Review the onset, peak, and duration of action of the insulin your patient uses. When her insulin is at peak effect, check her for signs and symptoms of hypoglycemia. Be familiar with oral antidiabetic drugs that can cause hypoglycemia, such as sulfonylureas. Whether she uses insulin or oral antidiabetic drugs, monitor her blood glucose level before meals and at bedtime and tell her to do the same at home.Advise your patient to administer her insulin and oral antidiabetic drugs on time. Patients should eat 5 to 30 minutes after insulin administration, depending on the type of insulin. For example, a patient should eat within 5 minutes after taking Humalog or 30 minutes after taking regular insulin. If your patient leaves the hospital unit temporarily, make sure she takes her insulin and eats her meals on schedule. If a meal will be delayed, give her a snack. Also, provide betweenmeal and bedtime snacks, if needed, at the time of insulin’s peak activity.

If your patient isn’t allowed anything by mouth before a procedure, contact her physician to obtain changes in orders for her insulin and oral antidiabetic drugs.

Patient Teaching

Teach your patient and her family how to prevent, recognize, and manage hypoglycemia . Making your patient an active participant in her care will help her counter feelings of helplessness and loss of control. Enlist her family’s help and ease their fears by teaching them about hypoglycemia as well.

If your patient experiences hypoglycemia, help her identify what may have caused it. Even mild hypoglycemia will disrupt her daily routine if it occurs frequently. Anticipating hypoglycemia without understanding its causes and treatment may affect her compliance with her regimen. For example, she may be afraid to inject insulin for fear of another hypoglycemic episode.

Assess your patient for administration problems, such as administering too much insulin or too high a dose of an oral antidiabetic drug. Ask her to demonstrate how she administers insulin. Also, discuss the timing, quantity, and content of her meals as well as the extent and timing of exercise.

Encourage your patient to monitor her blood glucose level regularly and whenever she experiences hypoglycemic symptoms. Such monitoring will help her learn her threshold for hypoglycemia and recognize her typical symptoms at various glucose levels. Then when she experiences hypoglycemia, she can treat it appropriately.

Teach your patient to recheck her blood glucose level 15 minutes after taking a rapidly absorbed carbohydrate. Encourage her to keep rapidly absorbed carbohydrates, such as hard candies or glucose tablets, available at home and to carry them with her when she goes out. Also, advise the patient to carry a nonperishable snack, such as a package of peanut butter crack­ers, to eat in case a meal isn’t available within 1 hour after a hyperglycemic episode.

Identify a family member or friend who can help your patient if she develops hypoglycemia. Teach this person how to prepare and administer glucagon if hypoglycemia hinders the patient’s ability to swallow. Warn the patient that nausea is a common adverse effect of glucagon; she may need to take small sips of a carbonated, uncaffeinated soft drink until her nausea subsides.

For an elderly patient who lives alone, identify someone who’s willing to learn about hypoglycemia and check on her regularly. Encourage your elderly patient to contact the physician if she experiences frequent hypoglycemia. Also, instruct her to notify the physician if her blood glucose level falls below the target level more often than prescribed guidelines permit. The patient’s drug dosage may need to be adjusted.

Advise your patient to buy a medical alert bracelet or necklace that describes her condition and lists the physician’s phone number-especially if she’s prone to severe hypoglycemia.

When your patient leaves the hospital, give her written discharge instructions about diet, exercise, drugs, blood glucose monitoring, and signs, symptoms, and treatment of hypoglycemia.

Whether your patient recently learned that she has diabetes or she has been treating herself for years, during her hospitalization you should teachor reinforce-certain essential information about hypoglycemia. Be sure you cover the following areas:

• Explore the possible causes of hypoglycemia.
• Discuss the signs and symptoms of hypoglycemia.
• Discuss how to recognize and treat hypoglycemia promptly.
• Remind her to carry a simple carbohydrate snack, such as peanut butter crackers, at all times to treat hypoglycemia.
• Explain the importance of wearing a bracelet or necklace or carrying a card that indicates she has diabetes.
• Discuss the importance of telling family and friends about her diabetes in case she has a hypoglycemic episode.
• If your patient uses insulin, recommend that she obtain a glucagon kit and teach her family and friends when and how to use it.
• Teach her to monitor her blood glucose level frequently.
• Explain the importance of a regular pattern for eating meals and administering insulin or oral antidiabetic drugs.
• Explain the need to adjust the amount of food, the timing of meals and snacks, or the times of insulin administration when she engages in strenuous physical activity.
• Explain the importance of checking with the physician before taking a new prescription or over-the-counter drug.
• Instruct her to tell her health care providers that she has diabetes and that she uses insulin or oral anti diabetic drugs, as appropriate.

The early signs and symptoms of hypoglycemia tend to be autonomic. Neuroglycopenic signs and symptoms generally appear later.

Autonomic Signs and Symptoms

• nervousness
• tremors
• palpitations
• diaphoresis
• anxiety
• pallor
• irritability
• hunger
• paresthesia

Neuroglycopenic Signs and Symptoms

• dizziness
• headache
• lack of coordination
• difficulty concentrating
• mental dullness
• severe lethargy
• slurred speech
• blurred vision
• mood changes
• seizures
• coma

To help confirm a diagnosis of DKA and guide treatment, the physician may order laboratory measurements of:

• blood glucose
• blood bicarbonate
• blood urea nitrogen (BUN)
• hematocrit
• urine specific gravity
• blood osmolality
• white blood cell (WBC) count
• blood phosphate
• blood potassium and sodium
• pH.

The blood glucose level may range from 300 to 800 mg/dl. The blood bicarbonate level may drop below 15 mEq/L. Dehydration causes BUN levels,hematocrit, and urine specific gravity to rise. Blood osmolality may soar as high as 330 mOsm/L.

The WBC count may be high from hemoconcentration or infection. If the WBC count remains high after DKA has been treated, the patient probably has an infection. The blood phosphate level may be low. Blood potassium and sodium levels may be high, normal, or low, reflecting shifts between intracellular and extracellular fluid. The total body potassium generally is depleted. As ketones accumulate in the blood, the patient’s pH drops below 7.3.

Providing nursing care to a patient with DKA presents a multisystem challenge. To prevent serious complications, think critically and act quickly.During fluid replacement, assess your patient’s fluid balance to ensure adequate hydration without the complications of fluid overload. Evaluate her vital signs, level of consciousness, body weight, intake and output, urine specific gravity, and blood osmolality. And assess her skin turgor and mucous membranes for signs of improved hydration.

Frequently check the I.V. site for signs of infiltration or infection. If your patient has a central line, check all connections. During rapid fluid replacement, monitor your patient for signs and symptoms of fluid overload especially if she’s elderly, a child, or at risk for heart failure. Signs and symptoms of heart failure include pulmonary crackles, labored respirations, hypotension, tachycardia, and heart sounds.

Monitor your patient’s blood sodium, potassium, bicarbonate, magnesium, and phosphate levels closely. And evaluate her electrocardiogram (ECG) tracings to detect arrhythmias or characteristic changes from abnormally high or low potassium levels.

Before starting the insulin infusion, flush the tubing with 50 ml of insulin solution to saturate the tubing with insulin. Remember, insulin adheres to I.V. tubing, so if you don’t saturate it with insulin, your patient won’t receive the full insulin dose. Use an infusion pump to ensure insulin delivery at the prescribed rate.

Monitor the blood glucose level hourly. As the level falls, monitor your patient closely for signs and symptoms of hypoglycemia.

Your patient also requires basic nursing interventions for comfort and hygiene. Although she’s dehydrated and thirsty, she may not be able to eat or drink anything until she’s no longer feeling nauseated, vomiting, or complaining of abdominal pain. Providing frequent oral care helps moisten dry lips and mucous membranes, increasing her comfort and giving you an opportunity to assess her hydration.

Skin care is especially important because dehydration and poor tissue perfusion from DKA increase the risk of skin breakdown. Turn and reposition your patient every 2 hours. Use an emollient to keep her skin from becoming scaly, flaky, and vulnerable to breakdown. As you provide skin care, check your patient’s skin turgor, color, temperature, and perfusion.

An acute complication of diabetes can quickly deteriorate into a metabolic crisis. Hypoglycemia, for instance, can make your patient’s mental status decrease quickly. Left untreated, she can become comatose and suffer permanent brain damage. Acute hyperglycemia can also trigger dangerous consequences.As a nurse, you’re in an excellent position to detect the early signs and symptoms of hypoglycemia, hyperglycemia, and other acute complications such as diabetic ketoacidosis (DKA), and hyperglycemic hyperosmolar nonketotic (HHNK) syndrome . You can also identify findings that suggest the Somogyi phenomenon, an acute complication of treatment, and the dawn phenomenon, another problem related to diabetes. And your quick detection can lead to swift interventions that save your patient from life-threatening consequences.

If acute illness or infection isn’t the cause of your patient’s hyperglycemia, it may be her diet, exercise level, or drugs. Or she may not be hyperglycemic, but may appear to be because she uses an incorrect technique for self-monitoring or an inaccurate glucose meter.Review your patient’s recent dietary intake. Did she exceed her allocated food intake? Ask her about mealtimes and eating habits, especially if her blood glucose level is consistently elevated at a particular time of day.

Ask your patient if she has changed her exercise program. A decrease in exercise or a change in the type of exercise can cause her blood glucose level to fluctuate.

Review your patient’s drugs. Have any dosages been changed recently? Has she stopped taking any drugs? Is she taking a drug that raises the blood glucose level?

If your patient injects insulin, find out if she uses insulin that’s beyond its expiration date. Ask her to demonstrate her administration technique. Does she gently roll cloudy insulin? Is she drawing up the prescribed amount? Do you see large air bubbles in the syringe that might cause her to inject a dose that’s smaller than prescribed?

Examine your patient’s glucose meter. Has it been coded correctly for the test strips she uses? If not, glucose values may be inaccurate. Ask her to demonstrate her blood testing technique; improper technique can affect test results. Review her glucose test records. Look for patterns that indicate the need to alter her drug therapy.