Blood Glucose (test), Hyperglycemia, Hypoglycemia, Diabetes

Also Consider:  Dehydration, Mental status change 

Follow the Low Blood Glucose Protocol if Blood Glucose (BG) is low 

1. Take Vital Signs

• Temperature:

• Blood Pressure:

• Heart Rate: 

• Respiratory Rate:

• Oxygen Saturation:

• Blood Glucose:

2. Evaluate Symptoms and Signs

• Acute mental status change

• Not eating or drinking as much as usual, or recent increased intake of sugar or starches

• Acute decline in ADL abilities

• Thirst, Signs of dehydration

• Fruity odor to breath

• Respiratory: New cough, abnormal lung sounds, Accessory muscle breathing, pursed lip breathing, Respiratory distress

• Cardiovascular:  Chest pain, palpitations, new irregular pulse, cyanosis, mottling, edema

• GI: Hunger, nausea, vomiting, diarrhea, constipation, abdominal distention or tenderness, rebound tenderness, bowel sounds

• GU: New or worsened incontinence, pain with urination, blood in urine, frequent urination, urinary retention / bladder scan

• Neurologic  changes: consciousness/alertness, orientation, weakness, tremor, gait changes (unsteadiness, loss of coordination or balance)

• Headache

• Blurred vision

• Anxiety, vivid nightmare

• Very low urinary output (<30cc/hr)

• Skin: sweats (diaphoresis), cold/clammy/pale skin; any new skin condition, i.e., bruising (including potential head trauma), rash, infection/cellulitis

• Review recent BGs and any sliding scale insulin use

3. Take Action using SBAR Report:

• Presence of other, significant symptoms or signs of illness

  • Refer to appropriate Situation-Specific Evaluation for the identified symptoms and signs.

• Immediately notify the medical staff & resident representative

  • Unless ordered otherwise: BG >500, OR 

  • Hypoglycemic episode not responding to additional glucose or glucagon.

• Notify medical staff & resident representative within the next 16 hours. 

  • Unless ordered otherwise: BG > 400, OR 

  • Change in oral intake requiring immediate alteration of medication regimen, OR 

  • Hypoglycemic episode that responded to intervention.

• Notify medical staff on the next business day 

  • BG > 250, OR 

  • BG <80 on hypoglycemic medication, OR 

  • Hypoglycemic episode in someone not on hypoglycemic/diabetes medication

• Notify medical staff at the next regular rounds 

  • Fluctuating or gradually rising blood glucoses on current regimen, or with progressive decline in sensory, neurological, or renal function

4. Implement Management Plan

• Recheck BG one hour after any hypoglycemic episode

• Monitor vital signs every 4-8 hrs for 24 hours

• Offer sugar-free  fluids frequently

• Oral, IV, or subcutaneous fluids if needed for hydration

• Place on Intake & Output monitoring

• Monitor meal acceptance

• Place on 24-hour report

• Obtain lab results (if ordered), and notify medical as needed of significantly abnormal values in lab tests (refer to appropriate Situation)

• Update care plan regarding  fall risk, pressure ulcer prevention, assistance needed with ADLs, supervision for safety, restorative needs

• Review status and plan of care with designated representative

2025-04-26