Management of a Patient with Hypoglycaemia Emergency - Essay Example

Discuss the Nursing Assessment and Management of a Patient with Hypoglycaemia Emergency Introduction: Carmen has been admitted this timeto the hospital with a very low blood glucose level of 1.3 mmol. I was assigned her care in the hospital, and after a literal battle, she has now stabilized. I came to know, after three years of independent travel around the world, she has settled into her own flat and is currently almost through with a "hair and beauty course" at a local college. She has a physically demanding part time job in a local 'gentleman's club'. She is very fashion conscious and tries very hard to maintain her tall elegant body shape, and hence, she has refused to acknowledge her newly diagnosed brittle diabetes and has consistently neglected the management with insulin and diet. She is consistently non-compliant with therapy, and as a result, she is suffering from complications of diabetes, such as, loss of vision and numerous other diabetic crises. Despite this, Carmen has thus far refused to modify her behaviour and is, therefore, at risk of such events. This time, she has been admitted with a hypoglycaemic attack, the sugar levels were way too far below the normal levels. On the face of a hypoglycaemic attack, this work will discuss how care and treatment of Carmen are planned and delivered. In doing so, this work will analyze the rationale of any particular intervention, justifying that with existing knowledge of evidenced-based practice. This work will also analyze and elaborate the preventative measures and the role of diabetic education in preventing complications of diabetes in a patient like Carmen, so she can learn to live with diabetes. Diabetes: Diabetes mellitus is a group of endocrine diseases that results from inadequate insulin in the body. Insulin controls the glucose levels in the body. Diabetes is characterized by persistent elevation of fasting plasma glucose levels greater than or equal to 7.8 mmol/L and/or post prandial plasma glucose post 75 g of glucose is greater than or equal to 11.1 mmol/L on two or more occasions. Diabetics are prone to develop many associated metabolic complications like hypoglycaemic crisis and many long-term complications involving an array of organ systems, such as, eyes, kidneys, nerves, and blood vessels. Pancreas: The pancreas is a gland that lies behind the stomach; it is a compound gland with both exocrine and endocrine components. The endocrine component is secreted in the islets of Langerhans, and this comprises of two hormones, glucagon and insulin. Within the islets, there are beta cells that secrete insulin (A Dictionary of Nursing, 2003). Pathophysiology of Diabetes: Diabetes results from deficient insulin secretion, decreased insulin action, or both. Many causative pathologic processes may be involved ranging from autoimmune destruction of beta cells of the pancreas to incompletely understood processes that result in insulin resistance. In both the mechanisms, there is strong evidence of a genetic counterpart. Whatever may be the mechanism of injury, deficiency of insulin leads to production of large volume of urine and excessive thirst. The excess sugar in the blood draws water, and the excess sugar starts appearing in urine, thereby leading to a loss of sugar in the urine. This results in weight loss, and the patient not only becomes thirsty, but also hungry. (A Dictionary of Nursing, 2003). Types of Diabetes Mellitus: Depending on the pathologic mechanism causing diabetes, diabetes has been classified into two types. One, where there is absolute deficiency of insulin due to destruction of islet cells, so the patients are entirely dependent on insulin for counteracting this deficiency state. This usually starts in childhood or adolescence, and this is termed as IDDM or insulin-dependant diabetes mellitus or type 1 diabetes mellitus. The other, where there is insulin resistance and inadequate pancreatic ability to compensate for the deficiency are involved. This usually starts after age 40, and due to some insulin reserve, these patients may be treated with other drugs that can either stimulate the pancreas to secrete some insulin or can treat insulin resistance. This is known as NIDDM or non-insulin dependent diabetes mellitus or type 2 diabetes mellitus (Herman, W., 1999). The Diabetes Carmen Has: The story tells about a woman who is in college in hair and a beauty course and is extremely conscious about fashion and weight. This lady is hardworking too, apart from college, she has a physically demanding job in a local gentleman's club. The instructions to strike a balance between blood sugar levels and timely food, the schedule of insulin injections, and increased demand of body energy for a physically demanding job would create trouble. For a woman who is anxious about her body weight, would always skip a meal or two to maintain her appearance, plus the college and work at the club will have a toll on the time management. Apart from that, she might not be educated well about the nature of her disease; she might not understand the seriousness of the diet and insulin programme. She might be working out putting a load on the body in terms of glucose control. She has fragile diabetes or brittle diabetes, which is type 1 diabetes that causes constant disruption of lifestyle from recurrent attacks of hypoglycaemia or hyperglycaemia from many causes, such as, therapeutic errors, emotional disorders, intercurrent illnesses, or self- or career-induced episodes. The problem of hypoglycaemia is more common in insulin-dependent diabetics. Carmen is suffering from type 1 diabetes (Concise Medical Dictionary, 2002). Diabetic Emergencies: There are three types of acute metabolic diabetic emergencies. The first and most common is hypoglycaemia, occurring most frequently in type 1 diabetes. These attacks are dangerous and portends to serious and even fatal outcome (Foster, D., 1998). The two other are diabetic ketoacidosis and hyperosmolar nonketotic coma. Diabetic ketoacidosis often results as a complication of NIDDM or type 2 diabetes. The result is very high glucose and ketone levels in the blood. Hyperosmolar nonketotic coma is also an acute complication of type 2 or non-insulin dependent diabetes mellitus. Hypoglycaemia: In diabetics, the nighttime 3 A.M. goal sugar level is to be greater than 3.6 mmol/L. In type 1 diabetics, a deficiency of glucose below that level would produce a symptom complex of muscular weakness and incoordination, mental confusion, and sweating. This usually results from a combination of relative insulin overdose and insufficient intake of carbohydrates (Concise Medical Dictionary, 2002). Carmen's presentation blood sugar was 1.3 mmol/L, which was way below the required range at that hour, 4 A.M. As a part of the therapeutic programme, there must have been efforts to keep both fasting plasma glucose and postprandial diet-induced hyperglycemia. In Carmen's case, both missing a meal for figure-consciousness, doing unexpected exercise in the form of workout or workload in college and in her part time job, might have been causative (Unger, R.H. and Foster D.W., 1997). The possible chain of events might have been, night before, she might have had a huge workload, she took the insulin for night before dinner, and she failed to eat the prescribed dinner, and in her case, the protective counter-regulatory mechanisms failed to activate, since she has taken exogenous insulin, and food was not available to the body (Metchich, L.N. et al., 2002). Normal Values in Diabetes: The ideal fasting blood sugar level should be 3.9 to 5.6 mmol/L, preprandial should be the same that is 3.9 to 5.6 mmol/L, one hour post prandial should be ideally less than 8.9 mmol/L, acceptable up to less than 11.1 mmol/L, and at 3 A.M. in the morning it should be greater than 3.6 mmol/L. Values in these ranges indicate a good diabetic control(Diabetes UK). Carmen's Presentation: A rapid steep fall in blood glucose would induce excessive secretion of epinephrine and norpeinephrine. Since brain mostly relies on glucose for its source of energy, deprivation of brain glucose would lead to neuroglycopaenia and central nervous system dysfunction. Carmen would have presented with sweating, tremor, tachycardia, anxiety, and hunger due to rapid epinephrine release. She would have dizziness, headache, clouding of vision superimposed on her basic visual compromise as a result of diabetes, blunted mental acuity, loss of fine motor skill, abnormal behaviour, and confusion. She had chances of convulsions and loss of consciousness if the hypoglycaemia would have prolonged without intervention in our care (Foster, D., and Rubenstein, A.H., 1998). Her glucose at presentation was 1.3 mmol/L. That is the reason, she was semiconscious, not unconscious. Usually cerebral symptoms predominate when the glucose level approaches 1 mmol/L. Since the time of presentation is 3 A.M. and she has type 1 diabetes, it can be assumed that she has fasting hypoglycaemia. In her case, the problem was excess glucose utilization with a relative excess of insulin, where her liver failed to sustain an adequate glucose level of at least 2.8 mmol/L. Carmen is a diabetic, and she had been admitted with symptoms and tests supporting hypoglycaemia, it is safe to conclude that no special diagnostic tests are necessary because these episodes are almost always related to therapy. Hypoglycaemia, hence, is a medical emergency, and this requires nursing team to be vigilant in detecting signs and symptoms, and the goals should be reversing the hypoglycaemia, treating any complications without compromising glycaemic control in baseline diabetes. Although most patients reverse from hypoglycaemia completely, if not reversed, it can progress from just lethargy to coma and then to death. The adrenergic symptoms serve as warning symptoms for precipitation of neurobehavioural symptoms. Inpatient team members must be alert to adrenergic hypoglycaemia signs and symptoms including anxiety, irritability, dizziness, diaphoresis, pallor, tachycardia, headache, shakiness, and hunger (Cryer, P.E., 1993). If these warning signs are ignored or not monitored, the blood glucose level will continue to fall, and more severe hypoglycaemia would lead to alteration of mental function that proceeds to headache, malaise, impaired concentration, confusion, disorientation, irritability, lethargy, slurred speech, irrational or uncontrolled behaviour, and ultimately a state of stupor or semi-consciousness (Tomky, D., 2005). A nurse in charge should be vigilant about the progressive signs of CNS dysfunction including focal seizures, hemiplagia, proximal choreoathetosis, or evolving deep coma, papillary dilatation, shallow breathing, bradycardia, and hypotonicity that may result from further reduction of blood glucose levels. Since most patients with diabetes never suffer from such symptoms, the chances for them happening in Carmen's case is less, yet it is better to be vigilant about these signs and symptoms. On presentation, Carmen was profoundly hypoglycaemic and she was semi-conscious, and her individual awareness as well as responses for comfort and self-preservation did no longer operate. In this situation, the patient is totally dependent on nurse's skills for her comfort needs and life. The normal reflexes protecting the conscious person are lost, and their protective function is assumed by the nurse until the patient's status is restored to normal. The nurse on initial encounter will establish and maintain a clear airway. In Carmen's case, she was breathing fine, hence there was no immediate necessity to establish the airway, but a vigil for any compromise was instituted and at the bedside, a correct size airway, suction device, and oxygen were arranged. Her level of consciousness was assessed repeatedly every hour during the first 48 hours, and the vital signs were recorded every 15 minutes until she stabilized. Systolic blood pressure is the best vital sign to distinguish whether the impaired consciousness is due to cerebral dysfunction (Directorate of Nursing Affairs). Hypotension was the usual finding, and this indicated a metabolic brain dysfunction. So frequent recording of these signs would indicate any impairment upon evaluation, and appropriate measures could have been instituted as early as possible. Maintenance of fluid and electrolyte balance comes next, and it is very important in Carmen's case (Ikeda, M. et al, 2002). Intravenous equipment should be ready at the bedside. Regarding hypoglycaemia, a possible protocol should be worked out depending on her response to therapy. On presentation and admission, there would be a rapid assessment of symptoms. Carmen was responsive but stuporous. The MD was notified immediately, and an intravenous (IV) access was established. Since IV access was promptly available, there was not much of haemodynamic instability, and 50 mL of 50% dextrose was immediately given. The nursing would be prepared to administer glucagon 1 mg IV since the problem in Carmen's case is impaired glucagon response to fasting. Monitoring of neurological signs to assess improvement or deterioration and fluid balance should be recorded in neurological and intake output observations charts. Carmen was a little restless, hence bed rails were arranged, and her semi-consciousness precludes appropriate hygiene, hence eye care, oral care equipments were instituted, and with the hope that she will recover soon, feeding equipments were arranged. After the appropriate nursing cares were all begun, it was time to assess her response to the intravenous dextrose. A blood glucose monitoring system is utilized to assess blood sugars every 15 minutes, and Carmen was catheterized and connected to a leg bag for accurate assessment of the output. The MD visit took place, and MD orders were followed. Due to her semi- consciousness, it was decided that until she regains full consciousness, no attempt would be made for oral delivery of glucose, rather a protocol of monitoring, assessment, and blood sugars will guide repeated doses of 15 to 20 g of dextrose via IV route, and since this has a chance of elevating the blood sugars to the diabetic range, strict monitoring of blood sugar levels would be the best idea. After 24 hours, Carmen was conscious but weak and fatigued, he blood sugars were still in the hypoglycaemic range, her vital signs were approaching normalcy. The MD visit happened, it was advised that there will be a trial of oral intake while monitoring of vital signs, neurological signs, fluid and electrolyte balance, and blood sugar levels will continue every four hours. This would continue until the glucose levels approach near normal with oral glucose drinks of 15 to 20 g. Towards the end of the second day, Carmen could sit up, bed rails and catheter were taken out, and a protocol for 6 hourly monitoring was put in place. She was having glucose drinks, and her blood sugars were in the range of 5s, and once it was 7.8, she was allowed snacks and meal, and she started to interact with the staff. This exchange was an opportunity to educate Carmen about her disease. The first thing the team can do is review the signs and symptoms of hypoglycaemia with Carmen. The approach was to recognize the fact that it is very difficult to accept that one has a chronic disease that requires a change in lifestyle(Tomky, D, 2005). It is particularly true in diabetics who are young, and they are almost forced to accept the injection insulin treatment, which is not still the ideal mode of therapy, and they are forced to a rigorous dietary regimen. The primary reaction hence can range from denial with an accompanying refusal to cooperate. The nursing staff should be aware of the fact that the emotional response to diabetes often hampers treatment, and they should make every effort to bring the patient to a middle ground of acknowledging the disease and its complications and responding prudently without becoming obsessed. In fact, Carmen's problems can be handled if common sense is coupled with sympathy and firmness. It is best to take the opportunity of an acute episode of illness to use teaching materials, chart, persuasion, suggestions about a new life style where the patient will participate in carrying out a preventative care plan to make her understand her disease, or in essence, Carmen should be educated about diabetes. It may also be appropriate to offer cautious hope that the disease will be handled better in the future than is possible now (Foster, D. E., 1998). The perfect goal will be to teach Carmen to live with diabetes. Reference List Cryer, P.E., Glucose Counterregulation: Prevention and Correction of Hypoglycemia in Humans, American Journal of Physiology, 264:E149, 1993. "diabetes n."A Dictionary of Nursing. Oxford University Press, 2003. Oxford Reference Online. Oxford University Press.British Council Delhi.2 May 2007http://www.oxfordreference.com/views/ENTRY.htmlsubview=Main&entry=t62.e2367 Directorate of Nursing Affairs, General Nursing Procedures, Unconscious patient, page 1-1. Donna Tomky, MSN, RN, C-ANP, Detection, Prevention, and Treatment of Hypoglycemia in the Hospital, From Research to Practice /Diabetes Care in the Hospital, p.39, Diabetes Spectrum Volume 18, Number 1, 2005 Donna Tomky, MSN, RN, C-ANP, Detection, Prevention, and Treatment of Hypoglycemia in the Hospital, From Research to Practice /Diabetes Care in the Hospital, p.42, Diabetes Spectrum Volume 18, Number 1, 2005 Donna Tomky, MSN, RN, C-ANP, Detection, Prevention, and Treatment of Hypoglycemia in the Hospital, From Research to Practice /Diabetes Care in the Hospital, p.43, Diabetes Spectrum Volume 18, Number 1, 2005 Foster, D. E., Diabetes Mellitus, Harrison's Principles of Internal Medicine, ch. 334, p 2069-2070, McGraw-Hill, 1998 Foster, D. E., Diabetes Mellitus, Harrison's Principles of Internal Medicine, ch. 334, p 2080, McGraw-Hill, 1998 Foster, D. W. and Rubenstien, A.H., Hypoglycemia, Harrison's Principles of Internal Medicine, ch. 335, p 2081-2083, McGraw-Hill, 1998. http://www.diabetes.org.uk/ Diabetes UK, Guide to Diabetes, accessed on May 2, 2007. "hypoglycaemia n."Concise Medical Dictionary. Oxford University Press, 2002. Oxford Reference Online. Oxford University Press.British Council Delhi.2 May 2007http://www.oxfordreference.com/views/ENTRY.htmlsubview=Main&entry=t60.e4784 "insulin n."Concise Medical Dictionary. Oxford University Press, 2002. Oxford Reference Online. Oxford University Press.British Council Delhi.2 May 2007http://www.oxfordreference.com/views/ENTRY.htmlsubview=Main&entry=t60.e5064 Reference List Masayuki Ikeda, Takashi Matsunaga, Noritsugu Irabu and Shohji Yoshida, Using Vital Signs To Diagnose Impaired Consciousness: Cross Sectional Observational Study, BMJ 2002;325;800- Metchich LN, Petit WA, Inzucchi SE: The Most Common Type Of Hypoglycemia Is Insulin-Induced Hypoglycemia In Diabetes. Am J Med 113:317-323, 2002. "pancreas n."A Dictionary of Nursing. Oxford University Press, 2003. Oxford Reference Online. Oxford University Press.British Council Delhi.2 May 2007http://www.oxfordreference.com/views/ENTRY.htmlsubview=Main&entry=t62.e6551 Unger, R.H. and Foster D.W., Diabetes Mellitus, In Williams Text Book of Endocrinology, 9th Ed., JD Wilson, DW Foster (eds). Philadelphia, Saunders, 1997. Read More