NURSING 1460 Case Study 109 Severe Hypoglycemia/ Case Study 109 Severe Hypoglycemia questions and answers graded A+

Scenario T.R. is a 19-year-old college freshman who lives in the honors dormitory. His friend finds him wandering aimlessly about the campus appearing pale and sweaty. He engages T.R. in conversation and walks him to the campus medical clinic, where you are on duty. The friend explains to you how he found T.R. and says T.R. is “diabetic” and takes insulin. T.R. is not wearing a medical warning tag. It is 1020. 1. What do you think is going on with T.R.? T.R. is experiencing a hypoglycemic reaction as evidence by diaphoresis, pallor, and his disorientation. 2. What is the first action you would take? Have T.R. sit down, and proceed by taking his blood glucose level. Once we know his blood glucose level it will be easier to diagnose and find the best treatment for T.R. 3. Which assessment findings would support the premise that T.R. is experiencing a hypoglycemic reaction? a. Extreme thirst and nausea b. Nervousness and tachycardia c. Hypertension with bounding pulses d. Fruity breath with deep, rapid respirations B: Nervousness and tachycardia 4. If no glucose meter were available, would you treat T.R. on the assumption he is hyperglycemic or hypoglycemic? Explain your reasoning. His current symptoms point to him having hypoglycemia. Symptoms are considered to be an important clue. Due to not having a glucose meter we should treat the patient based on his current symptoms. His current symptoms indicate he is suffering from hypoglycemia. Symptoms include confusion, fatigue, clamminess, sweating, and anxiety. Hypoglycemia can lead to lack of coordination, seizures, unconsciousness, and possibly death if left untreated. 5. It is 1025. T.R.’s glucose reading is 50 mg/dL (2.8 mmol/L). What should your next action be? Anything below 70 mg/dL is considered hypoglycemia. Chart 64-7 on page 1310 details how to manage hypoglycemia for mild cases (less than 60 mg/dL), moderate (less than 40 mg/dL), and severe (20 mg/dL). Glucose tablets/gel, 1/2 cup of fruit juice or soft drink, 8 ounces of skim milk, 6-10 hard candies, 4 cubes of sugar, 4 teaspoons of sugar, 6 saltines, 3 graham crackers, or 1 tablespoon of honey or syrup can be administered. 6. When you enter the room to give the juice, T.R. is not responsive enough to drink the juice safely. What should you do? Subcutaneous or IM glucagon and 50% IV dextrose are administered to patients who cannot swallow. Glucagon is the main counter regulatory hormone to insulin and is used as first-line therapy for severe hypoglycemia in DM. 7. T.R. is breathing at 16 breaths/min and has a pulse of 112 beats/min and regular. Because outpatient resources vary, describe your next actions if (1) your clinic is well equipped for emergencies or (2) your clinic has no emergency supplies. T.R. has normal respirations, his pulse rate is higher than normal however. If the clinic is supplied with emergency equipment, then cardio version will be used to deliver a shock to correct the pulse rate. If the clinic is not supplied with emergency equipment we should perform vagal maneuvers to correct the tachycardia by putting ice packs on the patients face. There are drugs that can be given as an alternative. CASE STUDY PROGRESS A few minutes after administering 2 mg subcutaneous glucagon, T.R. begins to awaken. He becomes alert and asks where he is and what happened to him. You orient him and then explain what has transpired. 8. What questions would you ask to find out what precipitated this event? We need to ask about insulin dosages and the type of insulin used by T.R. on a regular basis. We should also inquire about T.R.’s diet, and meals. Has he has and recent hypoglycemic episodes? 9. What further action do you need to take at this time? He should be given something sugary to drink or eat such as fruit juice or soda, he could eat hard candy or saltines. We want to see a rise in blood sugar levels. Rest is also suggested. 10. At 1045, you recheck T.R.’s glucose and the reading is 64 mg/dL (3.6 mmol/L). His vital signs are 120/72, 18, 92. Has his status improved or not? Defend your response. According to the latest blood sugar test report, T.R.’s condition has improved. His vitals are also starting to normalize other then his blood sugar being lower than 70 mg/dL. However, it was 50 mg/dL earlier so it is rising. 11. What would your next action be? To continue improvement of his blood sugar level we should provide T.R. with a meal to eat, and sugary drink such as fruit juice or soda. We want to encourage his blood sugar to keep rising to get him out of that hypoglycemic state. 12. At 1110, you recheck T.R.’s glucose and the reading is 104 mg/dL (5.8 mmol/L). What should you do now? This shows that the medication and our interventions are working. He is recovering. His glucose levels have improved. CASE STUDY PROGRESS T.R. tells you he took 35 units glargine (Lantus) insulin and 12 units of regular (Humulin R) insulin at 0745. He says he was late to class, so he just grabbed an apple on the way. 13. Based on this information, why did T.R. experience this episode of hypoglycemia? He skipped breakfast and just grabbed an apple. Lantus is a long-lasting insulin and is considered strong. Humulin is a short-acting insulin. Administering insulin of any kind without a proper meal can lead to hypoglycemia. 14. Based on your knowledge of the types of insulin T.R. is receiving, when would you expect T.R. to experience a hypoglycemic reaction? He will experience hypoglycemic episodes when there is insulin overdose or a delayed or missed meal. Lantus is classified as a long-acting insulin which starts working within 1-2 hours after administration and remains active up to 24 hours. Overdose can cause hypoglycemia and is the most common side effect of Lantus. 15. T.R. says he had a few similar episodes recently. He treated them by eating a candy bar. He says he is on a 2000-calorie, carbohydrate-controlled diet but has been checking his blood glucose levels every “couple of days” only. What common mistake in previously treated episodes of hypoglycemia did T.R. make? Carbohydrate content should be increased in food. It should not be controlled. Foods high in protein should be consumed. 15-20 grams of fast acting carbohydrates are advised for patients who are experiencing hypoglycemia. 16. He goes on to say he has had “a little bit much to drink at a few of the parties he has been to” on the weekends. What effect does alcohol have on blood glucose? Alcohol inhibits liver glucose production and leads to hypoglycemia. It interferes with the counter regulatory response to hypoglycemia and impairs glycogen breakdown. Ingest alcohol only with or shortly after eating a meal with enough carbohydrates to prevent hypoglycemia. Avoid excess alcohol at bedtime to prevent nighttime hypoglycemia. 17. What should you teach T.R. about alcohol consumption and managing his diabetes? Ingest alcohol only with or shortly after eating a meal with enough carbohydrates to prevent hypoglycemia. Avoid excess alcohol at bedtime to prevent nighttime hypoglycemia. 18. List 4 additional points you would stress in a teaching plan with T.R. -For better management of diabetes, it is important to take medicines as per recommended by the HCP. Patient needs to learn to adjust medications as per their routine or schedule. -The meal plan is one of the most important aspects in the management of diabetes. People suffering from DM should consume meals after regular time intervals. Skipping meals can lead to hypoglycemia. -Monitoring of blood sugar levels at regular intervals of time, before exercise and sports activities is especially important -Drinking beverages containing alcohol can induce hypoglycemic episodes. Avoid consumption of alcoholic beverages is recommended. 19. You tell T.R. to check his blood glucose at 1230 then eat lunch at the normal time. You determine that he understands your teaching regarding averting hypoglycemia if he states: a. “I need to eat within 30 minutes of taking the regular insulin.” b. “If I am too sick to eat, I will not take any insulin until I feel better.” c. “Only certain kinds of alcoholic drinks will affect my blood glucose levels.” d. “I will exercise just before eating and taking insulin so I do not get cramps.” The correct answer is A. 20. Write a sample documentation note for the encounter with T.R. 8/10/2020 T.R. is a 22 year old, senior in college. He lives in the dorms. He was found wandering around campus with obvious confusion. He appears pale and sweaty. Patient is a known diabetic who takes regular insulin. Patient is diagnosed with hypoglycemia due to symptoms. Upon return with fruit juice patient was unconscious. 2mg of glucagon was administered, patient started to recover consciousness. Patient said he takes 35 units of glargine insulin and 12 units of regular insulin. He experienced a hypoglycemic episode due to him skipping breakfast this morning after administration of medication. He is advised to continue to monitor blood glucose prior to and after meals and create a log. Patient demonstrated an understanding of proper teaching towards hypoglycemia. Patient should follow up in a week to discuss meal plans and insulin dosages. CASE STUDY OUTCOME T.R. follows up with you in 1 week to discuss how he has been managing his meals and insulin dosing. He states he feels that he has been doing a better job with eating meals at regular times and shows you the log from his new diabetes tracking app. You congratulate him on his progress and decide together that meeting weekly will help T.R. manage his diabetes while adjusting to college life. Diet/Exercise Carbohydrate intake avoids nutrient deficient sources and focuses on sources from vegetables, fruits, whole grains, legumes, and dairy products. Consume at least 25 g of fiber daily. Avoid sugar-sweetened beverages. Dietary fat and cholesterol intake focuses on the quality of fat rather than on the quantity of fat. Limit trans fat, saturated fats, and cholesterol the same as the general population. Alcohol consumption affect blood glucose. Two drinks for men, one for women can be ingested with the meal plan Exercise: Chart 64-4 Page 1301 • Teach the patient about the relationship between regularly scheduled exercise and blood glucose levels, blood lipid levels, and complications of diabetes. • Reinforce the level of exercise recommended for the patient based on his/her physical health • Instruct the patient to wear the appropriate footwear designed for exercise. • Remind patient to examine his/her feet daily, especially after exercise • Remind patient to stay hydrated and to not exercise in extreme cold or heat • Warn patient not to exercise within 1 hours of insulin injection or near the peak time • Teach patient how to prevent hypoglycemia during exercise: • Do not exercise unless blood glucose level is at level is at least 80 and less than 250 mg/dL • Have a carbohydrate snake before exercising if 1 hour has passed since the last meal or if the planned exercise is high intensity • Carry a simple sugar to eat during exercise if symptoms of hypoglycemia occur • Ensure the identification information about diabetes is carried during exercise • Remind patient to check blood glucose levels more frequently on days which exercise is performed and that extra carbohydrate and less insulin may be needed during the 24 hours period after extensive exercise.