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Home , Hyperglycemia

HHF – : ASSESSMENT & MANAGEMENT

CONSIDERATIONS: 8. American Association of Clinical Endocrinologist 1. Hyperglycemia is an abnormally high level of AACE (2011) recommends targets be glucose in the blood, most frequently associated individualized, take into account residual life with : expectancy, duration of disease, presence or a. Blood glucose level greater than 130 mg/dl is absence of microvascular and macrovascular considered high complications, CVD risk factors, comorbid b. Hyperglycemia may be the result of a slow or conditions and risk for severe . These sudden rise in blood glucose should be formulated in the context of the patient’s psychological, social, and economic status. 2. Persistent hyperglycemia has been shown to be a causative factor in such chronic complications as 9. ADA Standards of Care (2013) recommendations , , for glycemic control: cardiovascular complications, and peripheral a. Self-monitoring blood glucose (SMBG) should vascular disease. be carried out three or more times daily for 3. The most common causes for hyperglycemia in a patients using multiple injections or person diagnosed with diabetes include: therapy a. Inaccurate or inadequate amounts of insulin b. For patients using less-frequent insulin and/or oral or non-insulin injectable anti-diabetic injections, noninsulin therapies, or medical agents nutrition therapy (MNT) alone, SMBG may be useful as a guide to management b. Dietary non- adherence c. Perform the A1C test at least two times a year c. , illness, or in patients who are meeting treatment goals d. Decreased exercise or activity less than usual (and who have stable glycemic control) e. Pain d. Perform the A1C test quarterly in patients 4. Medications and therapies which can raise blood whose therapy has changed or who are not glucose include: meeting glycemic goals a. Total parental nutrition 10. ADA’s “Standards of Medical Care in Diabetes” b. Anti-metabolites recommends lowering A1C to 7.0% in most patients c. Atypical to reduce the incidence of microvascular disease. d. Less stringent A1C goals (such as < 8%) may be e. Steroids/immunosuppressive appropriate for patients with a history of severe f. Antihypertensives hypoglycemia,limited life expectancy,advanced g. Female replacement hormones microvascular and macrovascular complications, extensive comorbid conditions and those with long- 5. Signs and symptoms of hyperglycemia may be standing diabetes in whom the general goal is absent or unrecognized, but when present may difficult to attain despite DSME, appropriate glucose include: monitoring, and effective doses of multiple glucose- a. , , polydypsia lowering agents including insulin. b. Weakness or c. EQUIPMENT: 6. Conditions associated with hyperglycemia include Blood glucose testing equipment (See Blood Glucose /Cerebrovascular accident, Testing) underlying renal/cardiac disease, , anemia, and/or . PROCEDURE: 7. Target blood glucose levels should be established 1. If patient’s Blood Glucose Log or symptoms indicate by the primary care provider for: hyperglycemia, assess for causes and perform a a. blood . b. Pre-prandial 2. Assess the patient’s/caregiver’s diabetes c. Two-hour postprandial management since the last visit including: d. Hemoglobin A1C a. Blood glucose log book, if available, or through 3. American Diabetes Association and European the blood memory Association for the Study of Diabetes (ADA/EASD) b. Activity/exercise, including increases and Standards (2012) identify the glycemic target points decreases for as: c. management, with a. Fasting and pre-prandial < 130mg/dl attention to missed or under-dosing b. Postprandial < 180 mg/dl d. Meal planning and carbohydrate counting, with c. Hemoglobin A1C < 7% (mean plasma glucose attention to non-adherence to meal plan goals of 150 - 160 mg/dl) Endocrine System – Hyperglycemia: Assessment & Management Page 1 of 2

HHF Endocrine System – HYPERGLYCEMIA: ASSESSMENT & MANAGEMENT

e. Illness and use of sick day management f. Contact physician if or diarrhea protocol, as appropriate persists for more than 4 - 6 hours 3. Assess the patient’s health status for any indication of infection, including but not limited to urinary tract, AFTER CARE: dental, yeast, skin or upper respiratory . 1. Document in patient's record: 4. Assess for new medications added to the patient’s a. Signs or symptoms of hyperglycemia noted regime, particularly those that may increase insulin b. Results of blood glucose test resistance, for example: steroids, HIV and anti- c. Trends and patterns identified in glucose values cancer therapies. d. Causes identified leading to glucose excursions 5. Assess the patient for signs of depression, anxiety e. Treatment given and patient's response to the or confusion impacting the patient’s ability to treatment manage diabetes on a day-to-day basis. f. Confidence and commitment of the 6. Assure that the meter is functioning properly: patient/caregiver to implement a change and a. Assure proper coding regain glucose control b. Perform all quality control tests g. Physician notification, response and orders c. Assure all quality control results fall within received expected range h. Instructions given to patient/caregiver d. Check the machine to see if it needs cleaning 2. Communicate with physician if blood glucose is 300 e. Check the strips for any defaults mg/dl or is outside of parameters given by f. Batteries generally need replacing after about physician. 1,000 blood glucose checks or after about a year REFERENCE: 7. Have patient/caregiver perform a capillary blood American Association of Clinical Endocrinologist (2012). glucose test. (See Endocrine System - Blood American Association of Clinical Endocrinologist (2011). Glucose Testing.) If the blood glucose is greater Medial Guidelines for Clinical Practice for than 300 mg/dl, repeat the test to assure accuracy. Developing a Diabetes Mellitus Comprehensive 8. If the repeat blood glucose test is still greater than Care Plan. Retrieved May 18, 2012 from 300 mg/dl: https://www.aace.com/files/dm-guidelines- a. Guide the patient/caregiver in determining the ccp.pdf reason for hyperglycemia American Diabetes Association (2012). Position b. Notify the physician of the blood glucose level Statement of the American Diabetes value (greater than 300 mg/dl) and causative Association (ADA) and the European factors identified Association for the Study of Diabetes (EASD): c. Obtain plan verbal Management of HyperglycemiainType2 change orders from the physician, as American Diabetes Association (2013). Standards of appropriate Medical Care in Diabetes—2013. Diabetes d. Instruct the patient/caregiver on the diabetes Care. Retrieved October 8,2013 from management change orders http://care.diabetesjournals.org/content/36/Supp e. Unless contraindicated, encourage patient to lement_1/S11.ful l drink extra water (or other non-caloric, non- Diabetes: A Patient-Centered Approach. Retrieved May caffeinated beverage) 17, 2012 from 9. If patient is sick, instruct the patient/caregiver on http://care.diabetesjournals.org/content/early/20 “sick-day” guidelines: 12/04/19/dc12-0413 a. Always take oral medications or insulin Management of Hyperglycemia of Hospitalized Patients in Non-critical Settings. Retrieved May 17, 2012 b. Monitor blood glucose levels every 3 - 4 hours from: http://www.endo- around the clock society.org/guidelines/upload/FINAL- c. Drink 8-ounces of calorie-free fluids every hour Standalone-Management-of-Hyperglycemia- while awake Guideline.pdf d. If food is not tolerated, liquids or soft carbohydrate-containing foods (which contain 15 grams of carbohydrates) every other hour Adopted VNAA; Approved Policy Committee 03/11/14 are appropriate e. Contact physician if blood glucose levels are greater than 240 mg/dl for two consecutive tests, or as otherwise specified by the physician managing the patient’s diabetes Endocrine System – Hyperglycemia: Assessment & Management Page 2 of 2