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Nov.23.2020

Hyperglycemia Management (Ambulatory) - CE

ALERT

Untreated hyperglycemia can lead to diabetic coma caused by ketoacidosis, a life-threatening condition that requires immediate treatment. Signs and symptoms of impending diabetic coma include dyspnea, a fruity odor to the breath, nausea and vomiting, dry mouth, and changes in level of mentation.undefined#ref1">1

OVERVIEW

Hyperglycemia is abnormally high blood glucose that represents a risk of harm to the patient. Because glycemic thresholds for symptoms often shift, a single number value for hyperglycemia cannot be determined. However, a blood glucose reading of 249 mg/dl or higher functions as an alert for hyperglycemia.1

Hyperglycemia is associated with diabetes and may be further complicated by certain medications or infectious processes. Successful management of hyperglycemia begins with comprehensive education about the disease process, potential complications, and methods to control blood glucose levels. Pharmacologic management for reduction of glucose levels is done under a health care practitioner’s direction.

EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Teach the patient how to consistently self-monitor blood glucose levels.2
  • Teach the patient that avoiding hypoglycemia is important because it may affect cardiovascular or cognitive function.2,3
  • Teach the patient about the importance of annual eye, foot, and kidney function screenings to monitor vascular complications.
  • Teach the patient about infection prevention and immunization schedules and how and when to seek additional care.3
  • Provide culturally sensitive diet education in collaboration with a dietitian.
  • Educate the patient about adopting a low-glycemic index diet by reducing the consumption of carbohydrates.3
  • Educate the patient about weight reduction if he or she is overweight or obese. Provide an individualized weight-loss goal, and teach the patient that a reduction of 5% of body weight can improve glucose tolerance.3
  • Instruct the patient about the importance of increasing physical activity to reduce glucose levels.
  • Educate the patient on the need for tightly controlled glucose levels of 70 to 130 mg/dl before meals and less than 180 mg/dl 2 hours after eating.2 (Target blood glucose levels are individualized in collaboration with the practitioner.)
  • Teach the patient that improved glucose control lowers the incidence of cardiovascular events, thereby reducing morbidity.3,4
  • Teach the patient the signs and symptoms of hyperglycemia (e.g., high blood glucose, high levels of sugar in the urine, frequent urination, altered mental status, nausea and vomiting, and increased thirst) and instruct him or her on when to seek additional care.
  • Encourage questions and answer them as they arise.

PROCEDURE

  1. Perform hand hygiene and don gloves.
  2. Introduce yourself to the patient.
  3. Verify the correct patient using two identifiers.
  4. Explain the procedure to the patient and ensure that he or she agrees to treatment.
  5. Ensure that evaluation findings and laboratory results are communicated to the clinical team leader per the organization’s practice.
  6. Perform a thorough systems evaluation, including asking the patient about his or her pertinent medical history and the status of influenza and pneumococcal immunizations.3
  7. Evaluate the patient for signs and symptoms of hyperglycemia, including:1
    1. High blood glucose
    2. High levels of sugar in urine
    3. Frequent urination
    4. Altered mental status
    5. Nausea and vomiting
    6. Increased thirst
  8. If the patient is exhibiting signs and symptoms of hyperglycemia, obtain his or her blood glucose level using a blood glucose meter. A reading at or above 240 mg/dl indicates hyperglycemia.1 Refer to the manufacturer’s instructions for nonnumber readings.
    Rationale: Depending on the manufacturer, the monitor may read LLL or LOW (rather than a number) if the patient’s blood glucose level is below a certain level.
  9. If the patient demonstrates signs or symptoms of ketoacidosis (e.g., shortness of breath, fruity-smelling breath, nausea and vomiting, very dry mouth), activate the emergency response system per the organization’s practice.
  10. If the patient is insulin dependent and has an elevated blood glucose level, treat him or her with sliding scale insulin coverage as ordered.
  11. Evaluate the patient’s urine for ketones and glucose, if ordered by the practitioner.
  12. Evaluate the patient’s laboratory values, if available.
    Glycohemoglobin (A1C) levels should be less than 7%. 3
  13. If there is no response to treatment or the patient’s condition declines, activate the emergency response system per the organization’s practice, and stay with the patient. Obtain vital signs after the emergency response system has been initiated.
  14. If the patient stabilizes, perform these actions:
    1. Ask the patient about previous blood glucose readings that he or she has recorded.
    2. Ask the patient about his or her nutrition status and eating patterns.
    3. Ask the patient about his or her daily intake and output.
    4. Record a complete list of the patient’s medications, including over-the-counter medications that may affect glucose levels.
    5. Determine the patient’s compliance with his or her medication regimen. Educate the patient about the use of oral antidiabetic agents or subcutaneous insulin therapy as prescribed by the practitioner.2
    6. Evaluate the patient’s knowledge about how to prevent hyperglycemia and provide education as needed.
  15. Discard supplies, remove gloves, and perform hand hygiene.
  16. Document the procedure in the patient’s record.

EXPECTED OUTCOMES

  • Patient’s blood glucose returns to his or her normal level.
  • Patient can teach-back education about hyperglycemia.
  • Patient remains compliant with medication regimen.
  • Patient can effectively monitor own blood glucose.

UNEXPECTED OUTCOMES

  • Diabetic ketoacidosis
  • Comorbidities related to patient ineffectively monitoring own blood glucose (e.g., retinopathy, neuropathy, nephropathy, cardiac failure)
  • Hypoglycemia
  • Patient unable to teach-back education about hyperglycemia
  • Patient unable to effectively monitor own blood glucose

DOCUMENTATION

  • Education
  • Unexpected outcomes and related interventions
  • Laboratory values
  • Blood glucose readings before and after treatment
  • Interventions completed to address hyperglycemia
  • Plans for preventing further episodes
  • Medications administered
  • Evaluation findings and laboratory results communicated to the clinical team leader per the organization’s practice

OLDER ADULT CONSIDERATIONS

  • Older adult patients with diabetes who live alone require careful monitoring for the signs and symptoms of hyperglycemia.
  • Some symptoms of hyperglycemia are masked in older adults or are assumed to be part of the aging process.
  • Comorbidities affect blood glucose levels and the patient’s response to insulin and other diabetes medications.
  • Older adult patients’ intake should be monitored to ensure that they are not skipping meals owing to loss of appetite, depression, or low income.
  • Older adult patients who have poor vision may have trouble monitoring blood glucose or accurately measuring insulin.
  • Polypharmacy should be avoided as much as possible with older adults to reduce confusion and overdosing or underdosing of medications.
  • Older adult patients should avoid tightly controlling blood glucose because of the potential for hypoglycemia.2

REFERENCES

  1. American Diabetes Association® (ADA). (n.d.). Hyperglycemia (high blood glucose). Retrieved September 6, 2020, from (Level VII)
  2. American Diabetes Association® (ADA). (n.d.). The Big Picture: Checking Your Blood Glucose. Retrieved September 8, 2020, from (Level VII)
  3. American Diabetes Association® (ADA). (2019). Glycemic targets. Standards of medical care in diabetes—2019. Diabetes Care, 42(Suppl. 1), S61-S70. Retrieved September 8, 2020, from (Level VII)
  4. Ortiz, M.R. (2017). Hypoglycemia in diabetes. Nursing Clinics of North America, 52(4), 565-574. doi:10.1016/j.cnur.2017.07.006 (Level VII)

Elsevier Skills Levels of Evidence

  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports
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