Why is my pt's blood glucose so high?

[Bumashes]

Hey everybody,

Just want to throw a question out and see if I can get an answer before I leave for work tomorrow morning. I do hospice nursing, and I have a pt who just recently had a stroke about 10 days ago. This is not the reason he's on hospice, though. He was on our service prior to this due to CAD. But anyway, he had a stroke about 10 days ago. So, where he used to eat plenty, he now barely consumes a jar of baby food and a half a can of glucerna per day. And his blood sugar has been steadily climbing ever since. He had diabetes prior to this event also, but his BG usually ran between 100-200. Never as high as it currently runs. It's been creeping into the 300-400 range for the last 4-5 days. My interdisciplinary team meeting is tomorrow morning, so I'm going to tell our dr about this and see if he'll give a sliding scale or something. Normally, the pt gets Humulin-N 25units every day, unless his BG is below 70. He has no other insulin or oral anti-diabetic agents.

What I want to know is why this BG is going so high. I've got so much other stuff going on in my head that I just can't focus in on what's causing it to skyrocket like this. I know that BG can become elevated when the body is under stress, and I suppose a stroke does qualify as stress, but should it still qualify as stress since it's been almost 2 weeks since the stroke? I just don't want to look like a complete moron when I tell the dr about this tomorrow and have not even the slightest hint of what might be causing it. He's a nice dr actually, and I know he wouldn't begrudge me a little knowledge, but I'm vain I guess. So, all you A&P gurus out there, please throw me a hint if you can about what's up with my poor pt. All I can guess at is it's either stress from the stroke, or maybe he's developed an infection while he was in the hospital? Thanks so much to anyone who takes a shot!

Oh, and I guess I'll throw in that the other meds he takes aren't the kind that normally interfere with BG. No steroids or anything. Nothing new...

[blondy2061h, MSN, RN]

I guess most of our patients are actively dying when they go to hospice. I've never seen anyone go to hospice on anything except antiemetics, anxiolytics, and pain medication.

I've never heard of anyone on hospice getting active treatment for any disease, and it kinda goes against hospice, I thought?

Once our patients are comfort measures we no longer do any sort of labs.

[blondy2061h, MSN, RN]

of course a hospice pt's cbg's can, and should, be taken and insulin given. hospice is comfort care. why would you think otherwise?

cause i don't consider glucose checks or insulin shots to be "comforting?"

[blondy2061h, MSN, RN]

Don't mean to be a smart alec but why wouldn't he/she? Just because they are a Hopsice pt does not mean do not treat or make comfortable. I think it would be absurd & cruel not to do these things!

I know DNR does not mean "do not treat" but I thought hospice/comfort care did mean "do not treat except for things that will make them more comfortable."

[leslie :-D]

I guess most of our patients are actively dying when they go to hospice. I've never seen anyone go to hospice on anything except antiemetics, anxiolytics, and pain medication.

I've never heard of anyone on hospice getting active treatment for any disease, and it kinda goes against hospice, I thought?

Once our patients are comfort measures we no longer do any sort of labs.

see, that's the problem.

by the time you get your pts on hospice, it's likely they only have a matter of days.

if hospice was utilized as it should, these folks would have around 6 mos to make the most of their remaining time with.

docs should be referring these pts much earlier in the process.

comfort measures (while having varied meanings) is reserved for the last days, sometimes weeks, of life.

and, hyperglycemia or any process that throws your bodily functions out of whack, is uncomfortable.

that's why they should be treated w/insulin when they're alert and ambulatory.

once they start slipping away, is when meds are usually dc'd.

leslie

[Midwest4me]

cause i don't consider glucose checks or insulin shots to be "comforting?"

well of course the cbg's are not comforting; nor are the insulin shots---but hospice pts usually continue on their meds until actively dying---like others said. sounds to me like you're taking offense to our statements.

[crb613, BSN, RN]

I know DNR does not mean "do not treat" but I thought hospice/comfort care did mean "do not treat except for things that will make them more comfortable."

I was thinking of the things the body goes through with a high bs.....causing pain/discomfort & other problems. I also though with Hospice you did not try to cure....but treat anything you could in order to provide comfort. I am not a Hospice nurse so maybe Leslie can tell us how it is.

[corky1272RN]

:offtopic: But just to throw my 2cents in, for some hospice agencies the criteria can state 6 mos or less to live OR the disease process will become progressively worse ending in death.

Back to the original question. I agree with a few of the previous posters, Stress or infection. Let me know what the dr says. Thanks:D

[Hekate]

there are many possibilities.

first, is your patient a type i or ii diabetic?

secondly, what do you know about his stroke? what part of his brain was injured? was it an ischemic stroke or an hemorrhagic stroke? does he have residual deficiencies resulting from his stroke?

the association of hyperglycemia with congestive heart failure & brain injury (whether ischemic or hemorrhagic) may reflect a secondary stress response resulting from these complications (you said he has cad, does he also have chf?)

hyperglycemia in the setting of acute neurological injury is felt to be attributed, in part, to a catecholamine surge and generalized stress response.this increase in circulating catecholamines is, subsequently, associated with a rise in serum blood glucose.elevated levels of glucose may lead to continued anaerobic metabolism and the production of elevated lactate levels, which in turn can aggravate ischemic insult, increase neuronal injury, and worsen the neurologic outcome...

in ischemic stroke, hyperglycemia occurs in 20% to 40% of patients and is associated with infarct expansion, worse functional outcome, and an increased risk of death.

in other words, his resistant hyperglycemia may be neurogenic.

how high is his bg?

you have already mentioned that the patient wasn't on steroids- does he show any sign and symptoms of an infection? you mentioned that he was barely eating...is this a new finding post stroke? is he drinking enough water?

my next guess would be hhs:

hyperosmolar, hyperglycemic syndrome (hhs). the keys to answer this question are that the patient is a type ii diabetic, the blood glucose is very high (1200 mg/dl), and the patient has been ill for several days resulting in dehydration.

there are two ways that your patient can end up with high blood glucose: 1) too much glucose, and 2) too little water. think about making a glass of lemonade; you can make it sweeter by adding more sugar or by adding less water. diabetic ketoacidosis (dka) results from a lack of insulin (adding more sugar); hhs results from a loss of water to dilute the glucose (adding less water).

the keys to distinguishing these problems are: dka develops within hours, in type i diabetics, with glucose levels ranging from 250-800 mg/dl; hhs develops over a period of days, in type ii diabetics, and has higher glucose levels, usually greater than 600 mg/dl.

the treatment priority for dka is to replace the insulin because dka is caused by an absolute insulin lack. due to an osmotic dieresis from the high glucose level the patient with dka will also need fluids, but the mainstay of treatment is insulin. the treatment priority for hhs is to administer fluids because hhs is caused by fluid volume deficit. the patient in hhs may also need insulin to decrease the blood glucose and reduce osmotic dieresis, but the mainstay of therapy is fluid resuscitation.

sources: ed4nurses & pubmed

i hope this helps....keep us posted on your meeting and what comes out of it. i think it is important to find out what the cause of his hyperglycemia is, as it is likely a symptom, but whatever the cause is, it is equally important to treat his hyperglycemia to prevent further complications.

h

[blondy2061h, MSN, RN]

well of course the cbg's are not comforting; nor are the insulin shots---but hospice pts usually continue on their meds until actively dying---like others said. sounds to me like you're taking offense to our statements.

no, not taking offense. this is just a new concept for me. i've never really seen hospice utilized before the "actively dying" stage.

[Be_Moore]

I think Hekate nailed it. Occum's Razor would dictate that the BG is most likely climbing related to dehydration. But then you say "But the patient isn't eating, either!'' Odds are that the BG is being created by glycolysis and the lack of fluids is creating the increased BG levels. If the patient has IV access, consider giving a fluid bolus (or some runs if CHF is present).

[Bumashes, MSN, APRN, NP]

What meds is he on? Is he taking any steroids? Also, was the patient active before the stroke?

The meds he takes aren't the kind that effect BG. And yes, he was slightly more active before the stroke. Then, he could at least moves his arms a little, now he's totally bedridden and only responsive to painful stimuli.

[Bumashes, MSN, APRN, NP]

i would think infection, maybe uti, maybe get doc to order labs and check wbc's

That's what I'm hoping for this am. I want a CBC and BMP at least. And a u/a. But since he's a hospice pt, sometimes they aren't too keen on ordering this stuff. It sucks. I'm still getting used to the hospice perspective of not trying to make them better. To me, this would be basic comfort to treat an infection, but apparently that's not always the case to my clinical director who says what we will and will not pay for. Here's hoping...