Hypoglycemia

Hypoglycemia

Welcome back to the Nursing School Week by Week Podcast, where we talk about all the things you need to know to succeed in nursing school. I’m your host, Melanie, and today I’m talking about hypoglycemia.

Hypoglycemia is when the blood sugar level drops below 70 mg/dL. The normal range for blood glucose is between 70-100. A low blood sugar level is very serious and you, as the nurse, must act quickly to fix it. I mean, think about it, What is the main fuel source for your brain? Glucose. Your brain needs glucose, or sugar, for energy. If the brain goes too long without enough glucose, it can cause seizures, coma, permanent brain damage, and even death.

We’ll usually see hypoglycemia in diabetic patients who are taking insulin to manage their diabetes. But it can also occasionally happen in non-diabetics. In patients who do have diabetes, they can become hypoglycemic if they take too much insulin, or if they aren’t eating enough, or if they exercise too much, or even just exercising at the wrong time after taking the insulin. Because exercise naturally decreases your blood sugar level, but if diabetics exercise when the insulin is working at its peak, then they can drop their blood sugar too much and become hypoglycemic. 

Some reasons why a non-diabetic person might become hypoglycemic are: if they drink too much alcohol, because alcohol is broken down by the liver. The liver is also vital in stabilizing blood sugar levels by releasing glucose back into the bloodstream when your body needs it. But if it’s too busy breaking down a large amount of alcohol, then it can’t really do both at the same time, and you can become hypoglycemic.

Anorexia can obviously cause hypoglycemia if the patient is just not consuming enough food for their body to make enough glucose. Um, let’s see… Hepatitis can cause low blood sugar levels since it damages the liver and affects the release of glucose. Basically any disease that hurts the liver, pancreas, or the kidneys can cause hypoglycemia. Because if we think back to our anatomy and physiology days, and the process of how sugar is released and controlled in the blood, after we eat a meal, there’s a bunch of sugar floating around in our blood. This tells the pancreas to release the hormone insulin. The insulin tells the liver to take in a lot of the sugar and the liver will just hold it there until it’s been a while since you’ve eaten, and then the liver will release some glucose back into the bloodstream to keep things relatively stable.

Someone with kidney problems can develop hypoglycemia because the kidneys are the washing machines for the blood in the body. You can picture them as 2 kidney bean shaped washing machines. They help get rid of waste and break down medications, but if those kidney washing machines aren’t working, then medications can build up in the patient’s blood and lead to hypoglycemia.

Alright, let’s pretend for a second that you are the typical person that’s most likely to become hypoglycemic. You’re a type 1 diabetic, so you’re totally dependent on insulin, since your body can’t make its own. You’re about to eat lunch, so you take your normal dose of insulin. You sit down and eat about half your lunch, but then you get a phone call. It’s your sister and she’s just had a tough break up, so you talk to her for a while cause she thinks the world will not turn without him and she needs your support. An hour later, you throw out your half-eaten lunch and clean up the dishes. It’s one of the first nice Fall days outside, so you hop in the car and head to Hobby Lobby for some light Fall decor shopping. You MUST make your room smell like pumpkin spice everything! While you’re trying to decide between an adorable pumpkin pillow or a wooden sign that says, Grateful, Thankful, Blessed, you start to feel a little shaky. You notice you’re sweating, and your vision is going a little blurry. You think, “oh crap. I didn’t finish my lunch, but I took my full dose of insulin.” You think you can maybe make it back home in time, so you get in the car and head that way. As you’re driving, your tummy is grumbling and you feel super hungry. You're feeling light headed, and realize you’re not going to make it home. You see the hospital, and pull into the ER entrance. You walk in still feeling shaky and now cold. You tell them what happened and they get you a bed right away. The nurse pricks your finger and the glucometer reads 45. Yikes! Your blood glucose level is 45! They quickly bring you an apple juice and some crackers, and in a few minutes you already feel so much better, and you promise yourself you’ll never leave the house again without some glucose tablets or something in your purse. Just in case.

Alright, so that could have been a lot worse, and it helped that the patient came into the hospital already aware of what was happening. But as nurses, we need to know what hypoglycemia looks like so we can recognize it, even when the patient doesn’t. So, what are some signs and symptoms of hypoglycemia?  What are you, as the nurse going to look for? The mnemonic I want you to remember for this is TIRED. T-I-R-E-D. That’s Tachycardia, Irritability, Restless, Excessive Hunger, and Diaphoresis. Tired. T-I-R-E-D. Tachycardia (or heart rate faster than 100 beats per minute), Irritability, Restless, Excessive hunger, and diaphoresis (or sweating). I also like to remember, “Cold & Clammy? Give ‘em Candy!” If they feel cold and look sweaty, they need some sugar. Cold and clammy? Give ‘em candy. As a nurse, you probably won’t give your patients actual candy, but we’ll talk about exactly what to give in a minute.

Some other symptoms you might see in hypoglycemic patients are a headache, they might be shaky, and they might have changes in their vision, like they might not be able to focus their eyes very well. And they may be very pale. They also might be in a full-on seizure. Hopefully not, but seizures usually happen at very low blood glucose levels, so it’s a definite possibility.

But everyone is different. Technically, hypoglycemia is when the sugar level is below 70, and some people will show signs and symptoms at 69, and some won’t show until 23. Usually, we will start to see symptoms at a glucose level of around 55, but I’ve seen a patient with a blood sugar level of 25 and just slightly tachycardic, but otherwise non-symptomatic. So it just depends on the person.

However, there is something called hypoglycemia unawareness and this is pretty scary to me. This is when a patient gets hypoglycemia frequently, and their body just kinda stops making the symptoms. So these people can’t even tell anymore when their glucose is getting too low, so they don’t know they need to treat it.

Also, if the patient is on a beta-blocker medication, they probably won’t show the signs of hypoglycemia because this med is made to slow the heart rate, so you won’t get the tachycardia, and it masks the other symptoms as well. So it’s important to know what medications your patients are taking. 

So how is hypoglycemia actually diagnosed? If the patient, doc, or nurse notices any of the TIRED signs, tachycardia, irritability, restlessness, excessive hunger, or diaphoresis, then we can use a blood glucose meter to check their sugar level. The blood glucose meter, or glucometer, is just a little hand-held machine that sucks up one drop of blood from the patient’s finger and lets us know the glucose level right then and there at the bedside. 

If they are a known diabetic, they will most likely have this test routinely done every 4-6 hours while they're in the hospital. If the glucometer reads less than 70 mg/dL, and they have signs or symptoms, they are hypoglycemic. 

So what are our nursing interventions? What are we going to do about this patient whose blood sugar is tanking? And remember, we need to act quickly because the brain needs this energy fuel source! In the case of hypoglycemia, the treatment really depends on the level of severity. Is it mild, moderate, or severe? Is the patient still alert and cooperative and you could get them to drink something? Or are they unconscious and you need to give them a shot or something through their IV? 

If you get a job working in a hospital, and your patient is a known diabetic, there will be instructions in the MAR, or Medical Administration Record, on exactly what to give the patient for hypoglycemia. But basically, if their blood glucose level is above 40 and they are still able to drink something, we will give them a half cup of fruit juice. If they don’t want juice, you can try fat-free milk, or saltine crackers, or even just a straight sugar pack. The idea is you are giving them simple carbohydrates that their body can quickly use for energy. After they drink the juice, then they need a more complex carbohydrate. Something like wheat bread, or fresh fruits, and this will give a more steady, long-lasting rise in blood sugar and prevent them from crashing again. Try not to give them any foods high in fat, because the fat will actually slow down the absorption of glucose.

Now, if the patient has severe hypoglycemia, meaning their blood glucose level is less than 40, or they’re unconscious, or unable to swallow, then we would notify the doctor, and give them a liquid solution of 50% dextrose into their IV. Dextrose is almost chemically identical to glucose and the body uses it in the same way, so we give 50% dextrose, which is half dextrose and half water, so the body can quickly use that as a source of energy.

Sometimes we will also give a shot called glucagon for severe hypoglycemia. You may remember that glucagon is a hormone just like insulin, but it does the opposite of what insulin does. Insulin lowers blood sugar levels, but glucagon increases blood sugar levels. Glucagon is the hormone that tells your liver to start glycogenolysis and release some of that glucose that it’s been storing back out into your bloodstream. The glucagon shot is given either subcutaneously, or intramuscularly, but it can make the patient nauseous, so you want to turn them on their side after you give it, so they don’t vomit and then either choke on their vomit, or aspirate it into their lungs. Once they are alert and able to swallow safely again, you want to encourage them to eat something with protein to keep their glucose level up.

Ok. After you do your nursing interventions, either giving them a simple carbohydrate and then a complex carb, or giving them 50% dextrose and glucagon, then you want to recheck their blood glucose level 15 minutes later, to make sure it’s gone up to a stable level, of at least 70 mg/dL. And you’re not going to just check it once and say, “Ok, they’re good, let me just go to lunch.” You’re going to need to check them frequently for the next couple hours to make sure it’s not dropping again.

So let’s recap the nursing interventions for mild or moderate hypoglycemia with blood glucose between 40-70, give fruit juice, and then a complex carb and recheck blood glucose in 15 minutes. For severe hypoglycemia, with a level below 40, or a patient that’s unable to swallow safely, push 50% dextrose into their IV and possibly give a glucagon shot. Then recheck their glucose level in 15 minutes.

Not too crazy. But if you’re a visual learner, like me, and like 65% of people are, Picmonic has two really great audiovisual stories to help you remember all this information. One is on hypoglycemia assessment and the other is the interventions. You guys know I love Picmonic and have found it super helpful throughout nursing school to help me memorize all The Things and be way more prepared for classes. If you want to check it out, it’s totally free to sign up, and you get one Picmonic a day for free. If you want to do the subscription, it’s only like 3 bucks a month, and I’ll put a link in the show notes for 20% off. But I’d definitely recommend it if you’re a visual learner, or if you find stories helpful to remember things. I can’t think of a more useful way to spend $3 a month.

Alright, so we’ve assessed the patient and found signs and hypoglycemia, we did our nursing interventions, and we evaluated to make sure they worked. What else is there? Well, we know that nurses are also teachers. We don’t want to be treating the same patients for the same problem a week from now, so we need to educate them on how to prevent becoming hypoglycemia in the future. We would make sure they understand how often they should be checking their blood sugar level at home, if they’re diabetic, and about proper insulin dosing. Remind them not to skip meals, and not to exercise without eating. Also, tell them to keep some kind of fast acting simple carbohydrate with them at all times like glucose tablets, or they even have little glucose gummies that have exactly 15g per serving. This is helpful for diabetic patients because most of them follow the 15-15 rule. When they’re blood sugar falls between 55-69, they take 15 grams of carbs and then recheck they’re blood sugar in 15 minutes. If it’s still under 70, then they take another 15 grams and repeat. 

Alright, I have a little podquiz for you guys. I’ll say the question and the answer options, and then I’ll give you a little time to answer.

1. What is the normal range for blood glucose?
1. 75-110
2. 70-100
3. 69-80

The answer is B. 70-100 mg/dL. Under 70 is hypoglycemic.

1. What is the hormone called that naturally increases blood glucose levels?
1. Insulin
2. Melatonin
3. Glucagon

The answer is C. Glucagon. This hormone is given as a shot to fix severe hypoglycemia, to tell the liver to release any glucose into the bloodstream.

1. Which is not a sign of hypoglycemia?
1. Dry mouth
2. Tachycardia
3. Diaphoresis

The answer is a. Dry mouth. That’s actually a symptom of hyperglycemia, or high blood glucose. The other two options, tachycardia and diaphoresis are signs of hypoglycemia. Remember the mnemonic TIRED. Tachycardia, Irritability, Restless, Excessive Hunger, and Diaphoresis.

1. What medication will block the signs of hypoglycemia?
1. Antidepressants
2. Beta Blockers
3. NSAIDS

The answer is b. Beta Blockers. Beta blockers are used to slow the heart rate by blocking the effects of norepinephrine, but in doing so, they also mask the tachycardia, and shakes that come with hypoglycemia. This is why we have to know what meds our patients are taking, and do frequent blood sugar checks on diabetic patients. 

1. How long should you wait before rechecking blood glucose after an intervention?
1. 15 minutes
2. 5 minutes
3. 30 minutes

The answer is a. 15 minutes. You should recheck the glucose level 15 minutes after an intervention, and then every 15 minutes until they are back within the normal range. Also, educate the patient that after a hypoglycemic episode, their body may not show early symptoms if it happens again for 3 days following. 

Alright you guys, I think that about covers it for hypoglycemia. I hope this was helpful to you, and make sure you tune in next week cause I’m gonna do a whole verbal simulation with a hypoglycemic patient that I really think will help you, especially getting ready for the new Next Generation NCLEX case study questions. Also, I would love it if you wrote a review for the podcast. I always love reading what you guys think, and it really motivates me to make more episodes!

Alright y'all, have a great week, and I’ll talk to you next time!