NURSING PATIENT CARE POLICY & PROCEDURE
October 14, 2015
Nursing Manual (Red)
Policy #: 13.24AP
Title: Hypoglycemia, Care of the Hospitalized
Patient (Adult & Pediatric)
To ensure safety of pediatric and adult patients at risk for or experiencing
Hypoglycemia is any blood glucose less than 70 mg per dL. Severe hypoglycemia is
any blood glucose less than 40 mg per dL. For children ages five years and younger
without diabetes, the laboratory reference ranges will guide the definition of
hypoglycemia (Refer to UWHC Nursing Patient Care Policy 11.26, Nova Stat Strip
Blood Glucose Meter). Refer to specific provider orders for glucose levels, treatment,
and when to notify a provider due to the variability of anticipated normal blood
glucose values based on age (including neonates), risk factors, and clinical conditions
A. The nurse will assess for history of hypoglycemia on admission for patients with a
history of diabetes or high blood sugars.
B. Hypoglycemia treatment will be administered as ordered.
C. Glucose monitoring will be repeated within 15 minutes of hypoglycemia
D. A staff person who is competent to perform glucose monitoring must remain in
the room after treatment to ensure the repeat glucose is completed per policy. If
this is not feasible due to other identified safety concerns (i.e., other patient care
needs related to fall risk, emergent clinical demands, etc.), another mechanism
must be in place to remind staff of 15 minute re-check requirement (i.e., use of a
timer, remote monitoring, etc.).
1. Assess for history of hypoglycemia on admission.
2. Assess for signs and symptoms of hypoglycemia which may include
the following: shaking, sweating, dizziness/lightheadedness, hunger,
headache, “feeling funny," weakness, confusion, numb lips, tongue,
anxiety, lethargy, and infant sleepiness. NOTE: Patients may have
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hypoglycemia unawareness and may not display or sense any of the
above signs and symptoms of hypoglycemia.
B. Glucose Monitoring and Treatment
1. Check Point of Care (POC) glucose following policy (Nursing Patient
Care Policy 11.26, Nova Stat Strip Blood Glucose Meter).
2. Fingerstick blood glucose results of less than 40 mg per dL should be
repeated on the same meter and then sent for laboratory verification
according to policy (Refer to Nursing Patient Care Policy 11.26, Nova
Stat Strip Blood Glucose Meter.) Results of laboratory verification are
NOT required to initiate hypoglycemia treatment.
3. Provide hypoglycemia treatment based on provider orders.
4. Regardless of treatment choice, glucose monitoring must be completed
within 15 minutes after treatment was administered. Additional
treatment should be provided as ordered until hypoglycemia has
5. Once blood glucose has reached 70 mg per dL or greater, glucose
monitoring should be repeated within one hour for those patients who
had an initial glucose less than 40 mg per dL to ensure that glucose
levels continue to remain at or above 70 mg per dL. (For patients
whose initial glucose was 40-69 mg per dL, glucose monitoring within
one (1) hour should be considered as directed in glucose monitoring
orders and adult and pediatric hypoglycemia treatment algorithms.)
1. Document signs/symptoms (if any) and non-medication treatments
(e.g., juice) within the patient’s clinical record.
2. Document cause(s) of hypoglycemic episode (use “unknown” if
3. Document medications used for treatment in the Medication
Administration Record according to policy (UWHC Nursing Patient
Care Policy 10.19, Medication Administration).
4. Reason(s) should be documented for delayed recheck and/or ongoing
efforts to correct hypoglycemia (i.e., initiating antiemetic treatment to
promote oral intake, breast feeding, obtaining IV access, patient
D. Notify provider for critical values (Refer to UWHC Nursing Patient Care
Policy 11.26, Nova Stat Strip Blood Glucose Meter: Use and Maintenance,
and UWHC Hospital Administrative Policy 8.07, Communication of Critical
Results and Critical Tests/Procedures), and if hypoglycemia does not resolve.
E. Provide patient and/or family education as appropriate about hypoglycemia
prevention, signs and symptoms, causes, and treatment. Document
teaching/learning outcomes within the Patient Education Activity.
V. UWHC CROSS REFERENCES
A. Adult Hypoglycemia Treatment Algorithm (see Related section on U-Connect)
B. Pediatric Hypoglycemia Treatment Algorithm (see Related section on U-Connect)
C. Hospital Administrative Policy 8.07, Critical Results and Critical
Tests/Procedures, Communication of
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D. Nursing Patient Care Policy 10.19, Medication Administration Using Barcode
E. Nursing Patient Care Policy 11.26, Nova Stat Strip® Blood Glucose Meter: Use
A. American Diabetes, A. (2015). 13. Diabetes Care in the Hospital, Nursing Home,
and Skilled Nursing Facility. Diabetes Care, 38(Supplement 1), S80-S85.
B. Clarke, W., Jones, T., Rewers, A., Dunger, D., Klingensmith, G. J. (2009).
Assessment and management of hypoglycemia in children and adolescents with
diabetes. Pediatric Diabetes, 10(Suppl 12), 134–145.
C. Umpierrez, G. E., Hellman, R., Korytkowski, M. T., Kosiborod, M., Maynard, G.
A., Montori, V. M., & Van den Berghe, G. (2012). Management of
hyperglycemia in hospitalized patients in non-critical care setting: An endocrine
society clinical practice guideline. Journal of Clinical Endocrinology &
Metabolism, 97(1), 16-38. doi: 10.1210/jc.2011-2098
VII. REVIEWED BY
Inpatient Diabetes Quality Committee
Clinical Nurse Specialists, Diabetes (Adult and Pediatric)
Clinical Nurse Specialist, Neonatal Intensive Care
Nursing Patient Care Policy and Procedure Committee, October 2015
Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer