What is the nursing care plan for hypoglycemia?

One of the most common and important imbalances you will learn in nursing school is related to blood glucose levels, which can be too high or too low. In this article, we’ll be talking about the nursing management of hypoglycemia.

How does blood glucose work?

Glucose is a main energy source in the body and THE main source of fuel in the brain. For this reason, the body works very hard to keep blood glucose levels within a consistent range. When we fall below that range, we have hypoglycemia, and when blood glucose is too high, this is hyperglycemia. 

When blood sugar is elevated (such as after eating a meal), the beta cells of the pancreas release the hormone insulin. Insulin acts like a key to unlock the cells, allowing glucose to enter and provide energy to that cell. 

If there is excess glucose available, the body stores this as glycogen in muscles and the liver. As blood sugar levels drop, alpha cells in the pancreas secrete glucagon. This signals the liver to break down the glycogen, converting it back into glucose. A healthy liver can also make glucose from amino acids, fats and waste products. Because of the liver’s role in maintaining blood glucose levels, patients with severe liver disease often have persistent hypoglycemia and may require a continuous dextrose infusion.

What causes hypoglycemia?

Hypoglycemia is present when the blood glucose level is less than 70 mg/dL. It most often occurs in individuals with diabetes due to decreased oral intake, exercising more than usual, or incorrect use of insulin and other medications used to treat diabetes. 

It can also occur due to: 

• Decreased oral intake (if you’ve ever felt “hangry” chances are your blood sugar was on the low side
• Excessive alcohol use without eating prevents the liver from releasing its stored glucose
• Exercising more than usual (especially with decreased oral intake)
• Culprit medications such as beta blockers, indomethacin, levofloxacin and quinidine (which is used to treat malaria)
• Severe liver disease can inhibit the liver’s ability to create glucose (gluconeogenesis) or turn glycogen into glucose (glycogenolysis).
• An insulinoma (tumor of the pancreas) can cause overproduction of insulin. Other disorders of the pancreas can cause excessive release of insulin as well.
• Renal disorders can lead to decreased renal clearance of insulin and other medications used to treat hyperglycemia. Renal disorders may also play a role in impaired gluconeogenesis.
• Endocrine disorders related to the adrenal gland and pituitary can affect glucose production. Hypoglycemia can also occur in children with growth hormone deficiency.
• Hypoglycemia can occur after eating foods high in sugar due to too much release of insulin. This is called postprandial or reactive hypoglycemia and typically occurs in individuals who’ve had gastric bypass surgery, though it can occur in anyone.
• Critical illness can cause hypoglycemia, with sepsis being a common cause due to glucose being used faster than it can be produced.

Now that you have an understanding of hypoglycemia and what causes it, let’s go through hypoglycemia using the Straight A Nursing LATTE method. If you’re new to this method, you can learn about it and get a template to use here.

L: How does the patient LOOK?

The signs/symptoms of hypoglycemia typically begin to show when blood glucose levels are around 55 mg/dL, though this will vary by individual. The key signs/symptoms include shakiness, tachycardia, diaphoresis, anxiety, hunger, irritability, fatigue and pale skin. The patient may also report numbness/tingling of the face or tongue. As the blood glucose level decreases, the patient can have blurred vision, become increasingly confused, and lose consciousness or have seizures.

Note that patients taking beta blockers may not show some of the outward signs of hypoglycemia due to the medication preventing tremors and tachycardia from occurring. 

A: How do you ASSESS the patient?

A key component of the nursing management of hypoglycemia is your assessment of the patient and recognition that you need to intervene. Assess all patients at risk for blood glucose abnormalities for:

• Confusion
• Level of consciousness
• Presence of other signs/symptoms as outlined above
• Risk factors for developing hypoglycemia such as reduced oral intake, increased exercise, or inappropriate use of anti-diabetic medications
• Use of culprit medications

T: What TESTS will be conducted?

Blood glucose can be measured at the bedside with a glucometer, which is capable of reading levels within a specific range. This range will vary by the device used. If the blood glucose level falls below or above this range, the device simply displays a value of “low” or “high”. If the blood glucose level is not detectable by the glucometer, it will need to be measured via a traditional lab draw.

If the cause of the hypoglycemia is related to an endocrine, hepatic or renal disorder, lab tests specific to those conditions will be obtained.

T: What TREATMENTS will be provided?

The most important component of the nursing management of hypoglycemia is providing glucose. How the glucose is administered depends on the patient’s level of consciousness and how low the blood glucose level is. In the clinical setting, a typical hypoglycemia protocol looks like this and will vary based on the blood glucose level:

• If the patient is conscious and cooperative, provide fast-acting carbohydrate such as juice, jelly, sugar, dextrose gel or glucose tablets. How much will depend on the blood sugar level. 15 g carbohydrate is equal to 4 oz juice or 1 tablespoon jelly or sugar. If the patient takes the medication acarbose, use glucose gel. Treating a patient who takes acarbose with juice, jelly and sugar would be ineffective due to the properties of the drug.
• If the patient is unconscious or uncooperative, provide 25 grams D50 via IVP. If IV access is not available, give glucagon subcutaneously or IM.
• Recheck the blood glucose level after 15 minutes. 
• Retreat as necessary until blood glucose is above 70 or 80 mg/dL (will vary based on facility protocol).
• If it’s more than an hour until the patient’s next meal or snack, provide a snack of 15 g carbohydrate such as 6 saltine crackers or 8 oz skim milk. If the next meal or snack is more than two hours away, then also add protein such as 1 tablespoon peanut butter.

If the hypoglycemia is occurring due to an underlying condition, that condition should be addressed. For example: 

• If the patient has a pancreatic tumor, then surgery may be necessary to remove the tumor or even part of the pancreas.
• Hypoglycemia caused by culprit medications may warrant a change in medication regimen.
• Endocrine disorders should also be addressed accordingly and treatment will vary based on each specific condition.

E: How will you EDUCATE the patient/family?

Since hypoglycemia often occurs with diabetes, you want to ensure all patients with diabetes receive adequate education on their disease process, dietary modifications, how to test their blood sugar, and how to take medications. In addition:

• Teach the patient/family the signs of hypoglycemia. If the patient takes a beta blocker, ensure they understand their signs/symptoms may not be as noticeable.
• Teach the family not to place anything into the mouth of an unconscious patient. 
• Teach the patient/family the importance of carrying a glucagon kit.
• Teach the patient to always carry a fast-acting carbohydrate such as glucose tablets.
• Teach the patient/family which foods/beverages to use in cases of hypoglycemia and the carbohydrate counts of each. For example, 15 g carbohydrate is equal to 4 oz juice, 8 oz skim milk or 6 saltine crackers. 30 g carbohydrate is equal to 8 oz juice or 2 tablespoons jelly or sugar.
• If the patient is taking acarbose, ensure they understand to use the glucose gel for treatment as sugary foods/beverages will not be effective.
• Teach the patient to keep a log of their blood sugar levels and symptoms. Over time, with repeated incidences of hypoglycemia, the body will stop producing the classic signs/symptoms making the risk for life-threatening hypoglycemia very real. If the patient’s symptoms decrease or are absent even with low levels, this is called hypoglycemia unawareness and is cause for serious concern. These individuals may benefit from a continuous glucose monitor or even a diabetic alert dog. 

Your key takeaways for the nursing management of hypoglycemia are: 

• Symptoms are shakiness, irritability, diaphoresis and tachycardia 
• Patients taking beta blockers may not show outward signs of hypoglycemia
• Treatment is glucose (modality will vary based on blood glucose level, alertness of patient, and facility protocol)
• 15 g carbohydrate is equal to 4 oz juice, 8 oz skim milk, or 6 saltine crackers
• Recheck blood sugar after 15 minutes and repeat as necessary
• Patients should carry glucagon kit and fast-acting carbohydrates at all times

Drill this information in by listening to it in episode 191 of the Straight A Nursing podcast. Remember to subscribe so you never a miss an episode!

References:

American Diabetes Association. (n.d.). Hyperglycemia (High blood glucose). American Diabetes Association. https://www.diabetes.org/healthy-living/medication-treatments/blood-glucose-testing-and-control/hyperglycemia

Busti, A. J. (2015, October). How diabetics taking beta blockers still sweat with hypoglycemia. Evidence-Based Medicine Consult. https://www.ebmconsult.com/articles/diabetics-beta-blockers-hypoglycemia-sweating-sympathetic#:~:text=Therefore%2C%20beta%2Dblockers%20are%20not,use%20to%20recognize%20hypoglycemic%20episodes

Davis’s Drug Guide. (n.d.). Acarbose (Precose) | davis’s drug guide. Davis’s Drug Guide. https://www.drugguide.com/ddo/view/Davis-Drug-Guide/51003/all/acarbose?refer=true

Diabetes Teaching Center at UCSF. (n.d.). The liver & blood sugar. Diabetes Teaching Center at UCSF. https://dtc.ucsf.edu/types-of-diabetes/type1/understanding-type-1-diabetes/how-the-body-processes-sugar/the-liver-blood-sugar/#:~:text=The%20liver%20supplies%20sugar%20or,This%20process%20is%20called%20gluconeogenesis.

Mayo Clinic. (2020, March 13). Hypoglycemia—Symptoms and causes. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/hypoglycemia/symptoms-causes/syc-20373685

Medline Plus. (2020). Drug-induced low blood sugar. MedlinePlus Medical Encyclopedia. https://medlineplus.gov/ency/article/000310.htm