CATANDUANES STATE UNIVERSITY

COLLEGE OF HEALTH SCIENCES

NURSING DEPARTMENT

NCM 112 RLE - CARE OF CLIENTS WITH PROBLEM IN OXYGENATION, FLUID AND ELECTROLYTES, INFECTIOUS,
INFLAMMATORY, IMMUNOLOGICAL RESPONSE, CELLULAR ABERRATION, ACUTE AND CHRONIC

CASE STUDY OF

HYPOGLYCEMIA
By:
JOHN KOBE M. TOMAGAN
BSN 3B GROUP 3

To:
MR. SCHULTZ A. TUPLANO, RN
CLINICAL INSTRUCTOR
Republic of the Philippines
CATANDUANES STATE UNIVERSITY
Virac, Catanduanes

I. INTRODUCTION

Hypoglycemia is defined as a condition where plasma glucose concentration is low, which may expose patients to
possible harm. This is common amongst persons who have type 1 diabetes, with an annual incidence of severe
hypoglycemia ranging from 3.3% to 13.5%. While patients treated with insulin or insulin secretagogues (sulfonylureas and
meglitinides) are generally at higher risk, severe hypoglycemia is less common in patients with type 2 diabetes.

Glucose-lowering medications that do not cause unregulated insulin secretion, such as dipeptidyl peptidase-4 inhibitors,
metformin, glucagon-like peptide-1 receptor agonists, thiazolidinediones, and sodium-glucose cotransporter-2 inhibitors are
associated with lower risk of hypoglycemia, unless used in combination with insulin or insulin secretagogues.

II. PATIENT’S DATA

A. PERSONAL INFORMATION
Name: B. N.
Birthdate: August 06, 1949
Age: 74
Sex: Female
Civil Status: Married
Address: Mayngaway, San Andres, Catanduanes
Religion: Roman Catholic
Nationality: Filipino
Admission Date: November 8, 2023
Discharge Date/ Time: N/A

B. CHIEF COMPLAINT/ MEDICAL DIAGNOSIS

a. Chief Complaint
Hypoglycemia
b. Admission Diagnosis
Hypoglycemia; DM T2; HTN ST 2
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CATANDUANES STATE UNIVERSITY
Virac, Catanduanes

c. Final Diagnosis
Hypoglycemia; DM T2; HTN ST 2

III. HEALTH HISTORY

A. Past Health History
Patient was previously hospitalized due to fall for about a week. Patients also indicate that hospitalization occur
during 2013 was due to a certain slow progressive healing wound in the left foot part and hospitalized for a
couple of weeks.

B. Present Health History

Due to episodes of Hypoglycemia patient are being admitted on the same institution on 11-02-2023 due to
same concern and just been discharge right away couple of days pass.

C. Family Health History

The family of the patient on the father side have a DM and on the mother side of the patient there is a heart
related problem. The pt. children also experienced such DM, Mild Stroke, and HTN.

D. Environment
Patient is a housewife that stays at home to take care of household chores and her children. The usual
activities done by the patient are household chores such as cooking, cleaning, washing dishes and clothes,
and more.

E. Lifestyle
The patient’s lifestyle is the typical province lifestyle such doing gardening, walking in farm, and taking clean of
the background are the usual routine and exercise of the patient. Intake of the patient varies with vegies, meat
and fish as these are the prominent foods in their area however patient is in high consumption of sugar as its
favorite is sweets.

F. Activities Of Daily Living

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CATANDUANES STATE UNIVERSITY
Virac, Catanduanes

Before Hospitalization During Hospitalization

Nutrition Rice, and mostly vegetables and fish Rice, meat, fish
Urination is not felt since the
Normal urination, having a hard time patient is in IFC. BM are not
Elimination
defecating, 2 – 3 bowel movements per day frequent since the patient felt back
pain when moving.
Sleeping pattern are altered such waking up Can sleep more easily, 9 hours of
Rest and Sleep
early as 2 am and sleeping as early as 7-8 pm sleep
Unable to do such due to back
Hygiene Takes a bath 1 times per day
pain
Substance Use None None

IV. ANATOMY AND PHYSIOLOGY OF THE AFFECTED SYSTEM

Brutsaert, E. F. (2023, November 12) Hypoglycemia is uncommon in persons who do not have diabetes. It
can happen when fasting or after eating (1 to 3 hours later), and it can be insulin-mediated or non-insulin-mediated. A
useful practical classification is based on clinical status: whether hypoglycemia develops in healthy or unwell patients.
The differential diagnosis in healthy persons without diabetes encompasses insulin-mediated and non-insulin-
mediated diseases. Insulinoma is a rare neuroendocrine tumor of beta cells that produce insulin. It usually causes
fasting hypoglycemia, but it can also cause postprandial hypoglycemia. Hypoglycemia after bariatric surgery is a type
of hyperinsulinemic hypoglycemia that can arise years after bariatric surgery (particularly roux-en-Y gastric bypass). It
is uncommon, however the real prevalence is unknown, and pathology specimens demonstrate nesidioblastosis
(pancreatic beta cell hypertrophy). Postprandial hypoglycemia is common. Patients with NIPHS exhibit
hyperinsulinemic hypoglycemia, negative localizing imaging scans, and no history of bariatric surgery. Hypoglycemia
is typically postprandial, and surgical specimens show signs of nesidioblastosis.

Insulin autoimmune hypoglycemia is a disorder that most commonly affects people who have other autoimmune
diseases, such as systemic lupus erythematosus. Autoantibodies attach to and disassociate from insulin or insulin
Republic of the Philippines
CATANDUANES STATE UNIVERSITY
Virac, Catanduanes

receptors on cell membranes in target tissues (for example, the liver, muscles, and adipose tissue). Following
dissociation from the antibodies, circulating insulin becomes available to attach to the receptor, resulting in
hypoglycemia. Corticosteroids or immunosuppressants are used to treat the condition.

V. PATHOPHYSIOLOGY OF THE DISEASE

The body has inherent counter-regulatory mechanisms to prevent hypoglycemic episodes. All of these counter-
regulatory mechanisms include an interplay of hormones and neural signals to regulate the release of endogenous
insulin, to increase hepatic glucose output, and to alter peripheral glucose utilization. Among the counter-regulatory
mechanisms, the regulation of insulin production plays a major role. Decrease in insulin production as a response to
low serum glucose isn't the body's first line of defense against hypoglycemia. For endogenous glucose production to
take place, particularly hepatic glycogenolysis, low insulin levels are necessary. As plasma glucose levels decline,
beta-cell secretion of insulin also decreases, leading to increased hepatic/renal gluconeogenesis and hepatic
glycogenolysis. Glycogenolysis maintains serum glucose levels over 8 to 12 hours until glycogen stores are depleted.
Over time, hepatic gluconeogenesis contributes more to maintaining euglycemia when required.

The decrease in insulin production

occurs while the glucose level is in the low-
normal range. This serves as a distinctive
feature compared to other counter-regulatory
measures. Additional counter-regulatory
measures typically occur once the serum
glucose levels decrease beyond the
physiologic range. Among the additional
counter-regulatory mechanisms, pancreatic
alpha cell secretion of glucagon is the next
line of defense against hypoglycemia. Should
increased glucagon fail to achieve
Republic of the Philippines
CATANDUANES STATE UNIVERSITY
Virac, Catanduanes

euglycemia, adrenomedullary epinephrine is secreted.[7] All three counter-regulatory measures occur in the acute
stage of hypoglycemia.

On occasions the previously mentioned counter-regulatory mechanisms may fail to resolve the hypoglycemia.
At this point, further counter-regulatory measures are employed in the form of growth hormone and cortisol. Both the
release of growth hormone and cortisol are seen in prolonged hypoglycemic state.

Putative mechanisms of hypoglycemia unawareness. Recurrent hypoglycemia results in a reduced autonomic

response to hypoglycemia with attenuation of autonomic warning symptoms. The maladaptive response in the brain is
characterized by increased glucose transporter 1 (GLUT1) activity in a bid to preserve brain function and alter glucose
sensing in the ventromedial hypothalamus (VMH), mediated by elevated levels of gamma aminobutyric acid (GABA).
Adapted from Iqbal et all with permission from Elsevier. Citation: Iqbal A, Heller S. Managing hypoglycaemia. Best
Pract Res Clin Endocrinol Metab 2016; 30: 413-430. Copyright © Elsevier.

Mechanisms by which hypoglycemia may affect cardiovascular events. Hypoglycemic events may induce
inflammation by stimulating the release of C-reactive protein
(CRP), IL-6, and vascular endothelial growth factor (VEGF).
Hypoglycemia also increases the activation of platelets and
neutrophils. Sympathoadrenal response during
hypoglycemia increases adrenaline release and may lead to
arrhythmias and increased cardiac workload. Endothelial
dysfunction may also contribute to cardiovascular risk.
Adapted from Desouza et al[25] with permission from the
American Diabetes Association. Citation: Desouza CV, Bolli
GB, Fonseca V. Hypoglycemia, diabetes, and
cardiovascular events. Diabetes Care 2010; 33: 1389-1394.
Copyright ©The American Diabetes Association.
 Republic of the Philippines
CATANDUANES STATE UNIVERSITY
Virac, Catanduanes

VI. LABORATORY/DIAGNOSTIC EXAMINATIONS

LABORATORY SIGNIFICANCE /INTERPRETATION OF
RESULTS NORMAL VALUES
EXAMINATION THE RESULTS
Creatinine 148 Elevation Creatinine, BUN/urea, and uric
53 – 115.0 mmol/L
BUN/ Urea acid at the same time can suggest
Blood Chemistry 2.14 – 7.4 umol/L
10.78 impaired kidney function
150 – 420 umol/L
Uric Acid 478
Excess in potassium may have resulted
Serum Electrolytes Potassium 6.37 3.5 – 5.5 mmol/L
from kidney problems
Albumin is a protein normally found in the
blood, but its presence in urine may
Urine Examination
Albumin ++ suggest kidney dysfunction or damage, as
Results
the kidneys typically filter out waste while
retaining essential substances like proteins
Enlarged right This shows that the heart is having
atrium difficulties in meeting the patient’s needs.
Enlarged right The enlargement of the chambers of the
2D Echocardiogram
ventricle heart resulted from the backflow of blood
Tricuspid valve from the regurgitating tricuspid valve.
regurgitation
VII. DRUG STUDY

DOSAGE/ NURSING
NAME CONTRAINDICATI ADVERSE
FREQUEN Action INDICATION RESPONSIBILITI
MEDICINE ON EFFECTS
CY ES
Ceftriaxone 1 gram/ q12 Ceftriaxone is a Treatment of Hypersensitivity to Diarrhea, nausea, Assess for
Republic of the Philippines
CATANDUANES STATE UNIVERSITY
Virac, Catanduanes

third-generation various ceftriaxone or vomiting. allergies or

cephalosporin bacterial other previous adverse
antibiotic. It infections, cephalosporins. Allergic reactions reactions.
inhibits bacterial including (rash, itching). Monitor renal
cell wall respiratory, Previous severe function
synthesis, urinary tract, allergic reactions Potentially severe regularly.
leading to cell skin, and joint to penicillins. reactions like Administer over
death. infections. anaphylaxis or an appropriate
pseudomembrano duration as
us colitis. prescribed.
Observe for signs
of anaphylaxis
during
administration.
Report any
unusual or
severe side
effects promptly.
Digoxin 0.25 mg/tab Inhibits the Heart failure Ventricular Arrhythmias Monitor heart rate
2 tab/ OD sodium- fibrillation and rhythm
potassium Atrial fibrillation Nausea, vomiting regularly.
ATPase pump, Hypersensitivity to Assess for signs
increasing digoxin Visual of toxicity (e.g.,
intracellular disturbances nausea,
calcium and Severe ventricular anorexia, visual
enhancing arrhythmias disturbances).
myocardial Educate the
contractility. patient about the
importance of
regular follow-up
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CATANDUANES STATE UNIVERSITY
Virac, Catanduanes

appointments.
Check serum
digoxin levels as
ordered by the
healthcare
provider.
Bronchodilation Asthma and Hypersensitivity to Nausea, vomiting, Monitor
and chronic doxofylline or or gastrointestinal respiratory status
improvement of obstructive xanthine discomfort regularly.
airflow in the pulmonary derivatives Assess for signs
lungs. disease Headache of adverse
Anti- (COPD) Severe cardiac reactions.
inflammatory arrhythmias Palpitations Ensure patient
effects. education on
200 mg/tab Allergic reactions proper
Doxofylline
2 tab/ TID such as rash or medication use.
itching Monitor vital
signs, especially
heart rate.
Report any
significant
changes or
adverse effects
promptly.
Furosemide 20 mg/tab Furosemide is a Edema Anuria (no urine Electrolyte Monitor
OD loop diuretic that associated with production) imbalances electrolyte levels
inhibits heart failure, (hypokalemia, regularly.
reabsorption of liver cirrhosis, Hypersensitivity to hyponatremia) Assess fluid
sodium and or renal disease furosemide or balance and vital
chloride in the sulfonamides Dehydration signs.
 Republic of the Philippines
CATANDUANES STATE UNIVERSITY
Virac, Catanduanes

proximal and Hypertension Administer slowly

distal tubules Hypotension if intravenous to
and the loop of prevent
Henle in the Ototoxicity ototoxicity.
kidneys, leading (especially with Educate the
to increased rapid IV patient on the
urine production. administration) importance of
maintaining
adequate fluid
intake.
Osmotic laxative Constipation, Galactosemia, Diarrhea, Monitor bowel
that increases hepatic intestinal abdominal patterns and
water content encephalopathy obstruction, and cramps, assess for
and softens (reducing blood patients with a flatulence; dehydration.
stools, ammonia history of excessive use Administer with
promoting bowel levels) hypersensitivity to may lead to caution in
movements. lactulose electrolyte diabetic patients,
30 cc/ OD
Lactulose imbalance as lactulose
HS
contains sugar.
Educate patients
on the
importance of
adequate fluid
intake during
lactulose therapy.
Omeprazole 40 mg/ OD Inhibits proton Gastroesophag Hypersensitivity to Headache Administer before
pump activity in eal reflux omeprazole or meals for optimal
gastric parietal disease benzimidazoles Nausea effect.
cells, reducing (GERD) Monitor for signs
gastric acid Concurrent use Diarrhea of adverse
 Republic of the Philippines
CATANDUANES STATE UNIVERSITY
Virac, Catanduanes

secretion. Peptic ulcers with certain effects, especially

medications, e.g., Risk of if long-term
Zollinger-Ellison atazanavir and Clostridium therapy is
syndrome nelfinavir difficile infection involved.
Assess for
Rarely, risk of potential drug
bone fractures interactions.
and Educate the
hypomagnesemia patient on the
with prolonged importance of
use compliance and
potential side
effects.
Potassium- Hypertension Hyperkalemia Hyperkalemia Monitor
sparing diuretic. potassium levels
Edema Severe renal Gynecomastia regularly.
Blocks associated with impairment (breast Assess for signs
aldosterone heart failure, enlargement) in of hyperkalemia
receptors, cirrhosis, or Addison's disease males (muscle
promoting nephrotic weakness,
Spironolacto 25 mg/tab 1
sodium and syndrome Menstrual irregular
ne tab/ OD
water excretion irregularities heartbeat).
while conserving Educate patients
potassium. GI disturbances. about dietary
potassium intake.
Report any
unusual side
effects promptly.
Tadafil 20 mg/tab/ Inhibits Treatment of Concomitant use Headache Assess patient's
OD phosphodiestera pulmonary with nitrates or cardiovascular
 Republic of the Philippines
CATANDUANES STATE UNIVERSITY
Virac, Catanduanes

se type 5 arterial nitric oxide donors. Flushing status before

(PDE5), leading hypertension administration.
to increased (PAH) Hypersensitivity to Dyspepsia Monitor for signs
cyclic guanosine tadalafil or any of hypotension
monophosphate component of the Nasal congestion and advise
(cGMP) levels formulation. patients to avoid
and smooth Back pain nitrates.
muscle Educate patients
relaxation. on potential
adverse effects
and when to seek
medical attention.
Document any
pre-existing
conditions or
medications that
may interact with
tadalafil.

VIII. NURSING CARE PLAN (INDIVIDUAL BASED ON INDIVIDUAL PATIENTS)

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Subjective Elevated blood Short Term 1. Monitoring of 1. Thorough Following 12 hours
Data: pressure related to Goals: VS as well as the monitor to the pt. vs of nursing
pain secondary to pain scale of the to monitor any intervention, the
Patient reports immobilization as Improve gas pt. changes of the pt. patient was able to
pain in the evidence by facial exchange by status improve BP by
 Republic of the Philippines
CATANDUANES STATE UNIVERSITY
Virac, Catanduanes

back when grimace when maintaining 2. Elevate the 2. Head elevation maintaining oxygen
moving. moving and bp of oxygen saturation head of the bed to promotes lung saturation above
120/70 above 90% make breathing expansion and 90% as measured
Objective easier. alleviates by pulse oximetry.
Data: Reduce fluid respiratory
volume overload 3. Encouragement discomfort.
(+) Redness in through diuretic of deep breathing 3. to manage and
the back therapy exercises ease the pain
(+) Facial 4. Monitoring gives
grimace when Regain the bp at 4. Keep track of information for
moving. normal values your daily weights, changing treatment
VS input/output, and and assessing
BP- 120/70 Long Term vital signs. progress.
RR – 20 Goals: 5. Oxygen
PR- 82 5. As directed, promotes
O2 SAT – 96% Stabilized bp to administer oxygenation and
TEMP- 35.6 prevent further supplemental hence alleviates
complications oxygen. respiratory distress.

Maintain fluid
balance within
normal limits

Manage the pain

experience by the
pt.

References:
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CATANDUANES STATE UNIVERSITY
Virac, Catanduanes

Hypoglycemia - Endocrine and Metabolic Disorders. (n.d.). MSD Manual Professional Edition.
https://www.msdmanuals.com/professional/endocrine-and-metabolic-disorders/diabetes-mellitus-and-disorders-of-carbohydrate-
metabolism/hypoglycemia

Nakhleh, A., & Shehadeh, N. (2021). Hypoglycemia in diabetes: An update on pathophysiology, treatment, and prevention. World
Journal of Diabetes, 12(12), 2036–2049. https://doi.org/10.4239/wjd.v12.i12.2036

‌ athew,
M P., & Thoppil, D. (2022, December 26). Hypoglycemia. Nih.gov; StatPearls Publishing.
https://www.ncbi.nlm.nih.gov/books/NBK534841/