Nursing Care For Adults With Hypoglycaemia: Pathophysiology, Pharmacology, And Inter-Professional Care

Assessment Data

Low blood glucose or hypoglycemia occurs in instances when the levels of sugar in the blood are found much less than the normal range. Most people diagnosed with diabetes mellitus have a mean blood sugar level of 70 milligrams per decilitre (mg/dL). Although the symptoms of the physiological abnormality differs among people. However, the symptoms reported by most individuals comprise of shaky and jittery feelings, headache, blurred vision, dizziness, confusion, pale face, irritability, and irregular or fast heartbeat. Some of the severe symptoms of the condition encompass convulsions and seizures, unconsciousness, and the lack of ability to drink or eat (Seaquist et al. 2013, p.DC_122480).

This condition has most commonly been associated with adverse effects of insulin and other kinds of diabetes medications. Some of the most common medications that lead to hypoglycaemia include meglitinides and sulfonylureas (Pfeiffer 2016, p.117). Furthermore, failure of the affected individuals to consume adequate amount of carbohydrates, skipping or delaying meals, vigorous physical activity and alcohol consumption increases the risks of hypoglycaemia. This essay will elaborate on a case study about a hypoglycaemic patient, admitted to the emergency department in a hospital. Furthermore, it will also shed light on the pathophysiology of the condition and explain the nursing management that will be delivered to the patient.

The case study is about Mrs. Anthony, aged 35 years who has been admitted to the HHHS Ward 1. Some of her presenting complaints that resulted in her admission to the ED include multiple fractures, loss of consciousness, and smoke inhalation. Her past medical history includes diagnosis of diabetes mellitus (type 2). Upon conducting an assessment risks for hypoglycaemia were noticed. Some of her vital signs indicated hypotension, high pulse rate, high body temperature and low amount of oxygen saturation. Her respiratory rate was normal. Furthermore, the low amount of blood glucose levels were also observed in the patient. Diastolic hypotension is evidenced by the fact that her blood pressure levels were around 95/50. Diastolic blood pressure less than 60 mmHg is regarded as hypotension (Halliwill et al. 2013, p.12). Abnormally reduced blood pressure results in fainting and dizziness and can also be considered life-threatening. Her pulse rate of 120 beats per minute indicated presence of tachycardia, a condition characterised by heart rate that exceeds the resting or normal rate of 100 beats per minute (Fenoglio Jr et al. 2015, p.187). Presence of type 2 diabetes can be considered as a risk factor that increased her susceptibility to report an abnormally high pulse rate. Oxygen saturation generally measures the percentage of oxygen binding sites that are associated with haemoglobin in the bloodstream.

Pathophysiology

The patient reported 92% SAO2, thereby indicating the presence of hypoxemia that was characterised by an abnormal low amount of oxygen in the blood. This oxygen deficiency results in failure to supply adequate oxygen to the blood. The normal blood glucose levels are found to be 4.0 to 5.4 mmol/L during fasting and upto 7.8 mmol/L, after 2 hours of having a meal. The fact that Mrs. Anthony reported blood sugar levels of 2.8 mmol/L confirms the presence of hypoglycaemia that occurs when there is a drop in the amount of blood sugar, below the normal levels. This in turn increases the risk of the patient of suffering from trouble in talking, clumsiness, seizures, loss of consciousness, and subsequent death. Thus, hypoglycaemia can be cited as the primary reason that resulted in her loss of awareness, upon arrival to the ED.

Showing similarity with most animal tissues, the metabolism of the brain principally depends on glucose as the fuel. An inadequate quantity of glucose is generally obtained from the glycogen stored in astrocyte cells, but gets consumed within less time. Thus, the brain is highly dependent on a constant source of glucose that diffuses from the bloodstream into interstitial cells and tissues, present within the central nervous system. Therefore, reduction in the amount of glucose present in the blood primarily affects the brain. In most individuals, this lowering of blood glucose level below 3.6 mmol/L (65 mg/dL) manifests in the form of a lessening in the mental efficiency (Kovatchev & Cobelli 2016, p.508). This is most commonly exhibited in the form of an impairment in judgement and/or action that becomes more prominent at levels less than 2.2mmol/L (40 mg/dL). With a further reduction in the sugar levels, seizures might also occur. The neurons enter a state of electrical silence with a reduction in the blood glucose levels below 0.55 mmol/L (10 mg/dL), thereby leading to coma (Bergenstal et al. 2013, p.227). These effects on the brain are together referred to as neuroglycopenia.

There occurs huge number of hormonal, nervous and metabolic changes that occur in the body in response to inadequate supply of blood sugar to the brain. Most of the changes are adaptive or defensive, with an intent to increase the blood glucose levels by the process of gluconeogenesis or glycogenolysis. Under conditions when there is a huge reduction in the blood sugar levels, the liver is able to convert stored reserves of glycogen into glucose, thereby releasing it into bloodstream (Cryer 2013, p.369). This in turn prevents the affected individual from entering a state of diabetic coma. Mild or brief periods of hypoglycemia fails to exert any lasting effects on the human brain. However, the brain responses get temporarily altered. Severe hypoglycemia results in an impairment in motor control, cognitive function, and/or consciousness. Majority of patients with type 2 diabetes, like Mrs. Anthony in the case study are under the first line treatment that involves administration of compounds that promote insulin release. Sulfonylureas has become the mainstay treatment for obtaining glycemic control, and generates hypoglycaemia by bringing about changes that block the potassium channels present on the beta cells, thereby altering the membrane potential and triggering the release of insulin. Research evidences have established the fact the uptake of brain glucose increases in response to recurrent hypoglycaemia. Owing to the fact that the neurotransmitter epinephrine plays an essential role in tachycardia generation and nervousness among the patients, reduction in release of catecholamine contributes to the loss of consciousness during hypogylcemia.

Nursing Care Plan

Nursing care plan

Assessment	Goal	Intervention	Rationale	Evaluation
Subjective- Shaky and scared Objective- BSL 2.8 mmol/L	The client will resume normal blood sugar levels	· Administration of STAT 1mg IM glucagon · Check blood glucose levels at regular intervals · Make the patient consume simple sugars and small snacks	· The administration of STAT 1mg IM glucagon has been found effective for hypoglycemic reactions in diabetic patients, being treated with insulin. It acts as an insulin antagonist and stimulates the synthesis of cAMP for accelerating gluconeogenesis, and hepatic glycogenolysis, thereby increasing the blood sugar levels. It will also help in the relaxation of the GI tract smooth muscles (Arnold et al. 2015, p.159). · Ingestion of adequate amounts of protein and carbohydrates will provide energy (Choudhary et al. 2015, p.1018)	After 8 hours, an measurement of blood glucose levels will show values of 5.0 to 6.0 mmol/L.
Subjective- profuse sweating, unable to respond verbally Objective- BP 95/50	The patient will regain consciousness and report normal BP	· Make the patient drink more water · Put on compression stockings · Administer orvaten/midodrine	· Consumption of more water will help to increase the blood volume and will directly prevent dehydration · The stocking swill relive swelling and pain in veins and reduce blood pooling in the legs · Orvaten is used for treating orthostatic hypotension and belongs to the alpha receptor agonist group of drugs. These maintain proper blood pressure and prevents symptoms of light-headedness and dizziness (Izcovich et al. 2014, p.12)	Increased BP after 6 hours
Objective- Pulse 120bpm,	The pulse rate will lower to normal levels	· Perform vagal maneuvers · Prescribe anti-arrhythmic drugs · Perform cardioversion	· Vagal maneuvers will create an impact on the vagus nerve that controls the heartbeat · Class I antiarrhythmic agents will suppress the abnormal heart rhythm by interfering with sodium channels (Motoki et al. 2016, p.16). · Cardioversion will involve delivery of a shock to the chest that will affect electrical impulses and restore the heart beat (Cappato et al. 2014, p.3349)	Reduction in pulse rate to 90-100 bpm after 2 hours
Objective- SaO2 92%	Oxygen amount will increase	· Provide additional oxygen with the help of a nasal cannula · Make the patient sit in semi-fowler position	· Nasal cannula will deliver supplemental oxygen and increase the airflow to the lungs (Bressan et al. 2013, p.1653). · Semi-fowler position will lead to chest expansion	The patient will report SaO2 95-100% after 2 hours
Objective- temperature 38.3°C	Body temperature will be normal	· Administration of acetaminophen and ibuprofen · Encourage increased intake of fluids · Promote rest · Increase calories in the diet	· The drug selectively inhibits activities of COX in the brain, and contributes to a reduction in pain and high temperature (Young et al. 2015, p.2219) · Fluid intake will promote hydration · Taking rest will help to regain energy · Calorie rich diet will also lower temperature	The temperature will reduce to 36.5-37.5°C after 2 hours

Establishing a balance in the glycemic control by is the key management strategy for providing optimal care services to the patient Mrs. Anthony. The inpatient team will have to effectively reduce or prevent hypoglycemic events by 1) identifying the triggering or precipitating factors; 2) monitoring blood glucose levels at regular intervals; 3) educating the patient and the staff about the symptoms and suitable treatment; 4) providing nutritional requirements; and 6) eliminating medication errors. Precipitating and triggering factors encompass a delay in the meal timings and oral hypoglycaemic agent dosages. Errors in the medication timing, administered dosages, and presence of certain comorbidity increases the chances of a patient to suffer from hypoglycaemia (Munshi et al. 2016, p.316). The inpatient staff will be responsible for conveying instruction for medication administration and meal timings, and encouraging self-care in the patient. This is in accordance to the NSQHS standards that encompass proper identification of the patient and responding to major clinical deteriorations in them. Scheduled administration of insulin therapy will also prevent overdose of the drug and reduce its impacts on lowering blood glucose levels (Sahealth.sa.gov.au 2018). This can be facilitated by adherence to the medication safety and management standards that works to reduce the occurrence of medication related incidents.

A comprehensive and holistic health assessment of the patient should be conducted in order to retrieve relevant and accurate data associated with differential diagnosis. Furthermore, timely diagnostic intervention in accordance to statement 1.2 will greatly facilitate prevention of further deterioration (Nursingmidwiferyboard.gov.au 2018). Regular monitoring of blood sugar levels for minimum four times a day will help help in determining early peak in caloric intake. Adequate nutrition is paramount for the patient (Myers 2017, p.e.149). There is a need to administer a carbohydrate rich diet in a consistent manner for maintaining an optimum glucose level, thereby preventing hypoglycaemia. This will be governed by the statement 3.1 that illustrates the importance of prescribing pharmacological and non-pharmacological interventions to the patients (Nursingmidwiferyboard.gov.au 2018). Despite the evidence for adverse effects related to unsafe and old medication practice habits, there is a need to formulate a multidisciplinary team that will correctly implement all interventions upon the patient. Upon experiencing a hypoglycemic episode, beside assessment must include the circulatory and respiratory status, level of consciousness, results of capillary blood glucose test, IV access existence, amount and time of insulin dose, and the NPO status. Furthermore, before discharge of the patient, she and her family members should be educated through verbal instructions and written materials for self-management of glucose levels (Sahealth.sa.gov.au 2018). The professionals should abide by the statement of 2.2 and educate the patient, with the aim of enabling her to actively participate in the care process (Nursingmidwiferyboard.gov.au 2018). Furthermore, the multidisciplinary team should practice in accordance with the state, federal and territorial legislations that govern the professional practice.

Conclusion

Thus, it can be concluded that the patient Mrs. Anthony suffered from hypoglycaemia that resulted in a deterioration of her health condition and subsequent admission to the hospital. Her condition was characterised by low levels of sugar in the blood, which in turn is associated with her treatment for type 2 diabetes. Abnormalities were also observed in her vital signs such as, body temperature, pulse rate, and blood pressure. Owing to the fact that she presented some symptoms of sweating, shakiness, irregular heart beat and anxiety or scare, she was prescribed STAT 1mg IM glucagon for normalising the blood sugar levels. Thus, efforts must be taken by a multidisciplinary team to implement a nursing care plan in accordance with the aforementioned standards, with the aim of effectively managing hypoglycaemia and her irregular vital signs. Appropriate implementation of the formulated nursing care plan, in combination with providing education to the patient, will help her to manage the prevailing health conditions.

References

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