Med-Surg Endocrine System, part 19: Diabetes Complications - Hypoglycemia, DKA, HHS
by Cathy Parkes September 23, 2020 Updated: January 26, 2022 14 min read
In this article, we cover the common complications of diabetes, including hypoglycemia, DKA in type 1 diabetes, HHS in type 2 diabetes, as well as their risk factors, signs and symptoms, lab values and treatment. Diabetes is extremely common and so you will encounter it frequently in your exams as well as your career. We also cover some extended complications of diabetes.
Hypoglycemia is a common complication seen in patients with diabetes wherein blood glucose levels drop below 70 mg/dL.
You might remember from our endocrine lab values overview that the normal blood glucose levels are between 70 and 140 mg/dL, depending on the type of test. Values lower than 70 mg/dL indicate hypoglycemia.
Causes of hypoglycemia
There are a variety of reasons that a patient with diabetes can enter into hypoglycemia. A patient might become hypoglycemic because of excess insulin, not enough food intake, too much exercise, or alcohol consumption.
Excess insulin medication can lead to low blood sugar because if you remember, insulin is the escort that takes glucose to the cells to be used as energy, so when the body has excess insulin, it’s removing too much glucose and the glucose levels will drop, causing that hypoglycemic state.
Check out our overview of insulin medications, including rapid-acting, short-acting, intermediate-acting, and long-acting. These medications are covered in our Pharmacology Flashcards for Nursing Students.
If a patient skips a meal or is not eating enough food, they are not putting enough glucose into their body to begin with, so the levels don’t get a chance to rise to where they need to be.
If a patient gets too much exercise, their body is burning all of their glucose as energy (thanks to that escort insulin!) and they can exhaust their stores of glucose, which means the levels will be too low.
Alcohol consumption and hypoglycemia
Alcohol consumption can cause hypoglycemia in people with diabetes for an interesting reason that has to do with how our liver functions. If you remember from our overview of glucagon:
- Glucose is the sugar in our bloodstream that we can use for energy, and when it’s stored for later it’s converted to glycogen
- Glucagon is a hormone that controls these two processes in the liver:
- Glycogenolysis is when the liver converts glycogen back to glucose (for energy)
- GlucoNEOgenesis is when the liver forms NEW glucose (for energy)
You can think of these processes as a safety net that makes sure you have enough glucose. But as you may already know, alcohol consumption is taxing on the liver. Alcohol is toxic, so the liver works hard to break it down so it doesn’t poison you. In fact, the liver is so busy when it’s breaking down alcohol that it can’t make you any new glucose at the same time. Your body no longer has the safety net to rely on.
With alcohol in your system, and the insulin medications at work whisking the glucose away, blood glucose levels can quickly drop in a patient with diabetes.
Signs and symptoms of hypoglycemia
The signs and symptoms of hypoglycemia include hunger, irritability, confusion, diaphoresis, headache, shakiness, blurred vision, pale, cool skin, and decreased level of consciousness that can progress into a coma.
Cold and clammy… need some candy!
Nursing care of a patient with hypoglycemia
When you have a patient in a hypoglycemic state, your objective is to bring their blood glucose levels back up. The method by which you will do this depends upon if the patient is conscious or unconscious.
Hypoglycemia in conscious patients
For a patient that is conscious, you will need to quickly provide 15g of a readily-absorbed carbohydrate, like in juice or milk. Re-check their blood glucose 15 minutes later. If the level is still under 70 mg/dL, you will administer another dose of carbohydrates. Once their blood glucose level is over 70 mg/dL, you want to provide the patient with a snack that contains both a protein and carbohydrate. In this scenario, you are prioritizing getting the blood glucose to a safer level, then the snack with protein will provide longer-term energy.
Hypoglycemia in unconscious patients
If a patient is unconscious, they aren’t going to be swallowing any juice, so you will need to inject glucagon through the intramuscular or subcutaneous route. Remember that glucagon is a hormone that prompts the liver to make some glucose. Glucagon and all the other essential diabetes meds you need to know about are covered in our Pharmacology Flashcards.
After you give the glucagon, if your patient has not regained consciousness within 10 minutes, then you will administer another dose. Once your patient has regained consciousness and can safely swallow, then you can provide them a snack as explained above.
Glucagon does cause nausea and vomiting, so monitor your patient to make sure they don’t just vomit up the snack you give them.
Diabetic ketoacidosis (DKA)
Diabetic ketoacidosis (DKA) is a life-threatening, rapid-onset complication of diabetes that causes increased blood glucose levels and ketones in the blood and urine. It happens primarily in people with Type 1 diabetes, but it’s not unheard of in Type 2. This is hyperglycemia, so it’s the opposite of the hypoglycemia we just learned about above.
Risk factors associated with DKA include an infection or illness, stress, or untreated/undiagnosed Type 1 diabetes. In Cathy’s experience, it’s common at the hospital for patients to show up with DKA at the emergency room and that is the first time that patient finds out they have Type 1 diabetes.
Signs and symptoms
Signs and symptoms of DKA are the same signs and symptoms as those of hyperglycemia which we just covered in our diabetes overview. Symptoms of DKA include the 3 Ps: polydipsia, polyphagia, and polyurea; weight loss, fruity breath odor, Kussmaul respirations, and dehydration.
Lab values associated with DKA
The lab values you need to know for DKA include blood glucose, ketones, metabolic acidosis, and hyperkalemia.
Remember that the expected ranges for blood glucose are usually between 75-140 mg/dL depending on the type of test. In DKA, the blood glucose levels will be greater than 300 mg/dL — but under 600 mg/dL, because when blood sugar levels reach 600 mg/dL, we enter into hyperglycemic-hyperosmolar state (HHS) which we’ll cover next.
Ketones are chemicals created by your body when it breaks down fat to use for energy. The body does this when it can’t use glucose, either because the glucose is depleted or because, in the case of DKA and HHS, there is not enough insulin to use all of the glucose that’s there.
With DKA, the patient will have ketones in their urine and blood.
What about the keto diet? Doesn’t that have something to do with ketones? You don’t need to know this for Med-Surg or Critical care, but we should explain so you are aware of it.
Ketones are also the basis of a ketogenic diet or “keto,” which you have probably heard of by now. The idea behind a ketogenic diet is to keep carbohydrate intake extremely low, so that the body burns all of its glucose and switches to using stored fat for energy. When the body is burning fat for energy, it’s known as being in a state of ketosis. If you are in a state of ketosis due to the ketogenic diet, you have more ketones than someone eating a balanced diet, but not enough ketones to cause acidosis.
Diabetic ketoacidosis is a life-threatening complication of diabetes where the body can’t use glucose for energy despite having a lot of glucose, and nutritional ketosis is a state achieved through diet where glucose intake is kept low on purpose.
DKA can put the patient’s body into metabolic acidosis, which means the blood is too acidic. When ketones build up in the bloodstream, they make the blood more acidic, which is where the -acidosis suffix of this disease comes from.
Another lab value associated with DKA is hyperkalemia — when potassium levels are too high. The normal range for potassium is between 3.5 and 5.0 mEq/L. Potassium (K) levels over 5 mEq/L can indicate hyperkalemia, which can put the patient at risk for life-threatening dysrhythmias. The symptoms of hyperkalemia include dysrhythmias, muscle weakness, numbness/tingling, diarrhea, confusion.
The K in DKA will remind you to monitor K!
Hyperglycemic hyperosmolar state (HHS)
Hyperglycemic-hyperosmolar state (HHS) is a serious complication of diabetes, also marked by very high glucose levels. HHS has a more gradual onset and is more common in type 2 diabetes.
Two Hs in HHS, HHS is more common in Type 2
Risk factors for HHS are older age, inadequate fluid intake, decreased kidney function, infection, and stress.
Signs and symptoms
The signs and symptoms of HHS are the signs and symptoms of hyperglycemia as described above, in addition to the signs and symptoms of dehydration, which includes hypotension, weak pulses, headache and weakness.
Lab values associated with HHS
Remember that the expected ranges for blood glucose are usually between 75-140 mg/dL depending on the type of test. In HHS, the blood glucose levels will be greater than 600 mg/dL, which is extremely high.
Unlike DKA, there are no ketones present in the urine or blood with HHS, and thus no resultant metabolic acidosis.
The reason why there are no ketones even though HHS blood sugar is doubly high, is because in patients with Type 2 diabetes, their body actually does produce some insulin, and so the body does not have to switch entirely to fat burning.
It may be helpful to think of the two this way:
In DKA, the body is unable to access its high level of glucose and thinks it’s starving, so switches to fat to save itself.
In HHS, the body gradually got really high glucose and can access some of it for energy, so it doesn’t respond with that same emergency mechanism, even though it is still in grave danger.
HHS is more fatal than DKA.
Treatment of DKA and HHS
The first step in treating DKA or HHS is to address any underlying causes, like an infection, illness, or acute stress. The body can’t respond to other treatments if it thinks it’s under attack.
Administer IV fluids and insulin to the patient to help them become hydrated and process their blood glucose.
Monitor blood glucose levels hourly, aiming to bring them under 200 mg/dL.
If a patient has metabolic acidosis with DKA, administer sodium bicarbonate, an alkalinizing agent, to counter balance the acid in their blood (acid + alkaline = neutral).
Closely monitor the patient’s potassium levels. When a patient first presents to the ER with DKA, their potassium will be very high. You will likely administer calcium gluconate to protect the heart from dysrhythmia. However, as you treat the patient with insulin, their blood potassium levels will naturally decrease. Remember that in addition to glucose, insulin also brings potassium from the bloodstream into the cells.
Over the course of their treatment, the patient may end up with hypokalemia as their potassium is brought down. If that occurs, you may need to supplement their potassium to bring it back to a normal level.
Chronic diabetes complications
Diabetes can cause other serious complications over time, and there are a lot of associated risks. These are important to know as you will encounter them often throughout your nursing career.
Adults with diabetes are more likely to die of heart disease than adults without diabetes. Diabetes and cardiovascular disease have a correlated relationship because cardiovascular risk factors are common in people with diabetes, including obesity, high cholesterol and hypertension. Hyperglycemia can cause damage to the heart, making it more prone to heart failure.
Diabetes can cause neuropathy, which is nerve damage that leads to numbness or shooting pains. Diabetes can cause neuropathy because hyperglycemia can damage nerves, as well as the blood vessels that serve oxygen to your nerves. In diabetic patients, neuropathy often happens to the feet, which makes the feet more prone to injury as we discussed in our previous video.
Diabetes can cause nephropathy, which is kidney disease. Hyperglycemia can damage the kidneys through interruption of their filtering mechanism, as well as scarring. Kidney failure is a life-threatening condition that will require dialysis or a kidney transplant.
Diabetes can cause retinopathy, which is damage to the blood vessels in the back of the eye caused by hypergylcemia. Mild cases that are caught early can be treated with carefully managed diabetes, but advanced cases may require laser treatment, surgery, or regular shots in the eye.
Diabetes can cause gastroparesis, which is a condition where your stomach doesn’t work properly to move food down. As we have mentioned, hyperglycemia can cause nerve damage, and one of the nerves that it can damage is the vagus nerve near the stomach, which can affect stomach function. With gastroparesis patients have nausea, vomiting, heartburn, and feel uncomfortable whenever eating, which can greatly reduce quality of life.
Diabetes can also cause tooth decay, gum disease, and sexual dysfunction, among other things. There are many reasons to take diabetes seriously and manage it very closely to avoid complications.
Remembering these diabetes complications will be key for any Medical-Surgical Nursing and Critical Care Nursing exam. TheMedical-Surgical Nursing video series is intended to help RN and PN nursing students study for nursing school exams, including the ATI, HESI and NCLEX.
In this video, we are going to talk about the complications of diabetes. So this includes hypoglycemia, DKA, HHS, as well as some of the chronic complications of diabetes. So they're going to be some important critical care topics here that you'll definitely need to know.
Let's first talk about hypoglycemia. That is defined as a blood glucose level under 70 mg/dL.
What are some causes of hypoglycemia in diabetes patients? Well, if they have excess insulin, that can definitely cause hypoglycemia. If they skip a meal or just decrease their food intake, that can also cause hypoglycemia. Other causes include exercise, as well as excess alcohol.
The signs and symptoms of hypoglycemia are important to remember. And those are all here on the back of card 46 [of the Medical-Surgical Flashcard deck]. So those include hunger, irritability, confusion, diaphoresis, headache, shakiness, blurred vision, pale, cool skin, and decreased level of consciousness that could progress into a coma.
Regarding the skin, you remember when we were talking about hyperglycemia, I was like, "If the skin is warm and dry, sugar's high." With hypoglycemia, if the skin is cold and clammy you need some candy. So cold and clammy skin is definitely a sign of hypoglycemia.
In terms of nursing care of a patient with hypoglycemia, if that patient is conscious and their blood sugar levels are under 70, you can give them 15 grams of a readily absorbed carbohydrate. So this can be a half a cup of juice or soda or like eight ounces of milk. Then you're going to want to recheck their blood glucose in about 15 minutes. If their blood glucose level is still under 70, then you'll want to give them another dose of carbohydrates, so some more juice or soda or milk. And then, again, recheck. Once their blood glucose level is over 70, then you want to provide the patient with a snack that contains both a protein and a carbohydrate.
For your unconscious patient, you're going to want to provide glucagon through the IM or subcutaneous route. So my little saying to remember glucagon is, "When the glucose is gone, your patient needs glucagon." So if, after you give the glucagon, your patient has not regained consciousness within 10 minutes, then you're going to give them another dose of glucagon. Once your patient has regained consciousness and can safely swallow, then you can provide them a snack at that point. I will warn you that glucagon does cause nausea and vomiting so once your patient is conscious, you want to not only make sure they can safely swallow, you're going to also want to make sure that they're not going to just vomit up whatever snack you give them. So just something to keep an eye on.
Now let's talk about DKA, which is diabetic ketoacidosis. This is a life-threatening complication of diabetes that causes increased blood glucose levels as well as ketones in the blood and urine. It is definitely more common with Type 1 diabetics, and it has a rapid onset.
So some of the risk factors associated with DKA include an infection or illness, as well as stress and untreated or undiagnosed Type 1 diabetes. So often at the hospital, patients will show up with DKA at the emergency room and that is the first time that they find out that they have Type 1 diabetes.
In terms of the signs and symptoms, because the patient will have hyperglycemia, we're going to see the same signs and symptoms that I talked about in my previous video associated with hyperglycemia. So this includes the three Ps-- so polydipsia, polyphagia, polyurea, as well as weight loss, fruity breath odor, Kussmaul respirations, and dehydration.
Labs are going to be important to know how to differentiate DKA from HHS. So with DKA, blood glucose will be elevated over 300. And you will have ketones in the urine as well as the blood. That is different than HHS. HHS will actually have higher levels of blood glucose, often over 600. And there will be no ketones in the urine or blood.
Also with DKA, we're going to see metabolic acidosis present in the patient, as well as hyperkalemia. And anytime we have an abnormality in potassium levels, either too high or too low, the patient is at risk for life-threatening dysrhythmias. So when you see the word DKA, K is in the middle and that will help you to recall that you need to closely monitor the patient's potassium levels because they're going to be really high and that can definitely cause some life-threatening dysrhythmias, like I said.
Now moving on to HHS. HHS stands for hyperglycemic hyperosmolar state. With HHS, we have very high glucose levels as well as severe dehydration. HHS has a more gradual onset and it is definitely more common with Type 2 diabetic patients. So if you look at the initials HHS, there are two Hs, which will hopefully remind you that HHS is more common with Type 2 diabetes.
Some of the causes and risk factors associated with this condition include older age, inadequate fluid intake, decreased kidney function, as well as infection and stress.
Signs and symptoms of HHS will include the signs and symptoms of hyperglycemia, which we've talked about a lot, in addition to the signs and symptoms of dehydration, which may include hypotension, weak pulses, headache, and weakness.
In terms of the labs, blood glucose levels will be over 600, and there will be no ketones in the urine or blood and no metabolic acidosis present like we saw with DKA.
Now, let's talk about the treatment of DKA and HHS.
First of all, we're going to want to identify and treat any underlying cause of these complications. So if the patient has an infection, we're going to want to treat that infection.
We're going to be administering IV fluids and insulin to the patient.
We're going to want to check their blood glucose levels hourly. And our goal is to bring those levels under 200.
If the patient has metabolic acidosis with DKA, we're going to administer bicarbonate.
We're also going to closely monitor the patient's potassium [K] levels. So when the patient first presents to the emergency room with DKA, their potassium levels are going to be very high.
And we're going to want to give them calcium gluconate to help protect the heart from dysrhythmia.
However, as we treat the patient with insulin, insulin helps to bring glucose from the bloodstream into the cells. But it also brings potassium from the bloodstream into the cells. So over the course of treatment, the patient may end up with hypokalemia. And if that is the case, then we're going to want to replace their potassium as needed.
The last thing I want to touch on in this video are some of the chronic complications of diabetes. There's a lot of them. And left untreated and not managed, diabetes can really ravage the body and cause so many problems. So as a nurse, you need to really provide education to your patient on these risks.
So some of the complications associated with diabetes include cardiovascular disease, which can lead to a myocardial infarction as well as a stroke.
Diabetic neuropathy, which can lead to neuropathic pain as well as foot injury and infection.
It can cause nephropathy, so kidney damage, as well as retinopathy. So damage to the eyes which can lead to blindness.
It can cause gastroparesis which can lead to impaired digestion, as well as tooth decay, gum disease, and sexual dysfunction. So there are so many reasons to really take diabetes seriously and manage it very closely to avoid these complications.
Okay. That is it for the endocrine system. So I know there's a lot of videos. There's so many important topics with the endocrine system. I appreciate you hanging in there with me. I hope you've learned a lot. Be sure to subscribe to our channel, like this video, and I will see you again on another video soon!
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