Wynne Erica P.

Englatiera
Block AAA

ASSIGNMENT

1. What is hypoglycemia?
Hypoglycemia means low (hypo) sugar in the blood (glycemia). Hypoglycemia
occurs when the blood glucose falls to less than 70 mg/dL (3.7 mmol/L). Severe
hypoglycemia is when glucose levels are less the 40 mg/dL (2.5 mmol/L). It can occur
when there is too much insulin or oral hypoglycemic agents, too little food, or excessive
physical activity. Hypoglycemia may occur at any time of the day or night. It often
occurs before meals, especially if meals are delayed or snacks are omitted. For example,
midmorning hypoglycemia may occur when the morning insulin is peaking, whereas
hypoglycemia that occurs in the late afternoon coincides with the peak of the morning
NPH insulin. Middle-of-the-night hypoglycemia may occur because of peaking evening
or predinner NPH insulins, especially in patients who have not eaten a bedtime snack.
Hypoglycemia symptoms can develop suddenly and vary greatly from person to person
but among its common signs and symptoms (that diabetics should also be aware of and
should watch out for) are shakiness, hunger, weakness, sweating, and nervousness.

2. Differentiate the clinical manifestations of mild, moderate, and severe hypoglycemia.

Mild hypoglycemia: During a mild hypoglycemic episode, when blood glucose
levels drop, the sympathetic nervous system is triggered resulting in a spike of
epinephrine and norepinephrine causing clinical manifestations such as sweating, tremor,
tachycardia, palpitation, anxiety, and hunger.
Moderate hypoglycemia: With moderate hypoglycemia, the depletion in blood
glucose levels deprives the brain cells of the necessary fuel to function. Signs of CNS
dysfunction may include the inability to concentrate, headache, lightheadedness,
confusion, memory lapses, numbness of the lips and tongue, slurred speech, impaired
coordination, emotional changes, irrational or combative behavior, double vision, and
drowsiness. In this type of hypoglycemia, any combination of these symptoms (in
addition to adrenergic symptoms) can develop.
Severe hypoglycemia: In a severe hypoglycemic episode, the CNS functioning is
significantly impaired that the patient requires the assistance of another person to treat it.
Symptoms may include disoriented behavior, seizures, difficulty arousing from sleep, or
loss of consciousness.
3. Discuss thoroughly the immediate treatment for a conscious diabetic individual
manifesting hypoglycemia.
Oral administration of a 15g fast-acting concentrated source of carbohydrate (such
as 2 or 3 glucose tablets, 1 tube glucose gel, 0.5 cups of juice) is the most effective
therapy for a conscious patient. After approximately 15 minutes, blood sugar levels are
checked to see if additional doses of carbohydrates are necessary to alleviate symptoms
and raise blood sugar levels above the established threshold. After initial treatment, this
should be followed with snacks including starch and protein, such as cheese and crackers,
milk and crackers, or a half sandwich which can also help stabilize their blood sugar
levels.

4. Discuss comprehensively the emergency measures that should be provided to an

unconscious diabetic individual manifesting hypoglycemia.
If a patient becomes too disoriented, unable to swallow, is having seizures, or
losing consciousness, it is not safe to give them any food or liquid as this could be
inhaled. Instead, an injection of glucagon 1 mg can be given either subcutaneously or
intramuscularly. Glucagon, a hormone secreted by the alpha cells of the islets of
Langerhans, stimulates the liver to break down and release glycogen thereby increasing
blood glucose levels. Injectable glucagon is packaged as a powder in 1-mg vials and must
be mixed with a diluent immediately before being injected. The patient should also be
turned to their side as this ensures that the airway is not blocked and that choking is
prevented since the administration of glucagon can cause some to experience nausea and
vomiting. Once the patient is more alert and has regained consciousness, a concentrated
amount of carbohydrates followed by a snack should be administered to prevent
recurrence of hypoglycemia and to restore liver glycogen. Because the patient is at a
higher risk of having another hypoglycemia episode after a hypoglycemic episode
(because the duration of the action of 1 mg of glucagon is brief—its onset is 8 to 10
minutes, and its action lasts 12 to 27 minutes), close monitoring for the next 24 hours is
recommended. In hospitals and emergency departments, for patients who are unconscious
or cannot swallow, 25 to 50 mL of dextrose 50% in water (D50W) may be administered
IV. Because hypertonic solutions like 50 percent dextrose are particularly irritating to
veins, it's critical to make sure the IV line utilized for the injection of 50 percent dextrose
is patent. In general, diabetics who are on insulin should keep a glucagon kit on hand in
case of an emergency. In case of an emergency, family and friends should be aware of
where to find the kit and how to use it. Patients should be instructed to notify their
primary provider after severe hypoglycemia has occurred and been treated.

5. List all the essential components of patient education in the prevention of hypoglycemia.
 Hypoglycemia is prevented by a consistent pattern of eating, administering
insulin, and exercising. In the prevention of hypoglycemia, patients, family members, and
coworkers must be instructed to:
 Between-meal and bedtime snacks may be needed to counteract the
maximum insulin effect. In general, the patient should cover the time of
peak activity of insulin by eating a snack and by taking additional food
when physical activity is increased.
 Routine blood glucose tests are performed so that changing insulin
requirements may be anticipated and the dosage adjusted.
 Recognize the symptoms of hypoglycemia which includes hunger,
sweating, pallor, tremor, palpitations, and headache and other adverse
effects to report. Family members in particular must be made aware that
any subtle (but unusual) change in behavior may be an indication of
hypoglycemia. Family members must be taught to persevere and to
understand that the hypoglycemia can cause irrational behavior, due to
low supply of glucose to the brain.
 Because unexpected hypoglycemia can occur, all patients treated with
insulin should wear an identification bracelet or tag stating that they have
diabetes.
 Autonomic neuropathy or beta-blockers such as propranolol (Inderal) to
treat hypertension or cardiac dysrhythmias may mask the typical
symptoms of hypoglycemia. It is very important that patients taking these
medications perform blood glucose tests on a frequent and regular basis.
 It is important that patients with diabetes, especially those receiving
insulin, learn to carry some form of simple sugar with them at all times
(ADA, 2016e). There are commercially prepared glucose tablets and gels
that the patient may find convenient to carry.
 Patients are advised to refrain from eating high-calorie, high-fat dessert
foods (e.g., cookies, cakes, doughnuts, ice cream) to treat hypoglycemia
because their high fat content may slow the absorption of the glucose and
resolution of the hypoglycemic symptoms. The patient may subsequently
eat more of the foods when symptoms do not resolve rapidly, which may
cause very high blood glucose levels for several hours and may contribute
to weight gain.
 Patients should be instructed to report all severe hypoglycemic episodes in
addition to any increase in the incidence, frequency, and severity to the
primary provider.

Others:
 To avoid post-exercise hypoglycemia, especially after strenuous or
prolonged exercise, the patient may need to eat a snack at the end of the
exercise session and at bedtime and monitor the blood glucose level more
frequently.
  Patients who require insulin should be taught to eat a 15-g carbohydrate
snack (a fruit exchange) or a snack of complex carbohydrates with a
protein before engaging in moderate exercise
 Monitor your blood sugar. Depending on your treatment plan, you may
check and record your blood sugar level several times a week or multiple
times a day. Careful monitoring is the only way to make sure that your
blood sugar level remains within your target range.
 Don't skip or delay meals or snacks. If you take insulin or oral diabetes
medication, be consistent about the amount you eat and the timing of your
meals and snacks.
 Measure medication carefully, and take it on time. Take your medication
as recommended by your doctor.
 Record your low glucose reactions. This can help you and your health care
team identify patterns contributing to hypoglycemia and find ways to
prevent them.

6. Name the three (3) main types of macrovascular complications that occur frequently in
patients with diabetes.
Coronary artery disease, cerebrovascular disease, and peripheral vascular
disease are the three main types of macrovascular complications that occur more
frequently in the diabetic population.
 Coronary artery disease may account for 50% to 60% of all deaths in
patients with diabetes. One unique feature of coronary artery disease in
patients with diabetes is that the typical ischemic symptoms may be
absent. Thus, patients may not experience the early warning signs of
decreased coronary blood flow and may have “silent” myocardial
infarctions.
 Cerebral blood vessels are similarly affected by accelerated
atherosclerosis. Occlusive changes or the formation of an embolus
elsewhere in the vasculature that lodges in a cerebral blood vessel can lead
to transient ischemic attacks and strokes. People with diabetes have twice
the risk of developing cerebrovascular disease, and studies suggest there
may be a greater likelihood of death from cerebrovascular disease in
patients with diabetes.
 Atherosclerotic changes in the large blood vessels of the lower extremities
are responsible for the increased incidence (two to three times higher than
in nondiabetic people) of occlusive peripheral arterial disease in patients
with diabetes. Signs and symptoms of peripheral vascular disease include
diminished peripheral pulses and intermittent claudication (pain in the
buttock, thigh, or calf during walking). The severe form of arterial
occlusive disease in the lower extremities is largely responsible for the
 increased incidence of gangrene and subsequent amputation in diabetic
patients.

7. What is the cause of diabetic macrovascular complications?

Changes in the medium to large blood arteries cause diabetic macrovascular
problems. Plaque that attaches to the walls of blood vessels thickens, scleroses, and
occludes them which eventually causes obstruction of blood flow.

8. Discuss the pathogenesis of diabetic retinopathy.

Diabetic retinopathy is an eye condition that can cause blindness and visual loss
in diabetics. It is caused by changes in the small blood vessels in the retina, which is the
area of the eye that receives images and sends information about the images to the brain.
Once glucose levels are poorly controlled, there will be microaneurysms, small
hemorrhages, and leakage of lipids into the retina. This results in capillary closure and
retinal hypoxia leading to abnormal proliferation of retinal vessels which are prone to
bleeding. The vitreous is normally clear, allowing light to be transmitted to the retina.
When there is a hemorrhage, the vitreous becomes clouded and cannot transmit light,
resulting in loss of vision. Another consequence of vitreous hemorrhage is that resorption
of the blood in the vitreous leads to the formation of fibrous scar tissue. This scar tissue
may place traction on the retina, resulting in retinal detachment and subsequent visual
loss.

9. What are the microvascular complications of diabetes?

The types of microvascular complications that occur in DM can include
neuropathy (damage to nerve cells), retinopathy (damage to small blood vessels that
nourish the retina), nephropathy (damage to kidney cells), and disorders of
gastrointestinal motility.

10. Discuss the nursing management to patients with diabetic retinopathy.

Nursing management of patients with diabetic retinopathy or other eye disorders
involves implementing the individual plan of care and providing patient education. 
 Education focuses on prevention through regular ophthalmologic examinations,
blood glucose control, and self-management of eye care regimens. The
 effectiveness of early diagnosis and prompt treatment is emphasized in educating
the patient and family. 
 If vision loss occurs, nursing care must also address the patient’s adjustment to
impaired vision and the use of adaptive devices for diabetes self-care as well as
activities of daily living. 
Because the course of the retinopathy may be long and stressful, patient education
is essential. In educating and counseling patients, it is important to stress the following:
 Retinopathy may appear after many years of diabetes, and its appearance does not
necessarily mean that the diabetes is on a downhill course.
 The odds for maintaining vision are in the patient’s favor, especially with
adequate control of glucose levels and blood pressure.
 Frequent eye examinations allow for the detection and prompt treatment of
retinopathy.
 Psychological counseling may be warranted. To prevent further losses, glycemic
control remains a priority
Other nursing managements:
 The patient is reminded of the need to see an ophthalmologist regularly. If eye
changes are progressive and unrelenting, the patient should be prepared for
inevitable blindness. Therefore, consideration is given to making referrals for
educating the patient in Braille and for training him or her with guide (i.e.,
service) dogs. Referral to state agencies should be made to ensure that the patient
receives services for the blind. Family members are also taught how to assist the
patient to remain as independent as possible despite decreasing visual acuity. 
 During home visits, the nurse can assess the patient’s home environment and his
or her ability to manage diabetes despite visual impairments.

11. What is the most common complication in all people with diabetes?
The most common complication in all people with diabetes is nephropathy.
Nephropathy, or kidney disease secondary to diabetic microvascular changes in the
kidney, is a common complication of diabetes. Patients with type 1 diabetes frequently
show initial signs of kidney disease after 10 to 15 years; while patients with type 2
diabetes tend to develop kidney disease within 10 years after the diagnosis of diabetes.
Many patients with type 2 diabetes have had diabetes for many years before the diabetes
is diagnosed and treated. Therefore, they may have evidence of nephropathy at the time
of diagnosis (ADA,2013). If blood glucose levels are elevated consistently for a
significant period of time, the kidney’s filtration mechanism is stressed, allowing blood
proteins to leak into the urine. As a result, the pressure in the blood vessels of the kidney
increases. It is thought that this elevated pressure serves as the stimulus for the
 development of nephropathy. Various medications and diets are being tested to prevent
these complications.

12. Discuss the pathogenesis of diabetic neuropathy.

Diabetic neuropathy refers to a group of diseases that affect all types of nerves,
including peripheral (sensorimotor), autonomic, and spinal nerves. The pathogenesis of
neuropathy may be attributed to either a vascular or metabolic mechanism or both. There
may be capillary closure and thickening of the basement membrane. Demyelinization of
the nerves, which is considered to be linked to hyperglycemia, may also occur. When the
myelin sheaths are distorted, nerve transmission is interrupted. Nerves are living tissues
and need oxygen to survive. Raised blood sugars bind to structures and proteins in the
artery walls in a process called glycosylation and cause them to thicken. this is called
diabetic microangiopathy. Because oxygen has to diffuse across the walls of the blood
vessels to make its way into the nerve cell tissue beneath, any increase in blood vessel
thickness will impair the transfer of oxygen which causes hypoxia, a lack of oxygen to
the tissue.

13. Define peripheral neuropathy and describe its clinical manifestations.

Peripheral neuropathy refers to a group of conditions involving damage to the
peripheral nervous system which is the extensive communication network that carries
impulses between the central nervous system (the brain and spinal cord) and all other
regions of the body. It most commonly affects the distal portions of the nerves, especially
the nerves of the lower extremities, and affects both sides of the body symmetrically and
may spread in a proximal direction. Clinical manifestations include paresthesias and
burning sensations, especially at night. Numbing of feet can also occur as neuropathy
progress which increases the risk for injury and undetected foot infections. In addition, a
decrease in proprioception and a decreased sensation of light touch may lead to an
unsteady gait. The incorrect weight distribution on joints caused by this loss of
proprioception can then cause foot deformities. A reduction in deep tendon reflexes and
vibratory sensation is also detected on physical examination.

14. State the reason/s why diabetic individuals are at an increased risk for injury and
undetected foot infections.
Diabetic individuals are at an increased risk for injury and undetected foot
infection because of the impairment in pain sensation (sensory neuropathy) which
reduces their perception of pain. Thus, they are often unaware of the constant trauma to
the feet leading to an increased risk of cuts, sores, and blisters. Wounds that go unnoticed
 and untreated can soon get infected, resulting in complications and, in extreme cases,
amputation.

15. Why are diabetics (with neurogenic bladder) prone to urinary tract infections?
With diabetes, nerve degeneration (neuropathy) can cause urine retention and
difficulty to urinate correctly, reducing bacterial clearance and increasing the risk of
infection. The longer the urine stays in the bladder, the higher the risk of getting an
infection. Bacteria can benefit from a high level of glucose in the urine because it
contains a lot of nutrients and so it makes a fertile breeding ground. As a result, they can
continue to proliferate which ultimately results in the kidney getting infected. Moreover,
immunological defects such as having lesser amount of white blood cells and t cells to
destroy bacteria and viruses, reduced T cell-mediated immune response, and impaired
neutrophil function can also contribute to such increased risk for infection.

16. List all the essential elements in the patient education concerning foot care.
 Emphasize the importance of never going barefoot. It’s possible that you
could step on something and hurt your feet without being aware of it.
 Instruct patient to maintain proper foot hygiene by ensuring proper washing
and drying of feet every day, using warm water to avoid burns, and trimming
toenails to a natural shape of the nail to prevent cutting your skin and keep the
nails from growing into your skin.
 Instruct patient to protect feet from hot and cold by keeping them away from
heaters and open fires, wearing shoes on hot pavements, and wearing socks in
bed when feeling cold.
 Encourage the patient to avoid crossing legs, wearing garters and tight socks,
and applying lotions containing alcohol.
 Emphasize daily inspection of feet for any cuts, sores, blisters, swelling,
redness, or any other change.
 Encourage the usage of well-fit leather shoes and cotton socks.
 Encourage the patient to have his/her feet checked at least once a year,
preferably three to four times a year, for loss of sensation.
 Encourage easy and foot-friendly activities such as walking, dancing, riding a
bike, or swimming.
 Instruct patient to report any abnormalities immediately and seek prompt care.
 Encourage the patient to see a podiatrist regularly to help treat foot problems.
 Urge the patient to quit smoking as this can impair blood circulation which
can worsen foot problems.
 Emphasize management of blood sugar levels which should stay within
normal levels.