A nurse is providing teaching to a female client who has type 2 diabetes and a new prescription

The overlapping symptoms of hypo- and hyperglycemia (e.g., hunger, sweating, trembling, confusion, irritability, dizziness, blurred vision) make the two conditions difficult to distinguish from one another (Paradalis, 2005). Since the treatment is different for each condition, it is critical to test the patient’s blood glucose when symptoms occur. The risk factors that may have led to the condition, and the recent medical history of the patient also help to determine the cause of symptoms.


Hypoglycemia is a condition occurring in diabetic patients with a blood glucose of less than 4 mmol/L. If glucose continues to remain low and is not rectified through treatment, a change in the patient’s mental status will result. Patients with hypoglycemia become confused and experience headache. Left untreated, they will progress into semi-consciousness and unconsciousness, leading rapidly to brain damage. Seizures may also occur.

Common initial symptoms of hypoglycemia include:

  • Cold, clammy skin
  • Weakness, faintness, tremors
  • Headache, irritability, dullness
  • Hunger, nausea
  • Tachycardia, palpitations

These symptoms will progress to mood or behaviour changes, vision changes, slurred speech, and unsteady gait if the hypoglycemia is not properly managed.

The hospitalized patient with type 1 or type 2 diabetes is at an increased risk for developing hypoglycemia. Potential causes of hypoglycemia in a hospitalized diabetic patient include:

  • Receiving insulin and some oral antidiabetic medications (e.g., glyburide)
  • Fasting for tests and surgery
  • Not following prescribed diabetic diet
  • New medications or dose adjustments
  • Missed snacks

Hypoglycemia is a medical emergency that must be treated immediately. An initial blood glucose reading may confirm suspicion of hypoglycemia. If you suspect that your patient is hypoglycemic, obtain a blood glucose level through skin puncture. A 15 g oral dose of glucose should be given to produce an increase in blood glucose of approximately 2.1 mmol/L in 20 minutes (Canadian Diabetes Association, 2013). Table 9.2 outlines an example of a protocol that may be used in the treatment of hypoglycemia.

Table 9.2 Hypoglycemia Treatment
Capillary Blood Gas (CBG) Able to Swallow Nil per Mouth with IV Access Nil per Mouth with No IV Access
≥ 4 mmol/L No treatment necessary No treatment necessary No treatment necessary
2.2-3.9 mmol/L Give 15 g of glucose in the form of:
  • 3-5 dextrose/glucose tabs (check the label) (best choice), OR
  • 175 ml of juice or soft drink (containing sugar), OR
  • 1 tablespoon of honey, OR
  • 3 tablespoons of table sugar dissolved in water

Note: Milk, orange juice, and glucose gels increase blood glucose (BG) levels more slowly and are not the best choice unless the above alternatives are not available.

Repeat CBG every 15 to 20 minutes and repeat above if BG remains below 4 mmol/L.

Once BG reaches 4 mmol/L, give patient 6 crackers and 2 tablespoons of peanut butter. If meal is less than 30 minutes away, omit snack and give patient meal when it is available.

Notify physician.

Give 10-25 g (20-50 ml of D50W — dextrose 50% in water) of glucose intravenously over 1 to 3 minutes,

OR as per agency policy.

Repeat CBG every 15 to 20 minutes until 4 mmol/L.

Continue with BG readings every 30 minutes for 2 hours.

Notify physician.

Give glucagon 1 mg subcutaneously (SC) or intramuscularly (IM).

Position patient on side.

Repeat CBG every 15 to 20 minutes. Give second dose of glucagon 1 mg SC or IM if BG remains below 4 mmol/L.

≤ 2.2 mmol/L Call lab for STAT BG level.

Continue as above.

Call lab for STAT BG level.

Continue as above.

Call lab for STAT BG level.

Continue as above.

Data source: Canadian Diabetes Association, 2013; Paradalis, 2005; Rowe et al., 2015; VCH 2009


Hyperglycemia occurs when blood glucose values are greater than 7 mmol/L in a fasting state or greater than 10 mmol/L two hours after eating a meal (Pardalis, 2005). Hyperglycemia is a serious complication of diabetes that can result from eating too much food or simple sugar; insufficient insulin dosages; infection, illness, or surgery; and emotional stress. Surgical patients are particularly at risk for developing hyperglycemia due to the surgical stress response (Dagogo-Jack & Alberti, 2002; Mertin, Sawatzky, Diehl-Jones, & Lee, 2007). Classic symptoms of hyperglycemia include the three Ps: polydipsia, polyuria, and polyphagia.

The common symptoms of hyperglycemia are:

  • Increased urination/output (polyuria)
  • Excessive thirst (polydipsia)
  • Increased appetite (polyphagia), followed by lack of appetite
  • Weakness, fatigue
  • Headache

Other symptoms include glycosuria, nausea and vomiting, abdominal cramps, and progression to diabetic ketoacidosis (DKA).

Potential causes of hyperglycemia in a hospitalized patient include:

  • Infection
  • Stress
  • Increased intake of calories (IV or diet)
  • Decreased exercise
  • New medications or dose adjustments

Note that testing blood glucose levels too soon after eating will result in higher blood glucose readings. Blood glucose levels should be taken one to two hours after eating.

If hyperglycemia is not treated, the patient is at risk for developing DKA. This is a life-threatening condition in which the body produces acids, called ketones, as a result of breaking down fat for energy. DKA occurs when insulin is extremely low and blood sugar is extremely high.

DKA presents clinically with symptoms of hyperglycemia as above, Kussmaul respiration (deep, rapid, and laboured breathing that is the result of the body attempting to blow off excess carbon dioxide to compensate for the metabolic acidosis), acetone-odoured breath, nausea, vomiting, and abdominal pain (Canadian Diabetes Association, 2013). Patients in DKA also undergo osmotic diuresis. They pass large amounts of urine because of the high solute concentration of the blood and the body’s attempts to get rid of excess sugar.

DKA is treated with the administration of fluids and electrolytes such as sodium, potassium, and chloride, as well as insulin. Be alert for vomiting and monitor cardiac rhythm. Untreated DKA can be fatal.

Patients with hyperglycemia may also exhibit a non-ketotic hyperosmolar state, also known as hyperglycemic hyperosmolar syndrome (HHS). This is a serious diabetic emergency that carries a mortality rate of 10% to 50%. Hyperosmolarity is a condition in which the blood has a high sodium and glucose concentration, causing water to move out of the cells into the bloodstream.

Further information on the treatment of DKA and HHS can be found on the Canadian Diabetes Association clinical guidelines website.

  1. At 0930 hours, your diabetic patient complains of feeling faint. You check his blood sugar and get a reading of 2.8 mmol/L. What actions will you take?
  2. What blood glucose level range do you expect immediately post-operatively from your patient who has type 2 diabetes? Why?

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Review Notes for Diabetes Mellitus

If you need a quick review around the concepts of diabetes mellitus, please see the refresher below:


  • Diabetes mellitus is a disorder characterized by insufficient production of insulin in the pancreas or when there is a resistance or deficiency of available insulin resulting in hyperglycemia.
  • It is characterized by disturbances in carbohydrate, protein, and fat metabolism.
  • Sustained hyperglycemia has been shown to affect almost all tissues in the body and is associated with significant complications of multiple organ systems, including the eyes, nerves, kidneys, and blood vessels.


  • Type 1 diabetes mellitus or, formerly called insulin-dependent diabetes mellitus, typically occurs in younger people with the exact cause is unknown. Type 1 diabetes may result from an autoimmune process triggered by a virus 
  • Type 2 diabetes mellitus, formerly called non-insulin dependent diabetes mellitus, is characterized by defects in insulin release and use, and insulin resistance. Commonly occurs in patients with obesity and those with genetic susceptibility to DM. 
  • Gestational diabetes mellitus is characterized by glucose intolerance of any degree that occurs during pregnancy. 


  • Type 1 diabetes mellitus: 
    • There is a destruction of the islet cells in the pancreas causing insufficient insulin and excess glucagon. 
    • Glucose accumulates in the serum causing hyperglycemia. 
    • Blood being delivered in the kidneys has high glucose concentration causing osmotic diuresis and glycosuria. 
    • Osmotic diuresis causes water loss, resulting in polydipsia. 
    • Lack of insulin makes the body unable to use carbohydrates primarily and instead uses fats and proteins for energy production, resulting in ketosis and weight loss. 
    • Polyphagia and fatigue result from the break down of nutritional stores. 
  • Type 2 diabetes mellitus: 
    • Insulin resistance occurs in diabetes mellitus, wherein there is a decrease in tissue sensitivity to insulin. 
    • In normal conditions, insulin binds to special receptors on the cell surfaces and initiates reactions involved in glucose metabolism. However, in type 2 diabetes, these intracellular reactions are diminished, making insulin less effective at stimulating glucose uptake by the tissues and at regulating glucose release by the liver. 
    • If the beta cells cannot keep up with the increased demand for insulin, the glucose level rises and type 2 diabetes develops. 
  • Gestational diabetes mellitus: 
    • Hyperglycemia develops in pregnancy because of the secretion of placental hormones, which causes insulin resistance. 
    • Gestational diabetes is related to the anti-insulin effects of progesterone, cortisol, and human placenta lactogen, which increase the amount of insulin needed to maintain glycemic control.


  • Hypoglycemia is when the blood the glucose falls to less than 50 to 60 mg/dL and is linked to excessive use of hypoglycemic agents, decreased food intake, increased physical activity, excessive alcohol consumption, or renal failure. It often occurs before meals, especially if meals are delayed or snacks are omitted. It can occur on type 1 or type 2 diabetes. 
  • Diabetic ketoacidosis (DKA) is caused by an absence or severe inadequacy of insulin. This deficit in available insulin results in disorders in the metabolism of carbohydrate, protein, and fat. DKA is usually associated with incorrect or failure to take insulin as prescribed and stress and is occurring in clients with type 1 diabetes. 
  • Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS) is the combination of severe hyperglycemia and hyperosmolarity with little or no acidosis. The insulin level in HHNS is too low to prevent hyperglycemia but is high enough to prevent fat breakdown. HHNS occurs in older clients (50 to 70 years old)  with type 2 diabetes and is associated with stress or ingestion of certain drugs. 
  • Microangiopathy, or diabetic microvascular disease, is characterized by capillary basement membrane thickening most prominently in the retina and glomerulus. 
  • Diabetic retinopathy is the deterioration of the small blood vessels that nourish the retina causing visual impairment. 
  • Nephropathy is a renal dysfunction caused by microvascular changes in the kidney secondary to diabetes mellitus. 
  • Diabetic neuropathy refers to a group of diseases that affect all types of nerves characterized by paresthesias or decreased sensation. Peripheral neuropathy and autonomic neuropathy are two of the most common types of neuropathy found in diabetes. 
  • Increased susceptibility to infections results from an impaired ability of granulocytes to respond to infectious agents. 

Clinical Manifestations

  • Diabetes mellitus: 
    • Polyuria (increased urination), polydipsia (increased thirst), and polyphagia (increased appetite) are the classic symptoms of diabetes mellitus, also known as the “3 P’s of DM”
    • Fatigue and weakness
    • Weight loss
    • Sudden vision changes
    • Tingling or numbness in hands or feet
    • Dry skin
    • Skin lesions or wounds that are slow to heal
    • Recurrent infections (urinary, skin, vulva)
  • Diabetic Ketoacidosis (DKA)
    • Dehydration
    • Tachycardia
    • Kussmaul’s respirations
    • Nausea and vomiting
    • Abdominal pain
    • Acetone breath (fruity odor)
    • Decreased level of consciousness
    • Orthostatic hypotension
  • Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS)
  • Hypoglycemia
    • Mild hypoglycemia: stimulation of the sympathetic nervous system. 
      • Sweating
      • Cool, moist skin, or pallor
      • Tremors
      • Tachycardia
      • Palpitation
      • Nervousness
      • Hunger
    • Moderate hypoglycemia: decreased glucose levels for the brain cells.
      • Impaired CNS function
      • Inability to concentrate
      • Lightheadedness
      • Headache
      • Confusion
      • Memory lapses
      • Double vision
      • Drowsiness
    • Severe hypoglycemia: severe impairment of the CNS.
      • Disoriented behavior
      • Seizures
      • Difficulty arousing from sleep
      • Loss of consciousness

Laboratory and Diagnostics

  • Diabetes mellitus
    • Fasting blood glucose level above 140 mg/dL or postprandial (after meals) blood glucose levels above 200 mg/dl measured on more than one occasion is diagnostic. 
    • Glycosylated hemoglobin (HgbA1C) shows an elevated blood glucose level. 
  • Diabetic ketoacidosis (DKA)
    • Blood glucose levels between 300 and 8900 mg/dL
    • Ketoacidosis is reflected in low serum bicarbonate (0 to 15 mEq/L) and low pH values. 
    • Accumulation of ketone bodies is reflected in blood and urine ketone measurements. 
    • Sodium and potassium concentrations may vary depending on the degree of dehydration. Increased levels of creatinine, blood urea nitrogen, and hematocrit go along with dehydration. 
    • Arterial blood gas indicate metabolic acidosis
  • HHNS
    • Serum blood glucose higher than 700 mg/dL
    • Serum blood osmolality is higher than 350 mOsm/kg
    • Urine specimen reveals the absence of ketosis
    • Serum electrolyte levels show hypernatremia and hypokalemia. 
  • Hypoglycemia
    • Serum blood glucose level is less than 70 mg/dL

Medical Management

  • The main goal of treatment is to normalize insulin activity and blood glucose levels to reduce the development of complications. 
  • There are five components of management for diabetes: nutrition, exercise, monitoring, pharmacologic therapy, and education. 
  • Insulin is the primary treatment for type 1 diabetes. 
  • Weight reduction is the primary treatment for type 2 diabetes. 
  • Exercise enhances the effectiveness of insulin. 

Nursing Management

  • Monitor blood glucose levels and provide teaching to the patient on how to do so. 
  • Administer medications, as prescribed: 
  • Self-administering insulin
    • Provide information and teaching on how to self-administer insulin. 
    • On storing insulin: vials of insulin, when not in use, should be refrigerated (extreme temperatures should also be avoided).  Insulin vial that is currently in use can be kept at room temperature (1 month). Cloudy insulins should be thoroughly mixed by gently inverting the vial or rolling it between the hands before drawing the solution. Intermediate-acting insulin showing a frosted, whitish coating inside the bottle, should be discarded. 
    • On selecting syringes: syringes should match the insulin concentration. 
    • On mixing insulins: patients should be warned not to inject one type of insulin into the bottle containing a different type of insulin. Patients with difficulty mixing insulins may use premixed insulin. 
    • Selecting and rotating injection sites: the abdomen, upper arms, thighs, and hips are the four main sites for insulin injection. Rotation of injection sites is recommended to prevent lipodystrophy which may cause a decrease in the absorption of insulin. Encourage the patient to use all available injection sites within one area rather than randomly rotating sites from area to area. 
    • Inserting the needle: insulin should be injected into the subcutaneous tissue, the incorrect technique may affect the rate of absorption. 
  • Nurse teaching on diabetes
    • Assess readiness to learn and include the patient’s family in developing a diabetic teaching plan. 
    • Prevention of complications
    • Dietary and lifestyle changes
    • Proper self-care (especially foot care)
    • Administration and management of insulin
    • Use of hypoglycemic medications
  • Management of  DKA. 
    • Treatment goal is to prevent dehydration, electrolyte loss, and acidosis. 
    • Normal saline (0.9%) is infused at a high rate to replace fluid loss. Hypotonic solution (0.45% NS) may be used for hypertension or hypernatremia. 
    • Administer regular insulin, as ordered.
    • Monitor serum glucose levels as insulin is administered. 
    • Monitor potassium levels, because potassium shifts affect the heart. 
    • Monitor respirations as respiratory distress can occur. 
    • Assess vital signs, intake and output, and monitor ketone levels. 
  • Management of HHNS
    • Assess vital signs, fluid status, and laboratory values. Fluid status and urine output are closely monitored because of the risk for renal failure secondary to severe dehydration. 
    • Because clients are usually older, monitor for heart failure and cardiac arrhythmias.
  • Management of Hypoglycemia. 
    • Monitor blood glucose levels. 
    • Administer glucose (oral glucose, I.V. glucose, or glucagon). 
    • Advise client to carry simple sugar at all times to prevent case of hypoglycemia. 

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