Hypoglycemia Management (Home Health Care) - CE

ALERT

Untreated hypoglycemia may lead to seizures or loss of consciousness. Overtreatment may lead to hyperglycemia.

Fatigue, irritability, and confusion are symptoms of both hypoglycemia and hyperglycemia. If unable to test blood glucose, treat the symptoms as hypoglycemia.^{undefined#ref3">3}

Never give food or fluids to an unresponsive or uncooperative patient. Avoid administering chocolate because it contains fats that will inhibit the absorption of carbohydrates.

OVERVIEW

Hypoglycemia is abnormally low blood glucose that represents a risk of harm to the patient. Because glycemic thresholds for symptoms often shift, a single number value for hypoglycemia cannot be determined. However, a blood glucose reading of 70 mg/dl or lower functions as an alert for hypoglycemia.³

The most common cause of hypoglycemia is an insulin reaction. Other causes are delayed food intake, exercise, alcohol consumption, and overmedication with sulfonylureas. Signs and symptoms can develop rapidly and demand immediate action. In the home setting, the nurse should summon emergency medical services (EMS) if the patient does not respond to treatment or shows other signs of condition deterioration.

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
• After the patient recovers from the hypoglycemic incident, assess his or her, the family’s, and the caregivers’ knowledge of hypoglycemia. Provide appropriate education. Diabetic education is initiated at the time of diagnosis but must be reinforced as part of ongoing diabetes management.
• Ensure that the patient and caregiver can draw the correct dosage of insulin into a syringe and administer it correctly.
• Ensure that the patient and caregiver can correctly use the blood glucose monitor, including following the manufacturer’s instructions for calibration.
• Identify possible trigger for a hypoglycemic episode by reviewing the patient’s history for skipped meals or snacks, increased activity, or changes in antihyperglycemic medication dosage.
• 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
• Advise the patient and caregiver to keep a few quick sources of sugar, such as jam, jelly, corn syrup, honey, cake icing in a tube, or a sweet fruit juice in the home. Also teach them about other simple carbohydrate sources, such as raisins, low-fat milk, and regular (not diet) soda.⁴
• Encourage questions and answer them as they arise.

PROCEDURE

1. Perform hand hygiene and don gloves.
2. Introduce yourself to the patient, family, and caregivers.
3. Verify the correct patient using two identifiers.
4. Explain the procedure to the patient, family, and caregivers and ensure that the patient agrees to treatment.
5. Verify the practitioner’s order and assess the patient for pain.
6. Prepare an area in a clean, convenient location and assemble the necessary supplies.
7. Evaluate the patient for signs and symptoms of hypoglycemia, which include:³
1. Shakiness
2. Nervousness or anxiety
3. Sweating, chills, clammy skin
4. Irritability or impatience
5. Confusion, including delirium
6. Bounding pulse
7. Light-headedness or dizziness
8. Hunger or nausea
9. Sleepiness
10. Blurred or impaired vision
11. Tingling or numbness in lips or tongue
12. Headache
13. Weakness or fatigue
14. Personality changes
15. Lack of coordination
16. Seizures
17. Unconsciousness
8. Assess the patient’s cardiopulmonary function and be prepared to summon EMS and perform cardiopulmonary resuscitation (CPR), if necessary.
9. If the patient is unconscious, confused, or unable to swallow, consider the hypoglycemia severe and take the following actions:
   1. Summon EMS immediately and stay with the patient until EMS arrives and assumes care.
   2. Administer injectable glucagon intramuscularly, if ordered and available in the home, but only if an accurate blood glucose reading can be obtained.³

   Rationale: Obtaining an accurate blood glucose reading may not be possible with a confused or uncooperative patient.³

   Do not give food or fluids to an unresponsive or uncooperative patient.

10. Assess the patient’s blood glucose level, following the manufacturer’s instructions for calibrating and using the blood glucose meter.
1. A reading at or below 70 mg/dl indicates hypoglycemia.³
2. Refer to the manufacturer’s instructions for non-number readings.

Rationale: The monitor may read LLL or LOW (rather than a number) if the patient’s blood glucose level is below a certain level, depending on the manufacturer.

11. For a conscious patient exhibiting symptoms of hypoglycemia with a blood glucose level at or below 70 mg/dl, administer 15 to 20 gm of a fast-acting carbohydrate.^3,4
1. Glucose tablets (follow package instructions)
2. Gel tube (follow package instructions)
3. 30 ml (2 tablespoons) of raisins
4. 120 ml (½ cup) of juice or soda (not diet)
5. 15 ml (1 tablespoon) of sugar, honey, or corn syrup
6. 240 ml (1 cup) of nonfat or 1% milk
7. Hard candies, jellybeans, or gumdrops (see package to determine amount to equal 15 g of carbohydrate)

Avoid chocolate because it contains fats that will inhibit absorption of carbohydrates.

12. Recheck the patient’s blood glucose after 15 minutes, and if it is still at or below 70 mg/dl, administer another 15 g of a fast-acting carbohydrate.³
13. Once blood glucose is above 70 mg/dl, administer a small snack containing a complex carbohydrate, such as cheese and crackers or half of a peanut-butter sandwich.³
14. Once the patient is stable, assess his or her, the family’s, and the caregivers’ knowledge about how to prevent hypoglycemia. Provide education as needed.
15. Notify the clinical supervisor and the home health organization of the situation and contact the practitioner for further orders.
16. Discard supplies, remove gloves, and perform hand hygiene.
17. Document the procedure in the patient’s record.

EXPECTED OUTCOMES

• Patient’s blood glucose returns to normal level.
• Patient understands the signs and symptoms of hypoglycemia.
• Patient can teach back education about hypoglycemia.
• Patient can effectively monitor own blood glucose.

UNEXPECTED OUTCOMES

• Hyperglycemia
• Injury resulting from fainting or seizures
• Choking

DOCUMENTATION

• Blood glucose readings before and after treatment
• Interventions completed to address hypoglycemia
• Unexpected outcomes and related interventions
• Steps taken to identify causes of hypoglycemic incident
• Plans for preventing further episodes
• Education
• Patient’s progress toward goals
• Medications administered
• New practitioner orders, if applicable
• Revised nursing care plan
• Plan for follow-up visit
• Assessment of pain, treatment if necessary, and reassessment

OLDER ADULT CONSIDERATIONS

• Older adult patients with diabetes who live alone require careful monitoring for the signs and symptoms of hypoglycemia.
• Some symptoms of hypoglycemia are masked in older adults or are assumed to be part of the aging process.
• Comorbidities and polypharmacy 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 might 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.³

REFERENCES

1. American Diabetes Association (ADA). (n.d.). Hypoglycemia (low blood glucose). Retrieved November 8, 2021, from http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/hypoglycemia-low-blood.html (Level VII)
2. American Diabetes Association (ADA). (n.d.). The big picture: Checking your blood glucose. Retrieved November 8, 2021, from https://www.diabetes.org/diabetes/medication-management/blood-glucose-testing-and-control/checking-your-blood-glucose (Level VII)
3. American Diabetes Association^® (ADA). (2019). Standards of medical care in diabetes—2019. Diabetes Care, 42(Suppl 1), S4-S6. Retrieved November 8, 2021, from http://care.diabetesjournals.org/content/diacare/suppl/2018/12/17/42.Supplement_1.DC1/DC_42_S1_2019_UPDATED.pdf
4. Ortiz, M. (2017). Hypoglycemia in diabetes. Nursing Clinics of North America, 52(4), 565-574. doi:10.1016/j.cnur.2017.07.006

ADDITIONAL READINGS

American Diabetes Association^® (ADA). (2019). Standards of medical care in diabetes—2019. Abridged for primary care providers. Clinical Diabetes, 37(1), 11-34. doi:10.2337/diaclin.33.2.97

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