A nurse is teaching self-administration of nph insulin to a client who has type 2 diabetes mellitus

The overlapping symptoms of hypo- and hyperglycemia (e.g., hunger, sweating, trembling, confusion, irritability, dizziness, blurred vision) make the two conditions difficult to distinguish from one another (Paradalis, 2005). Since the treatment is different for each condition, it is critical to test the patient’s blood glucose when symptoms occur. The risk factors that may have led to the condition, and the recent medical history of the patient also help to determine the cause of symptoms.

Hypoglycemia

Hypoglycemia is a condition occurring in diabetic patients with a blood glucose of less than 4 mmol/L. If glucose continues to remain low and is not rectified through treatment, a change in the patient’s mental status will result. Patients with hypoglycemia become confused and experience headache. Left untreated, they will progress into semi-consciousness and unconsciousness, leading rapidly to brain damage. Seizures may also occur.

Common initial symptoms of hypoglycemia include:

Cold, clammy skin
Weakness, faintness, tremors
Headache, irritability, dullness
Hunger, nausea
Tachycardia, palpitations

These symptoms will progress to mood or behaviour changes, vision changes, slurred speech, and unsteady gait if the hypoglycemia is not properly managed.

The hospitalized patient with type 1 or type 2 diabetes is at an increased risk for developing hypoglycemia. Potential causes of hypoglycemia in a hospitalized diabetic patient include:

Receiving insulin and some oral antidiabetic medications (e.g., glyburide)
Fasting for tests and surgery
Not following prescribed diabetic diet
New medications or dose adjustments
Missed snacks

Hypoglycemia is a medical emergency that must be treated immediately. An initial blood glucose reading may confirm suspicion of hypoglycemia. If you suspect that your patient is hypoglycemic, obtain a blood glucose level through skin puncture. A 15 g oral dose of glucose should be given to produce an increase in blood glucose of approximately 2.1 mmol/L in 20 minutes (Canadian Diabetes Association, 2013). Table 9.2 outlines an example of a protocol that may be used in the treatment of hypoglycemia.

Table 9.2 Hypoglycemia Treatment


Capillary Blood Gas (CBG)	Able to Swallow	Nil per Mouth with IV Access	Nil per Mouth with No IV Access
≥ 4 mmol/L	No treatment necessary	No treatment necessary	No treatment necessary
2.2-3.9 mmol/L	Give 15 g of glucose in the form of: 3-5 dextrose/glucose tabs (check the label) (best choice), OR 175 ml of juice or soft drink (containing sugar), OR 1 tablespoon of honey, OR 3 tablespoons of table sugar dissolved in water Note: Milk, orange juice, and glucose gels increase blood glucose (BG) levels more slowly and are not the best choice unless the above alternatives are not available. Repeat CBG every 15 to 20 minutes and repeat above if BG remains below 4 mmol/L. Once BG reaches 4 mmol/L, give patient 6 crackers and 2 tablespoons of peanut butter. If meal is less than 30 minutes away, omit snack and give patient meal when it is available.	Notify physician. Give 10-25 g (20-50 ml of D50W — dextrose 50% in water) of glucose intravenously over 1 to 3 minutes, OR as per agency policy. Repeat CBG every 15 to 20 minutes until 4 mmol/L. Continue with BG readings every 30 minutes for 2 hours.	Notify physician. Give glucagon 1 mg subcutaneously (SC) or intramuscularly (IM). Position patient on side. Repeat CBG every 15 to 20 minutes. Give second dose of glucagon 1 mg SC or IM if BG remains below 4 mmol/L.
≤ 2.2 mmol/L	Call lab for STAT BG level. Continue as above.	Call lab for STAT BG level. Continue as above.	Call lab for STAT BG level. Continue as above.
Data source: Canadian Diabetes Association, 2013; Paradalis, 2005; Rowe et al., 2015; VCH 2009

Hyperglycemia

Hyperglycemia occurs when blood glucose values are greater than 7 mmol/L in a fasting state or greater than 10 mmol/L two hours after eating a meal (Pardalis, 2005). Hyperglycemia is a serious complication of diabetes that can result from eating too much food or simple sugar; insufficient insulin dosages; infection, illness, or surgery; and emotional stress. Surgical patients are particularly at risk for developing hyperglycemia due to the surgical stress response (Dagogo-Jack & Alberti, 2002; Mertin, Sawatzky, Diehl-Jones, & Lee, 2007). Classic symptoms of hyperglycemia include the three Ps: polydipsia, polyuria, and polyphagia.

The common symptoms of hyperglycemia are:

Increased urination/output (polyuria)
Excessive thirst (polydipsia)
Increased appetite (polyphagia), followed by lack of appetite
Weakness, fatigue
Headache

Other symptoms include glycosuria, nausea and vomiting, abdominal cramps, and progression to diabetic ketoacidosis (DKA).

Potential causes of hyperglycemia in a hospitalized patient include:

Infection
Stress
Increased intake of calories (IV or diet)
Decreased exercise
New medications or dose adjustments

Note that testing blood glucose levels too soon after eating will result in higher blood glucose readings. Blood glucose levels should be taken one to two hours after eating.

If hyperglycemia is not treated, the patient is at risk for developing DKA. This is a life-threatening condition in which the body produces acids, called ketones, as a result of breaking down fat for energy. DKA occurs when insulin is extremely low and blood sugar is extremely high.

DKA presents clinically with symptoms of hyperglycemia as above, Kussmaul respiration (deep, rapid, and laboured breathing that is the result of the body attempting to blow off excess carbon dioxide to compensate for the metabolic acidosis), acetone-odoured breath, nausea, vomiting, and abdominal pain (Canadian Diabetes Association, 2013). Patients in DKA also undergo osmotic diuresis. They pass large amounts of urine because of the high solute concentration of the blood and the body’s attempts to get rid of excess sugar.

DKA is treated with the administration of fluids and electrolytes such as sodium, potassium, and chloride, as well as insulin. Be alert for vomiting and monitor cardiac rhythm. Untreated DKA can be fatal.

Patients with hyperglycemia may also exhibit a non-ketotic hyperosmolar state, also known as hyperglycemic hyperosmolar syndrome (HHS). This is a serious diabetic emergency that carries a mortality rate of 10% to 50%. Hyperosmolarity is a condition in which the blood has a high sodium and glucose concentration, causing water to move out of the cells into the bloodstream.

Further information on the treatment of DKA and HHS can be found on the Canadian Diabetes Association clinical guidelines website.

At 0930 hours, your diabetic patient complains of feeling faint. You check his blood sugar and get a reading of 2.8 mmol/L. What actions will you take?
What blood glucose level range do you expect immediately post-operatively from your patient who has type 2 diabetes? Why?

1. Malmberg K for the DIGAMI Study Group. Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. BMJ 1997;314: 1512-15 [PMC free article] [PubMed] [Google Scholar]

2. Gill G, Benbow S. Managing surgery in the elderly diabetic patient. In: Sinclair AJ, Finucane P, eds. Diabetes in Old Age, 2nd edn. Chichester: Wiley, 2001

3. Scott JF, Robinson GM, French JM, et al. Glucose potassium insulin infusions in the treatment of acute stroke patients with mild to moderate hyperglycaemia: the Glucose Insulin in Stroke Trial (GIST). Stroke 1999;30: 793-9 [PubMed] [Google Scholar]

4. Hendra TJ. Insulin therapy. In: Sinclair AJ, Finucane P, eds. Diabetes in Old Age. 2nd edn. Chichester: Wiley, 2001

5. Stuck AE, Siu AL, Wieland GD, Adams J, Rubenstein LZ. Comprehensive geriatric assessment: a meta-analysis of controlled trials. Lancet 1993;342: 1032-6 [PubMed] [Google Scholar]

6. Collins C, Wade DT, Davies S, Horne V. The Barthel ADL index: a reliability study. Int Disabil Stud 1988;10: 61-3 [PubMed] [Google Scholar]

7. Jitapunkul S, Pillay I, Ebrahim S. The abbreviated mental test: its use and validity. Age Ageing 1991;20: 332-6 [PubMed] [Google Scholar]

8. Folstein MF, Folstein SE, McHugh PR. ‘Mini-mental state’: a practical method for grading the cognitive state of patients for the clinician. J Psychiatry Res 1975;12: 189-98 [PubMed] [Google Scholar]

9. Herrmann C. International experiences with the Hospital Anxiety and Depression Scale—a review of validation data and clinical results. J Psychosomatic Res 1987;42: 17-42 [PubMed] [Google Scholar]

10. Royal College of Physicians. Standardised Assessment Scales for Elderly People. London: RCPL, 1992

11. Sinclair AJ, Turnbull CJ, Croxson SCM. Document of care for older people with diabetes. Postgrad Med J 1996;72: 334-8 [PMC free article] [PubMed] [Google Scholar]

12. Hendra TJ, Sinclair AJ. Improving the case of elderly diabetic patients: the final report of the St Vincent Joint Task Force for Diabetes. Age Ageing 1997;26: 3-6 [PubMed] [Google Scholar]

13. UK Prospective Diabetes Study Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). Lancet 1998;352: 837-53 [PubMed] [Google Scholar]

14. Taylor C, Towse K, Reza M, Ward JD, Hendra TJ. Transferring elderly type 2 patients to insulin: a prospective study of diabetes nurses', physicians', and patients' perceptions. Practical Diabetes 2002;19: 37-9 [Google Scholar]

15. Turner HE, Matthews DR. The use of fixed-mixture insulins in clinical practice. Eur J Clinical Pharm 2000;56: 19-25 [PubMed] [Google Scholar]

16. Herbel G, Boyle PJ. Hypoglycaemia. Pathophysiology and treatment. Endocrinol Meta Clin N Am 2000;29: 725-43 [PubMed] [Google Scholar]

17. Hendra TJ, Taylor CD. Effect of insulin on the quality of life of elderly type 2 diabetic subject—a randomised trial. Age Ageing 2001;30(suppl 2): 70 [Google Scholar]

18. Rosenstock J, Schwartz SL, Clark CM Jr, et al. Basal insulin therapy in type 2 diabetes: 28-week comparison of insulin glargine (HOE 901) and NPH insulin. Diabetes Care 2001;24: 631-6 [PubMed] [Google Scholar]

19. Puxty JAH, Hunter DH, Burr WA. Accuracy of insulin injection in elderly patients. BMJ 1983;287: 1762 [PMC free article] [PubMed] [Google Scholar]

20. Coscelli C, Balabrese G, Fedele D, et al. Use of premixed insulin among the elderly. Reduction of errors in patient preparation of mixtures. Diabetes Care 1992;15: 1628-30 [PubMed] [Google Scholar]

21. Bantle J, Neal L, Frankamp L. Effects of the anatomical region used for insulin injections on glycaemia in Type 1 diabetes subjects. Diabetes Care 1993;16: 1592-7 [PubMed] [Google Scholar]

22. Taylor CD, Hendra TJ. Which insulin injection system do elderly patients choose? Diabet Med 2001;18 (suppl 2): 132 [Google Scholar]

23. Da Costa S. A coordinated approach to insulin transfer in the older, type 2 client. J Diabetes Nurs 1997;4: 123-6 [Google Scholar]

24. Thomson FJ, Masson EA, Leeming JT, Boulton AJM. Lack of knowledge of symptoms of hypoglycaemia in elderly diabetic patients. Age Ageing 1991;20: 404-6 [PubMed] [Google Scholar]

25. Mutch WJ, Dingwell-Fordyce. Is it a hypo? Knowledge of the symptoms of hypoglycaemia in elderly diabetic patients. Diabet Med 1985;2: 54-6 [PubMed] [Google Scholar]

26. Sinclair AJ, Turnbull CJ, Croxson SM. Document of diabetes care for residential and nursing homes. Postgrad Med J 1997;73: 611-12 [PMC free article] [PubMed] [Google Scholar]

27. British Diabetic Association. Guidelines of Practice for Residents with Diabetes in Care Homes. London: BDA, 1999

28. Taylor C, Hendra TJ. The prevalence of diabetes mellitus and quality of diabetic care in residential and nursing homes. A postal survey. Age Ageing 2000;29: 447-50 [PubMed] [Google Scholar]