Managing Hypoglycemia in Primary Care as a Practice Nurse - Essay Example

Managing hypoglycemia in primary care as a practice nurse Introduction Hypoglycemia presents a unique challenge for a practice nurse, since it is oneof the most serious complications associated with glucose-lowering medication. Hypoglycemia therefore acts as a limitation regarding initiation and optimization of glucose-lowering therapy. Additionally, hypoglycemia compromises a patient’s long-term compliance to glucose-lowering regimens as many patients are forced to bring about a change in their drug regimen following an episode of hypoglycemia. Enduring an episode of hypoglycemia can have far reaching consequences and patients tend to modify many routines and habits in an attempt to prevent any similar happenings in their future. Many patients opt to increase their food intake to an extent where hyperglycemia becomes inevitable. Others respond by being psychologically upset which in turn compromises their quality of lif e. Long-term consequences may include a less productive lifestyle coupled with feelings of anxiety and fear. Glucose acts as the primary fuel for the large variety of functions that nervous system performs. Despite the fact that glucose is vital for neuronal survival, the local storage of glucose within the substance of brain is limited; astrocytes contain glycogen which may produce glucose for a very limited period of time. For this reason, neuronal survival is mainly dependent upon a sustained supply of glucose through the blood brain barrier. Consequently, brain becomes one of the primary targets of hypoglycemia and suffers the first insult when blood glucose level starts to fall below a certain level (65 mg/dl). Irregular electrical activity at neuronal level may precipitate seizures when the level falls below 40mg/dl. Neuronal electrical activity ceases to exist when blood glucose level is below the 10mg/dl range (Ahrens et al, 2010). Since the control mechanism related to glycemia is affected in diabetes, it is common for diabetics to encounter hypoglycemic events due to reduced food intake, altered level of activity or overuse of glucose-lowering drugs. In severe cases, hypoglycemia may bring forth worst prognostic outcomes like coma or death. Due to the fact that different symptoms like hunger, irritability or anxiety are often attributed to hypoglycemia by health care workers without documenting actual hypoglycemia, the exact incidence of hypoglycemia cannot be determined with certainty. Among people presenting with symptoms suggestive of hypoglycemia, only 5-10% are actually hypoglycemic i.e. blood sugar levels below 50 mg/dL. Moreover, the incidence of hypoglycemia in general population is different from the incidence of hypoglycemia in diabetic population, in which it often relates to glucose-lowering therapy (Hamdy, 2014). In England, the average cost per emergency call related to hypoglycemia is around £263. The annual cost of hypoglycemia related emergency calls amounts to £13.6m (Farmer et al, 2012). Keeping in view the above mentioned facts, it can be inferred that management of hypoglycemia is an essential part of a nurse’s professional life and the role of nurse in primary care setting regarding management of hypoglycemia cannot be overlooked. Since the vast majority of individuals when going through an event of hypoglycemia seek assistance from a primary healthcare unit, every nurse working in a primary care setting should be able to diagnose and take corrective measures to prevent loss of lives. Discussion In many countries, substitution of physicians by nurses is an ongoing discussion and many countries have witnessed satisfactory results in this regard. The primary reason for this transformation is the acute shortage of physicians at hospital level (Martínez-González, t al, 2014). In this scenario, the role of primary care nurses become even more important, since they are expected to perform a role equivalent in some aspects to their physician counterparts. Various studies have indicated that NMP (non-medical prescribing) is favored and well accepted by health care workers, pharmacists, nurses and patients alike. Legislation to implement NMP in clinical workplace is underway and nurses are likely to perform their new role in near future (Bhanbhro et al, 2011). Symptoms & Signs The clinical manifestations of hypoglycemia vary among individuals and the symptoms reported by patients demonstrate wide differences. These differences may be attributed to the physical status of individuals as well as to the presence of comorbidities that are present in these individuals. Individual of old age who are suffering from neuropathy are likely to miss these symptoms unless they become severe enough to inflict damage to their health (NHS, 2013). According to Ahmed (2010) Whipple’s triadhas three elements: Signs and symptoms suggestive of hypoglycemia Low plasma glucose level (as confirmed by laboratory or other means) Resolution of the symptoms and signs detected earlier Symptoms suggestive of hypoglycemia may be reported when plasma glucose level start falling below 60mg/dL. This finding is however not uniform and many patients who experience more frequent hypoglycemic events may develop tolerance and hence manifest symptoms at much lower levels than this limit. Due to the hypoactivity of neurons, brain function impairment is witnessed when the plasma glucose level falls below 50mg/dL. The severity of symptoms at this stage varies between different individuals and the symptoms are classified into neuroglycopenic symptoms and adrenergic symptoms. Neuroglycopenic symptoms manifest in the form of personality changes, blurring of vision, syncope, diplopia, fatigue, drowsiness, weakness, seizures and in some cases headache (Frier et al, 2013). If hypoglycemia is related to diabetes, additional manifestations like hemiparesis, confusion, convulsions and coma may also be added to this list. Adrenergic symptoms may include tremulousness, dizziness, confusion, sweating, palpitations and in some cases anxiety. Signs pertaining to hypoglycemia may include tachycardia coupled with premature contractions of ventricles, hyperthermia or hypothermia, seizures, Babinski’s sign, hemiparesis, aphasia, trembling, diaphoresis and coma. Interesting to note are the signs that are associated with hypoglycemia in infants. A primary care nurse should be aware of these signs to detect the possibility of ongoing hypoglycemia in infants. Signs included in this category are large body size (macrosomia), hypotonia, jitteriness, cyanosis, poor feeding, apnea, cyanosis and hypothermia. Diagnosis of a patient undergoing an event of hypoglycemia should therefore be based on subjective and objective findings of the primary care nurse. Before approaching the patient, it is always a good idea to inquire about the history of the patient. As pointed out in the DCCT and UKPDS studies, patients undergoing intensive glucose control are more likely to experience episodes of hypoglycemia (Bloomgarden, 2008). Therefore the history should take into consideration aspects like recent change in medication, eating habits, exercise habits, meal times, history of alcohol intake along with the presence of any comorbidities like renal or liver disease, family history related to DM, hypoglycemia or other endocrine disorders. The physical examination of a hypoglycemic patient should be aimed at determining the presence of endocrine disorders, neurologic manifestations and a search for needle marks as an evidence of using insulin. Confirmation of diagnosis At this stage it is important to highlight the fact that various underlying pathologies should be included in the differential diagnosis. The primary care nurse should keep in mind other conditions like hyperventilation, panic attacks, alcohol intoxication, psychosis, generalized anxiety disorder, cerebrovascular accidents or transient ischemic attacks and pheochromocytoma, when trying to determine the cause. Confirmation of diagnosis should be based upon the outcomes of laboratory testing of plasma blood glucose levels. Plasma glucose levels in the range of 45-60mg/dL should raise the suspicion of ongoing hypoglycemia. Hypoglycemia is ascertained if plasma glucose level is below 45 mg/dL (Holt, 2009). The perfect time to carry of glucose level testing is during an ongoing episode of hypoglycemia. Concurrent occurrence of symptoms and hypoglycemia that are relieved by carbohydrate intake confirm the diagnosis of hypoglycemia. If the history does not reveal a certain pathology that is related to hypoglycemia (e.g. DM), further investigations to detect the underlying etiology should be done. This may include plasma insulin levels, C-peptide levels, urine and plasma sulfonylurea levels, insulin antibodies, creatinine and BUN, liver functions tests, ACTH/cortisol levels and alcohol levels. Management of hypoglycemia The initial nursing management of a hypoglycemia patient should be aimed at corrected the ongoing low glucose level in plasma. This is important since the deleterious effects of hypoglycemia can be life threatening and the nurse should act immediately to correct this issue. It should therefore be regarded as a medical emergency and be treated accordingly. For patients who are alert, the nurse should administer 6 – 12 ounces of fruit juice containing no sugar. If this is not available, a cup of milk or glucose tablets can be used for the same purpose. In patients with altered conscious level, IV administration of dextrose can prove to be life-saving. An alternative is Glucogon hydrochloride which may be administered IV, IM or subcutaneously. If at any point, the nurse detects that hypoglycemia may recur in a patient due to any cause; she should act to ensure admission of the patient to hospital for an extended period of time to ensure close observation and needful testing. Prevention of complications The long term management of hypoglycemia should be aimed at treating the underlying cause. This is only possible if the diagnostic interventions discussed earlier succeed to detect an underlying pathology (Dunphy, 2011). In addition to treating the underlying pathology, the patient should be informed about dietary modifications that are required at this stage. The primary care nurse’s role in this regard cannot be overlooked. The patients should be advised to follow health care setups frequently to make possible their evaluation at regular intervals. The nurse should ensure reviewing of record pertaining to hypoglycemic episodes during these visits. If the problem continues despite these measures, a consultation with endocrinologist should be arranged for the patient (Brunner & Smeltzer, 2010). Educating the patient A primary care nurse should take into consideration the benefits of educating her patients when dealing with resistant hypoglycemia. Dietary advice in this regard is the most important aspect of patient care and the nurse should ensure that every patient gets access to the required information (Kedia, 2011). Patients should be advised to take balanced meals containing appropriate amounts of fats, proteins and carbohydrates. Dietary charts may assist the patients in this regard. Additionally, the nurse should inform the patients about the negative consequences of consuming alcohol, caffeine and smoking cigarettes. The importance of limiting the use of refined sugars should be stressed upon. Additionally, the benefits of eating multiple small meals should be explained. Those who are diagnosed as having diabetes should be advised to report hypoglycemic incidents to their health care centers while trying to achieve their glycemic goals. A more rigorous approach to glucose level monitoring should be advised which may include monitoring blood sugar levels before going to bed, and before/after exercise (Mayo clinic Staff, 2014). Critical Analysis Although the above mentioned recommendations are based on evidence that has accumulated with experience and over time, it should be kept in mind that these suggestions are not final and as new evidence starts to emerge, the guidelines may change. It is therefore important for a practicing nurse to update her knowledge with the passage of time and on a continued basis. At this point I would like point out a few things that in my opinion are ‘better’ than those mentioned in standard guidelines. First and foremost is the notion of confirming diagnosis prior to administering treatment of hypoglycemia. Although confirmation of diagnosis is contributory towards providing new data that is then used for analysis at local and national level for the development of policies etc, this confirmation of diagnosis may be time taking and it may even cause the death of patient if this time is lost. So, in my opinion, if the patient’s history and clinical findings are suggestive of hypoglycemia corrective measures should be started even before laboratory confirmation of diagnosis. Another area where recommended guidelines appear to be faulty is the concept of making decisions based on the glucose level readings provided by patients themselves. Since the vast majority of patients utilize fingerstick monitors as a means of recording blood glucose level, the readings cannot be accurate since they are well-known for providing false readings at both extremes (high & low). In my opinion, such glycemic records should only be regarded as indicative of hypo or hyperglycemia, and they should not be considered as being indicators of the severity of glycemic condition. An additional aspect that a primary care practice nurse should keep in mind is the hypoglycemia that is not related to diabetes. Nurses should be adequately educated regarding the non-diabetic hypoglycemia and its causes (Tomky, 2005). The nurses should then pass on this knowledge about reactive hypoglycemia and fasting hypoglycemia to their patients to make sure they are aware of the possible causes. Relevant information about commonly used medications like salicylates, sulfa drugs, quinine and pentaamidine should be provided to patients as they can precipitate hypoglycemia in patients who are non-diabetic. Future development in diabetes care and management Keeping in mind the points learnt during writing this paper, I am confident about bringing the following improvements in my nursing practice in future; Upon initially encountering a patient whose symptoms are suggestive of hypoglycemia, I will initiate a brief inquiry to know about the history of the patient. This in my opinion will provide the relevant information that is required for my subsequent performance. If patient is conscious, I will ask direct questions to get an idea about the mental status of the patient. My additional questions will be directed towards ruling out the possibility of ongoing hypoglycemia. If however, the symptoms are suggestive of hypoglycemia, I will continue forward with the physical examination. The patient’s physical examination will be directed at eliciting the signs that are suggestive of hypoglycemia. Even if I am not convinced about ongoing hypoglycemia, I will include glucose level analysis in the list of laboratory investigations that I’ll order subsequently. This is due to the fact that clinical presentation of hypoglycemia demonstrates marked variation and the chances of missing the diagnosis are high. If the patient is a hypoglycemic infant, I will look for signs that are suggestive of hypoglycemia. After this, I’ll order laboratory investigation of plasma glucose level. Upon confirmation of the diagnosis I will initiate appropriate measures to correct the ongoing abnormality. For a conscious patient, I will provide the patient 6 to 12 ounces of juice or milk containing no sugar. In cases where patient is unconscious, administration of IV dextrose bolus or IM/IV/SC Glucagon hydrochloride will be given. After recovery, I will repeat the laboratory testing of plasma glucose level to make sure the required levels have been achieved. If the etiology of hypoglycemia is unclear at this point, I will retain the patient for further investigations. I will also make sure to arrange appropriate consultations with relevant specialists to prevent future complications for the patient. I strongly feel that educating the patients is an essential part of nursing practice. Therefore, I will spend sufficient time with the patient to educate him/her regarding the various aspects of hypoglycemia and their medical condition. This is the best way to ensure that patients do not suffer from the same problems over and over again. Dietary advice is extremely important. For this reason, I will arrange a consultation with dietitian for expert advice in this regard. I will call the patients for frequent follow-ups if I detect that they can undergo hypoglycemic events on a recurrent basis. Recommendations After understanding the concept of hypoglycemia and its management in the primary care setup, the following recommendations can be made; Due to the increasing incidence of diabetes, more and more patients experience hypoglycemia on regular basis. The primary health care setups should therefore be well equipped for immediate detection and treatment of hypoglycemia. Ambulances should carry with them the required apparatus that is essential for diagnosing and managing hypoglycemia; this ‘on the spot’ treatment approach is likely to save many lives annually. Primary care nurses should be adequately trained to diagnose an ongoing hypoglycemia episode. When dealing with a hypoglycemic patient, the primary care nurse should keep in mind a wider differential diagnosis. This will prevent any faulty decisions and add to the safety of patient. Patient education is an essential element of hypoglycemia management. The nurses should therefore adopt the approach of educating all diabetic patients, right after the diagnosis of their medical conditions. The patients should be allowed to reflect upon their experience of hypoglycemia in the presence of other diabetic patients, in order to give them first-hand knowledge of the feelings that are associated to hypoglycemia. Patient education should include information about developing hypoglycemia secondary to the use of common medications like salicylates, sulfa drugs and various others. Conclusion Based on the above discussion, it can be concluded that hypoglycemia poses considerable threat to the life of patients and for this reason hypoglycemia should be treated as early as possible. Missing a diagnosis of hypoglycemia may equate to inflicting death upon a patient, since body’s own mechanisms are unable to overcome hypoglycemia, which is a life threatening conditions. A primary care nurse holds a special position in this scenario because s/he acts as the first line of defense in this regard. Since many health care setups are inclined towards bestowing additional responsibilities to the nurses due to shortage of qualified physicians, the position of nurses becomes even more important. It is therefore safe to assert that nurses should be adequately trained to handle emergency situations like hypoglycemia and the likes to foster favorable prognostic outcomes for their patients. Treatment of a patient undergoing a hypoglycemia event should not be directed towards treating the ongoing abnormality in isolation; instead a holistic approach should be adopted and an attempt should be made to reveal the underlying pathological process by relevant testing. An approach that takes into account the information gained through history of the patient, subjective / objective findings and laboratory investigations, should be adopted to make sure that the underlying pathological mechanism is revealed and actions taken accordingly. After recovery from the acute state of hypoglycemia, the patients should be educated about the causes and consequences of hypoglycemia. They should be informed and trained about managing the condition by themselves at homes. Doing this will lower the burden of hypoglycemia related disease on local and national level. References Ahmed, N. (2010). Clinical biochemistry. Oxford: Oxford University Press. Ahrens, T., Prentice, D., & Kleinpell, R. M. 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Blood sugar testing: Why, when and how - Mayo Clinic. Retrieved January 1, 2015, from http://www.mayoclinic.org/diseases-conditions/diabetes/in-depth/blood-sugar/art-20046628 NHS (2013). Hypoglycaemia (low blood sugar) Retrieved January 1, 2015, from http://www.nhs.uk/conditions/hypoglycaemia/Pages/Introduction.aspx Tomky, D. (2005). Detection, prevention, and treatment of hypoglycemia in the hospital. Diabetes Spectrum, 18(1), 39-44. Read More