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Nursing 5263: Hypoglycemia and Hyperglycemia Presented by: Excalibur Group Daphney Jacques, Bridgette Jenkins, Opal Jobson-Cudjoe , Kelly miller
Objectives Distinguish between normal and abnormal blood glucose levels based on patient population Classify the different diagnosis associated with hypoglycemia/hyperglycemia based on patient age Compare the common causes of hypoglycemia/hyperglycemia based on patient population
Objectives Formulate the appropriate interventions for hypoglycemia/hyperglycemia management based on patient population Differentiate between the different medications used to manage the hypoglycemic/hyperglycemic patient. Predict immediate complications of hypoglycemia/hyperglycemia
Objectives State potential long term complications of uncontrolled blood sugar levels Determine the appropriate educational strategies to prevent hypoglycemia/hyperglycemia
NORMAL BLOOD GLUCOSE for PREGNANT WOMEN 65mg/dl (fasting) <140 mg/dl (2 hr pp)
CLASSIFICATION OF DIABETES IN PREGNANT WOMEN (cdc.gov) Pregestational Diabetes Type I: primarily due to pancreatic islet beta cell destruction. Type II: most common type of diabetes that is a result of insulin resistance or insufficiency. Gestational Diabetes Any degree of glucose intolerance with the onset or first recognition occurring during pregnancy.
SCREENING FOR GESTATIONAL DIABETES (Lowdermilk, Perry, & Bobak) Screening should be done between 24-28 weeks gestation. Glucose Tolerance Test (GTT): 50 grams of glucose is consumed, blood is taken after 1 hour and sent to a laboratory for evaluation.
140mg/dl or greater is considered as positive
Oral Glucose Tolerance Test (OGTT) is done if the GTT is positive.
After a overnight fast, a fasting blood glucose level is drawn. Then 100 grams of glucose is consumed and blood is drawn at 1, 2 and 3 hour intervals.
The patient is diagnosed with gestational diabetes if 2 or more values are met or exceeded: Fasting 105mg/dl 1 hr 190mg/dl 2 hr 165mg/dl 3 hr 145mg/dl
HYPOGLYCEMIA IN PREGNACY Blood glucose: < 60mg/dl Causes: excess insulin, insufficient food, excessive exercise or work, vomiting or diarrhea.
MANAGEMENT OF HYPOGLYCEMIA Check blood sugar when symptoms first appear (fingerstick) Eat 10-15 grams of simple carbs Recheck blood glucose 15 minutes after intake Notify healthcare provider if blood glucose remains low If patient is unconscious call 911 If in hospital administer 50% dextrose or glucagon as ordered. Recheck blood sugar, send urine/blood to lab
HYPERGLYCEMIA IN PREGNACY Blood glucose > 200 mg/dl Causes: Insufficient insulin, excess or wrong kinds of food, infection, illness, injuries, emotional stress or insufficient exercise
MANAGEMENT OF HYPERGLYCEMIA Notify healthcare provider Administer insulin in accordance with blood glucose level (sliding scale) Give IV fluids (NS or 0.45 NS) Monitor blood & urine laboratory testing
2000-2500 daily, less if overweight or morbidly obese
Active women are encouraged to continue physical activity, sedentary are encouraged to get active. Walking is recommended
Monitoring of blood glucose levels
Findersticks are done at home. Usually done upon waking (fasting) and after meals (postprandial)
Insulin therapy: done on a individual basis to maintain normal blood glucose levels Close monitoring of fetus after 40 weeks until delivery
COMPLICATIONS OF DIABETES IN PREGNACY Congenital malformations Macrosomia: infant weight of 4,000-4,500 grams Intrauterine growth retardation (IUGR) Stillbirth Respiratory Distress Syndrome (RDS) Spontaneous abortion in early pregnancy Shoulder Dystocia Pregnancy induced hypertension (PIH) Infections (UTI’s, yeast infection) Ketoacidosis
PREVENTION Seek counseling before getting pregnancy Maintain a healthy weight Exercise regularly Eat healthy and balanced meals Seek prenatal care early in pregnancy Keep all prenatal appointments Follow regime prescribed by physician
REFERENCES CDC.GOV (2009). Information on gestational diabetes. Retrieved July 9, 2009, from: http://diabetes.niddk.nih.gov/dm/pubs/gestational/ Lowdermilk, D., Perry, S., & Bobak, I. (1999). Maternity Nursing (5th. Ed). St. Louis: Mosby.
CASE STUDY Maria, a 40 y/o G4P3 at 29 weeks present to Labor & Delivery with c/o dizziness, headache, nausea and vomiting for 3 days. After interviewing Maria, you note that she has not had any prenatal care, has a h/o diabetes Her past obstetrical history includes delivery of a 4500 gram male complicated by shoulder dystocia. She weighs 312 pound. Her Bp 129/83, HR 82, RR 26 and Temp 98.8. A UA shows 3+ glucose, and negative ketones. Her accucheck is 179mg/dl.
CASE STUDY DISCISSION Questions 1. What tests, if any, should be done to evaluate the Maria’s glucose tolerance? 2. How is the diagnosis of gestational diabetes mellitus (GDM) established? 3. What would be the best treatment and follow-up strategy for Maria? Discussion This patient has several risk factors for GDM. She is over the age of 30, has a history of GDM and is obese. All these place her at a greater risk for developing GDM. She needs to be referred to a dietician or diabetic counselor. She needs to continue prenatal care and started on insulin therapy. Maria should be followed closely for the remainder of the pregnancy. Birthing options (vaginal vs caesarean section) should be discussed with the patient. Maria should also be followed closely after delivering to assess for the development of Type II diabetes.