Hyperglycemia

Definition/Etiology:

• Definition
  • Hyperglycemia is blood glucose greater than 125 mg/dL while fasting and greater than 180 mg/dL 2 hours postprandial.
    • Not enough insulin
      • Insulin acts like a key to the doors of a cell, so that sugar leaves blood and enters the cell.
    • Can’t USE insulin properly
      • Cell doesn’t have enough doors to open
• Etiology
  • Infection
  • Inflammation
  • Ingestion – (Steroids/Cocaine)
  • In adherance – not taking dm meds

Pathophysiology:

• DKA = Type 1 (Alphabet trick!)
  • FAST
  • Zero insulin + high sugar + ketones.
  • High levels of ketones can poison the body = Metabolic acidosis (Review blood gasses if that is not clicking!)
  • Dehydration & Electrolyte imbalance
• Hyperglycemic Hyperosmolar State (HHS) = Type 2
  • SLOW
  • Low Insulin + EXTREMELY high sugar + NO ketones.
  • EXTREME dehydration and death

Noticing: Assessment & Recognizing Cues:

• Hyperglycemia
  • Vitals
  • 3 P’s
    • Polydipsia—thirst
    • Polyuria—urination
    • Polyphagia—appetite
  • Fatigue – Cell doors are not open for glucose. STARVING.
• DKA
  • Type 1
  • Young
  • Abd pain + N/V
  • Breathing
    • Kussmaul’s
    • Fruity
• HHS
  • Type 2
  • Elderly
  • AMS change

Interpreting: Analyzing & Planning:

• DKA
  • Glucose 350-550
  • pH < 7.35 (acidosis)
  • Anion Gap >20
    • ACid-Base + Electrolytes
  • Ketones
    • Blood & Urine
• HHS
  • Glucose >600
  • Urine Osmolality >320
    • SEVERE DEHYDRATION
• Diagnostics
  • ECG/Telemetry
    • Electrolyte imbalances = dysrhythmia
    • Especially Hypokalemia
      • ST depression/Tall T waves

Responding: Patient Interventions & Taking Action:

• General Considerations
  • Dysrhythmia Watch – KCL Shifts
  • Electrolyte Watch
    • Draw panel Q 2 hours and replace
    • Could be another protocol in place – ask questions
  • 2 large bores or central line – lots of infusions
• DKA
  • Bolus Fluids First (0.9% NS)
  • REG IV insulin = 1 hour after fluids
  • KCL IV same time as Insulin GTT
    • Because insulin pulls K into the cell = hypokalemia
  • Add d5 when glucose <250
    • Prevent hypoglycemia
• HHS
  • Fluids First (0.9% NS)
  • Reg IV INsulin – When Blood sugar no longer drops on its own (severe dehydration)
  • KCL IV same time as Insulin GTT

Reflecting: Evaluating Patient Outcomes:

• DKA & HHS
  • Telemetry
  • Glucose < 200
  • Hydrated
    • Vitals, Cap refill
    • Urine Output regulated
  • Specific Labs
    • DKA = Ketones/AG Resolved
    • HHS = Osmolality WNL

Linchpins (Key Points):

• Notice
  • High Blood Sugar & SPECIFIC symptoms
• Interpret
  • Labs DKA vs HHS
  • Example (Ketones vs osmolality)
• Respond
  • Fluids & Insulin gtt (open cell doors)
  • Don’t forget KCK
• Reflect
  • Patient Hydrated
  • Labs Resolved
  • Avoided Dysrhythmias