stored until their expiration date. Instruct patient to keep a spare vial of the insulin types prescribed. Cloudy insulins should be thoroughly mixed by rolling the vials between the hands before drawing the solution.

11. Instruct patient that insulin vial that is in use should be kept at room temperature.
Keeping insulin at room temperature helps reduce local irritation at the injection site.

12. Stress the importance of achieving blood glucose control.
Control of blood glucose levels within non diabetic range can significantly reduce the development and progression of complications.

13. Explain the importance of weight loss to obese patients with diabetes.
Weight loss is an important factor in the treatment of diabetes. Weight loss of around 5-10% of the total body weight can reduce or eliminate the need for medications and significantly improve blood glucose levels.

14. Explain the importance of having consistent meal content or timing.
Recommendation is three meals of equal size, evenly spaced meal times (5-6 hours apart), with one or two snacks. Pacing food intake throughout the day places more manageable demands on the pancreas.

15. Refer the patient to support groups, diet and nutrition education and counseling.
To help the patient incorporate weight management and learn new dietary habits.

16. Educate the patient on maintaining consistency in the amount of food and the approximate time intervals between meals.
A consistent amount of food and time interval between meals helps prevent hypoglycemic reactions and maintain overall blood glucose control.

17. Educate the patient about the health benefits and importance of exercise in the management of diabetes.
Exercise plays a role in lowering blood glucose and reducing cardiovascular risk factors for patients with diabetes. Exercise lowers blood glucose levels by increasing the uptake of glucose and improving utilization of insulin.

18. Review exercise precautions for patients taking insulin.
Hypoglycemia may occur hours after exercise, stress the need for the patient to eat a snack at the end of the exercise session.

19. Provide instructions to patients using self-monitoring blood glucose (SMBG).
Frequent SMBG is another important factor in diabetes management. When patients know their SMBG results, they can adjust their treatment regimen and obtain optimal blood glucose control. Additionally, SMBG is helpful in providing motivation to patients to continue their treatment. It can also help in monitoring the effectiveness of exercise, diet, and oral antidiabetic agents.

20. Observe and review the patient’s technique in self-monitoring blood glucose (SMBG).
Determines if there are errors in SMBG due to incorrect technique (e.g., blood drop too small, improper cleaning and maintenance, improper application of blood, damage to reagent strips). The patient may obtain erroneous blood glucose values when using incorrect techniques in SMBG. Additionally, the patient should conduct a comparison of their device’s result with a lab-measured blood glucose levels to determine the validity of the device’s reading.

21. For patients using insulin pumps, educate the patient on the importance of maintaining its patency.
The needle or tubing in an insulin pump may become occluded (from battery drainage, or depletion of insulin) which may increase the risk of the patient for DKA.