Hyperglycemia & ketoacidosis or diabetic hypoglycemia.

Hyperglycemia & ketoacidosis or diabetic hypoglycemia. 80 years old female patient presented in the emergency department. Confused, LOC, secretion was coming from her mouth, excessive sweating, and cold extremities. Patient was kept in resus bed. Connected to cardiac monitoring. Patient connected to cardiac monitor v/s checked as the following shows (HR=109 beats/min, RR=24 breaths/min, BP=136/69 mmhg, Spo2=98% in room air, T=36.5C). Blood sugar checked; RBS found 1.5 mmol/L. • Management: Patient was kept in resus bed. Intravenous (IV) access has been established and blood investigations were collected Patient kept Oxygen therapy has been started as ordered through face mask 5L. She received 50ml of 50% dextrose 50ml IV bolus over 1-3 mint. Then started 10% Dextrose at rate 100ml/hr. After 5 min RBS was checked=24.1mmol/L. Patient became conscious oriented. Fluid 10% Dextrose disconnected as Dr advice. Then patient was kept under observation and keep checking RBS each 30min.Then patient admitted for observation. RBS rechecked again last reading was 6.6 mmol, 10% Dextrose at rate 100ml/hr started again. Differentiate Between the Two Type of Diabetic Hypoglycemia Hyperglycemia & DKA Hypoglycemia is a condition occurring in diabetic patients with a blood glucose of less than 4 mmol/L. Common initial symptoms:  Cold, clammy skin  Weakness, faintness, tremors  Headache, irritability, dullness  Hunger, nausea  Tachycardia, palpitations -Development of autonomic or Neuroglycopenic symptoms. Hyperglycemia occurs when blood glucose values are greater than 7 mmol/L in a fasting state or greater than 10 mmol/L. The common symptoms:  Increased urination/output (polyuria)  Excessive thirst (polydipsia)  Increased appetite (polyphagia) followed by lack of appetite.  Weakness, fatigue  Headache -In DKA> presence pf ketones body in the urine. Management of the hypoglycemia According to the Saudi Kingdom (2019) Guidelines and Protocols of Diabetes Emergencies. The steps of managing adult patient with Hypoglycemia are: Step 1: 1. Assess ABC, level of consciousness and ability to drink. 2. Send blood sample to the laboratory for verification (but do not wait for result) Step 2: Unconscious OR unable to drink: INTRAVENOUS ACCESS IS SECURED: MILD: (2.5 – 4.0 mmol/L): ≈(45-72mg/dL) • Administer 25 mL 50 % dextrose IV over 1-3 minutes • Repeat blood glucose test in 5 minutes • If blood glucose is still ≤ 4.0 mmol/L, (72mg/Dl) readminister the dose and check BG using finger stick in 5 minutes; repeat the process until Blood Glucose level exceed 4.0 mmol/L (72mg/Dl) • SEVERE (< 2.5 mmol/L) ≈ (45 mg/dL) • Administer 50 mL of 50 % dextrose IV over 1-3 minutes • Repeat blood glucose test in 5 minutes • If blood glucose is still ≤ 4.0 mmol/L, readminister the dose (50 mL of 50 % dextrose IV over 1-3 minutes) and • check BG using finger stick in 5 minutes; repeat the process until BG level exceed 4.0 mmol/L ≈(72mg/dL) NO SECURED INTRAVENOUS ACCESS: • Administer 1 mg glucagon subcutaneously or intramuscular • Repeat blood glucose test in 15 minutes • If blood glucose is still ≤ 4.0 mmol/L ≈(72mg/dL), readminister the dose and check BG using finger stick in 15 minutes; repeat the process until BG level exceed 4.0 mmol/L ≈(72mg/dL) When the patient is conscious and able to eat give a meal of 30 gram of complex carbohydrate such as 2-3 toasts. Conscious AND able to drink: Give 15 gram of glucose (sugar) orally (1/2 cup apple or orange juice or one table spoonful sugar dissolved in water or one tablespoon of honey) • Repeat blood glucose test after 15 minutes • If blood glucose is still ≤ 4.0 mmol/L (72mg/dl) repeat the process x 3 till glucose is > 4.0 mmol/L (72mg/dl) • Then give a snack of 15-20 gram of complex carbohydrate such as one toasts Step 3: Assess and manage the precipitating factors. Step 4: Adjust dose of insulin and other hypoglycemic agents. Call MD if any of the following: • Patient is put NPO, tube feeding or TPN initiated or stopped • Persistent nausea/vomiting • Deterioration of the level of consciousness or seizure • For patients who presented with hypoglycemia secondary to long-acting sulphonyl urea (e.g. Gliclazide MR or Glibenclamide) there might be a need for prolonged observation. 2. Implementation of Appropriate Nursing Responsibilities: o Assess causative or contributing factors by identifying the factors present. o Assess the degree of impairment. o Check the current blood glucose. o 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. o For unconscious patients and patients unable to swallow administer dextrose 50% 50ml bolus per IV as prescribed. o Repeat the patient’s blood glucose level after 1 hour. o Monitors patient’s vital signs. o Draw blood for baseline electrolytes. References: Mathew, P., & Thoppil, D. (2018). Hypoglycemia.‏ Retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK534841/ Morgan, R. K., Cortes, Y., & Murphy, L. (2018). Pathophysiology and aetiology of hypoglycemic crises. Journal of Small Animal Practice, 59(11), 659-669.‏ doi.org/10.1111/jsap.1291 Marsden, J., & Pickering, D. (2015). Urine testing for diabetic analysis. Community eye health, 28(92), 77.‏ Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4944103/ Ministry of Health: Saudi Kingdom (2019). Guidelines and Protocols of Diabetes Emergencies. Retrieved from https://www.moh.gov.sa/Documents/Diabetes- Emergencies.pdf. RNspeak (2020). Hypoglycemia nursing management. Retrieved from: https://rnspeak.com/hypoglycemia-nursing-management/