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    Diabetes: Problem Solving

    It is important to know what to do if your blood glucose is outside your target range. See the guidelines below.

    Low Blood Glucose (Hypoglycemia)

    Low blood glucose, also called hypoglycemia, is a true emergency. It can happen suddenly and progress rapidly to a coma. It is important to know how to prevent, recognize and treat low blood glucose.

    Low blood glucose is a reading under 70 mg/dL with or without symptoms, or between 70 - 100 mg/dL with symptoms.

    Symptoms of low blood glucose:

    • Early symptoms

      • Shakiness

      • Sweaty, cold or clammy skin

      • Dizziness or lightheadedness

      • Anxiousness or nervousness

      • Fast heart beat

      • Hunger

      • Headache

      • Irritability

      • Weakness or fatigue

      • Vision changes
    • Late symptoms

      • Tingling around the mouth

      • Mental dullness

      • Personality changes

      • Seeing spots in front of your eyes or vision changes
    You may have low blood glucose even if you do not have all of these symptoms. If you have symptoms of low blood glucose, do a test right away. If you can not test, treat as if you have low blood glucose.

    To treat low blood glucose, follow the 15/15 Rule below.

    Low Blood Glucose Treatment: 15/15 Rule

    1. Treat low blood glucose by taking one serving of fast-acting sugar from the following list (each serving below contains about 15 grams of fast-acting sugar):

      • 3 square or 4 round glucose tabs

      • 1/2 cup (4 oz) fruit juice

      • 1/2 cup (4 oz) of regular (not diet) soda

      • 1 Tablespoon of honey or sugar

      • 5 small sugar cubes

      • 8 Lifesavers® candies

      • 2 Tablespoons of raisins (mini box size)

      • 1 cup of non-fat milk
    2. 15 minutes after treating the symptoms, test your blood glucose:

      • If your blood glucose is still less than 70 mg/dL, or between 70 - 100 mg/dL with symptoms, take another 15-gram serving of fast-acting sugar from the list above.

      • Repeat until your blood glucose is over 70 mg/dL and the symptoms are gone.

      • If low blood glucose has not resolved after two servings of fast-acting sugar (in 30 minutes), get medical help.

      • If your next meal or snack is more than 30 minutes away, eat a snack once your blood glucose returns to normal. The snack should include protein and carbohydrate.

      • Examples of Snacks:
        • 8 oz of milk

        • a 1/2 sandwich with protein, cheese, or peanut butter

        • 6 crackers with meat, cheese, or peanut butter

    If you take insulin or pills that make you produce more insulin, always carry fast-acting sugar!

    Driving and Low Blood Glucose

    If your blood glucose is below 70 mg/dL, your driving skills will be impaired and put you and others at risk for injury. To be safe, check your blood glucose before driving. Always carry your blood glucose meter, glucose tabs and a small snack with you. That way, if you get stuck in traffic or your blood glucose gets low, you can treat it.

    Do not drive if:
    • Your blood glucose is below 70 mg/dL

    • Your blood glucose was below 70 mg/dL earlier in the day (must be above 100 mg/dL to drive)

    • You have symptoms of low blood glucose

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    Low Blood Glucose Emergency: Glucagon

    If your blood glucose level gets so low that you can not safely swallow food or drink UorU you pass out, you need to raise it quickly. Glucagon is a medicine that raises your blood glucose immediately. It is given by injection (shot). Someone else must give you the injection because you may not be fully conscious. Tell your caregiver to read the following guidelines with you. Your health care provider gives you a prescription for a glucagon rescue kit which contains the following:

  • A syringe filled with liquid

  • Simple instructions – please refer to these in addition to reading the guidelines below
  • If You Can Not Safely Swallow, or You Pass Out from Low Blood Glucose:
    1. Your caregiver must give you the glucagon injection.

    2. Someone must call 911.
    If you do not wake up in 15 minutes, your caregiver must give you another glucagon injection.

    A diabetes educator can teach a family member, friend or co-worker how to give a glucagon injection. Call the Center for Diabetes Services at 415-600-0506 to make an appointment.

    Preparing Glucagon for Injection
    (Adapted from the Eli Lilly™ glucagon instruction sheet. Other kits are available on the market.)

    1. You must mix the dry glucagon with the liquid in the syringe before giving the injection.

    2. Remove the flip-off seal from the bottle of glucagon. Wipe the rubber stopper with alcohol.

    3. Remove the needle cover from the syringe. Do not remove the plastic clip from the syringe. This clip prevents the plunger from being pulled out of the syringe.

    4. Inject all of the liquid in the syringe into the bottle of glucagon, then remove the syringe from the bottle.

    5. Swirl the bottle gently until the dry glucagon dissolves completely. The mixture will look clear like water. Do not use the medicine if it looks cloudy or thick.

    6. Hold the bottle upside down and insert the syringe into the bottle. Pull the plunger back until the syringe fills with the mixture.

    7. For adults, fill the syringe to the 1 mg mark.
    Now you can give the injection:
    1. Clean a spot on the buttock, arm or thigh with an alcohol swab.

    2. Inject the glucagon mixture, then withdraw the syringe. Press an alcohol swab on the injection site.

    3. Turn the person on his or her side. This helps prevent the person from choking if he or she vomits.

    4. Call 911.

    5. As soon as the person is awake enough to safely swallow food and drink, he or she must drink (regular soft drink or juice) to prevent a rebound low glucose, and then eat (crackers and cheese or a 1/2 sandwich).

    6. If the person does not wake up within 15 minutes, give another dose of glucagon.
    Always tell your doctor if you have had a low blood glucose emergency, even if you feel fine afterwards.

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    High Blood Glucose (Hyperglycemia)

    High blood glucose, also called hyperglycemia, is when your blood glucose is over 160 mg/dL or over your target range.

    It is unhealthy if your blood glucose is high for long periods of time because it can increase the risk of complications to your organs and blood vessels. In the long-term, it may lead to damage to your eyes, heart and kidneys. It may also put you at more risk for heart attack and stroke. High blood glucose can lead to health problems in the short-term as well. Your treatment plan may need to be changed if your blood glucose values are frequently high.

    Call your health care provider when your blood glucose is:

    • Over 250 mg/dL for several tests or several days in a row

    • Over 300 mg/dL one time

    • Consistently over your target range
    Symptoms of high blood glucose include:
    • Increased thirst

    • Increased urination

    • Dry mouth or dry or itchy skin

    • Drowsiness or fatigue

    • Blurred vision

    • More frequent infections

    • Sores or cuts that heal slowly

    • Hunger

    • Unexplained weight loss
    Symptoms of severe high blood glucose include*:
    • Heavy, labored breathing

    • Nausea and vomiting

    • Pains in stomach

    • Loss of appetite

    • Severe weakness

    • Aching all over

    • Presence of ketones

    *(If you have any of these symptoms, contact your health care provider immediately.)

    Causes of high blood glucose include:
    • Too much food

    • Too little exercise or decreased physical activity

    • Stress, illness, injury, infection or surgery

    • Certain medications such as steroids (for example, Prednisone® or Decadron®)

    • Too little diabetes medication

    • Too little insulin, or insulin that has spoiled or been exposed to extreme temperatures (extreme heat or cold)

    • Insulin pen or pump malfunction
    Note: Make sure your blood glucose meter is working accurately.

    What should you do if your blood glucose is too high?
    • Drink plenty of sugar-free fluids (water is best). If you have a fluid restriction, ask your health care provider before drinking more fluids.

    • If your blood glucose is over 250 mg/dL twice in a row or you are sick and on insulin, check your urine or blood for ketones. If you have ketones, follow your Sick Day Plan and call your health care team.

    • Ask yourself what may have caused the high glucose and take action to correct it. Check with your health care team if you are unsure what to do.

    • Try to figure out if there is a pattern to your high blood glucose levels. Speak with your health care team about possible changes to your diabetes management plan.

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    What is Diabetic Ketoacidosis (DKA)?

    Diabetic Ketoacidosis (DKA) is a very serious condition that occurs most often in people with type 1 diabetes. The body burns fat for energy when it does not have enough insulin and blood glucose levels are too high. The fat breakdown causes the formation of ketones (acids) which may show up in the blood and urine. High ketone levels are very dangerous and can lead to DKA. Although DKA is most common in people with type 1 diabetes, it can also affect people with type 2 diabetes.

    DKA can develop quickly, especially if you have a fever or are sick with a cold or flu. DKA is a serious illness that can advance to a severe illness and even death.

    Common Symptoms of DKA

    • Unusual thirst and hunger

    • More frequent urination

    • Throwing up or feeling sick to the stomach

    • Stomach pain

    • Fruity smell on your breath

    • Breathing fast and deep
    When you are sick and on insulin it is very important to test your ketones if:
    • Your blood glucose is above 240 mg/dL

    • You can not keep food or liquids down (this includes vomiting even one time)

    • You have the common symptoms of DKA

    How to Check Your Urine for Ketones

    1. Purchase Ketostix® or Keto-Diastix® (reagent strips) at any pharmacy.

    2. Place a small amount of urine in a clean cup.

    3. Dip the strip into the urine.

    4. Remove the strip from the urine and wait 15 seconds. The strip will change color if there are ketones in the urine.

    5. Match the color of the strip to the color chart that comes on the side of the bottle or inside the package of strips.

    How to Interpret Urine Ketones Results and When to Call for Help

    If you have moderate or large ketones, get immediate medical attention. If you can not speak to your health care provider right away, go to the emergency room or call 911.

    If you have small or trace ketones, contact your health care provider for treatment recommendations.

    Anytime you have ketones, make sure you:
    • Check your blood glucose every 2 - 3 hours

    • Drink more water or sugar-free, uncaffeinated drinks

    How to Check Your Blood for Ketones

    As of 2011, two meters test for blood ketones: the Nova Max Plus® and the Precision Xtra®. You can get this at any pharmacy. Your diabetes educator can show you how to use this meter. It is similar to using a blood glucose meter. You can only use the fingertips for blood ketone testing.

    How to Interpret Blood Ketones Results
    • Normal blood β-ketone (beta ketone) levels are less than 0.6 mmol/L.

    • High blood β-ketone levels are more than 8.0 mmol/L. Do a second test. If the result is still over 8.0 mmol/L, go to the emergency room immediately or call 911.

    • At risk blood β-ketone levels are 1.5 mmol/L or higher. This means you may be at risk for developing DKA. Call your health care provider immediately. If you can not reach your health care provider, go to the emergency room.

    • Call your health care provider for instructions if your blood β-ketone results are between 0.6 and 1.5 mmol/L with a glucose level above 250 mg/dL.

    How to Prevent DKA

    Early detection and treatment is the key to preventing DKA.

    Call your health care provider if you test positive for ketones. Getting the right treatment from your health care provider lowers the chance that you could develop DKA. Make sure you:

    • Drink more fluids. The extra fluids help to flush ketones out of your body.

    • Do not exercise if you have ketones. Exercise may increase the ketone level.

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    Sick Day Plan - When You Have Diabetes

    The stress of illness can make controlling your blood glucose more difficult. When you are sick, it is very important that you:

    • Take your diabetes medications (including insulin) as you normally do, even if you can not eat your usual meals, unless your doctor tells you otherwise.

    • Test and record your blood glucose at least every 2 - 4 hours.

    • If you have type 1 diabetes, test your urine or blood for ketones every 4 - 6 hours. If you have type 2 diabetes and take insulin, you may also need to test for ketones.

    • You may replace your regular meals with one small serving (15 grams) of carbohydrates every 1 - 2 hours. Some carbohydrates that are easy to digest are:

      • 1/2 cup fruit juice

      • 1/2 cup regular soda (not diet)

      • 1/2 cup Jell-O®
      • 1 cup Gatorade®

      • 1 double popsicle

      • 1/2 cup regular ice cream

      • 1/4 cup sherbet

      • 1 slice bread/toast

      • 1/2 cup cooked cereal

      • 6 saltine crackers

      • 3 graham crackers
    • Drink plenty of sugar-free, uncaffeinated fluids such as water, diet soda, broth or tea (uncaffeinated). To avoid dehydration, take sips often or drink at least ½ cup every half hour. For people with fluid restrictions, follow your primary care provider’s instructions.

    • Check your temperature every 4 - 6 hours for fever.
    When to Call Your Health Care Provider if You Are Sick
    • Your blood glucose is over 250 mg/dL twice in a row if on insulin or over 250 mg/dL for 2 days in a row.

    • You can not eat or drink.

    • You have ketones in your urine or blood.

    • You vomit more than once or have severe abdominal pain.

    • You have diarrhea for more than 6 hours.

    • You have a fever of 100° F or more.

    • You have trouble breathing.

    • You have any other unusual symptoms!

    Make a “Sick Day Kit”

    It is best to be prepared. Keep these items in a small box so they are ready if you get sick:
    • Jell-O® packets, crackers, a few cans of regular soda

    • Thermometer

    • These Sick Day Plan instructions

    • Your health care provider’s phone number

    • Urine Ketostix® or Precision Xtra® to monitor ketones (if needed)
    If you live alone, try to have someone check on you every few hours. Otherwise, you may set a timer to remind yourself to attend to your diabetes sick day needs.

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    Diabetes Care During a Disaster

    A disaster is a sudden occurrence that inflicts widespread destruction, hardship and distress, and can be a serious threat to your diabetes health. Water and food may be limited and/or contaminated, and diabetes supplies may be very difficult to get.

    Routine Diabetes Care Supplies

    Have two weeks’ worth of your routine diabetes care supplies, or have them ready to add to your diabetes disaster kit (see below) at a moment’s notice:
    • Diabetes pills, insulin and all daily medication

    • Insulin syringes, alcohol swabs and tissue

    • Glucose monitor kit with extra batteries

    • Test strips, lancet device and lancets

    • Cellular phone

    • Fast-acting sugar (glucose tabs, small box of raisins, juice box)

    • Snacks (peanut butter crackers, nuts)

    • Glucagon rescue kit (if you use insulin)

    • Sharps container

    Diabetes Disaster Kit

    Prepare an easy-to-carry diabetes disaster kit that is both insulated and waterproof. You can store the following:
    • Extra comfortable clothing including undergarments

    • Small first aid kit to treat minor cuts or abrasions

    • Notepad and pencil to write down any glucose values

    • List of your health care providers and phone numbers

    • List of all medications, medical conditions and past surgeries

    • Space to add the items from your routine diabetes care supplies
    You will need to prepare and store several food items. This includes at least three days’ supply of non-perishable foods (for example, crackers, peanut butter, nuts, powdered milk, cheese and crackers, canned tuna), and one gallon of water per person, per day, with several cans of juice and diet soda.

    Tips to Remember

    • Protect your feet. Wear shoes at all times and examine your feet often for cuts or infection. Debris can increase your risk for injury.

    • Stress can cause your glucose to rise.

    • Wear a medical alert bracelet or necklace.

    • Stay hydrated!

    • Consider choosing a designated meeting place in case you are separated from your family or are unable to reach them by phone.

    Produced by the staff and physicians at California Pacific Medical Center in association with the Center for Patient and Community Education. Last updated: 12/11

    Funded by: A generous donation from the Mr. and Mrs. Arthur A. Ciocca Foundation.

    Note: This information is not meant to replace any information or personal medical advice which you get directly from your doctor(s). If you have any questions about this information, such as the risks or benefits of the treatment listed, please ask your doctor(s).

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