Managing Diabetes in Acute Care

Dr Kat Riley

Alright, Tom, diabetes. Such a massive topic, isn’t it? But let’s talk basics. Type 1 and Type 2—two names we throw around all the time. The big question is: what makes them so different, especially in acute care settings?

RN Tom

Absolutely. So, Type 1 is your autoimmune condition, where the pancreas simply decides it’s on an indefinite strike. No insulin production at all. Type 2, on the other hand, is more about resistance. The body’s making insulin, but it’s kind of... losing the plot in using it effectively.

Dr Kat Riley

Yeah, and isn’t it fascinating how the management strategies are on opposite ends? Type 1 needs that constant insulin replacement, whereas Type 2 patients might start with lifestyle changes, oral meds, and, yep, eventually move to insulin.

RN Tom

Exactly. And that means, as nurses, particularly in acute care, we've gotta tailor how we handle each. Take blood glucose levels—super critical for both. But for someone with Type 1, we’re also keeping an eye on avoiding that nasty ketoacidosis. And for Type 2? Sometimes, hyperosmolar hyperglycemic state creeps in.

Dr Kat Riley

Oh, definitely. And speaking of blood tests, let’s not forget HbA1c. When someone’s admitted, that's a big piece of the puzzle, right?

RN Tom

It really is. HbA1c tells you how well their blood sugar’s been managed over the past two to three months. It’s our window into whether this is a long-term issue or an acute bump in the road. And in New South Wales hospitals, one of the clinical priorities is making sure that document is sorted early in the admission.

Dr Kat Riley

Wait—so basically, it’s like a cheat sheet for someone’s blood sugar habits?

RN Tom

Pretty much! And it guides us in knowing what adjustments we need to make during their hospital stay, especially if insulin comes into play or if glycaemic control is, well, out of control.

Dr Kat Riley

Right, but here's the worrying bit, Tom. Did you know that diabetes mishaps—I mean prescribing errors, poor timing of insulin—rank so high in hospital incidents in New South Wales?

RN Tom

Unfortunately, yeah. And those incidents don’t just add to a patient’s stress. They prolong hospital stays, lead to complications, and blow up resourcing costs. That’s where following clear, evidence-based nursing protocols becomes so important. And really, it’s not just about insulin management—early testing, four glucose checks daily, proper documentation. That stuff can make or break the patient journey.

Dr Kat Riley

It gets me thinking, you know? For nursing students listening in, this isn't just textbook knowledge. This is about catching those red flags before they escalate. You mess up glucose monitoring, and you’re opening the door to a cascade of issues.

RN Tom

Exactly. And what we’re teaching here isn’t just theoretical. It’s their bread-and-butter work in acute settings. Like, if you don't start strong with protocols—accurate admission assessments, diligent monitoring—you’re chasing complications instead of managing them effectively.

Dr Kat Riley

And that’s not where anyone wants to be. Solid start, Tom. Let’s keep this momentum going because there’s so much more to unpack.

Dr Kat Riley

Tom, speaking of catching those red flags early, blood glucose levels are such a moving target, aren’t they? Too high, too low, and the body just starts throwing in the towel. Let’s zero in on hypoglycemia first. What’s the absolute must-know for nurses managing this in an acute care setting?

RN Tom

Great question. So, hypoglycemia—it’s defined as a blood glucose level below 4, and when it hits, quick action is key. We’re talking fast-acting carbohydrates like glucose gel, juice, or even sugary soft drinks right away. I mean, within minutes.

Dr Kat Riley

And you reassess the BGL after, what, fifteen minutes?

RN Tom

Exactly! Rechecking is critical. If the levels are still low, you repeat the carbs. But if the patient’s unresponsive or can’t take anything orally, that’s when it gets serious. Glucagon IM or IV glucose, depending on their condition, can be administered. But before all that, don't forget to escalate as per the local Clinical Emergency Response System (CERS) protocols.

Dr Kat Riley

See, this is what’s tricky, right? Recognising symptoms fast. Hypoglycemia can present as just a bit of dizziness or sweating early on, but it can spiral into confusion, agitation—or worse, seizures—if you miss that window.

RN Tom

Exactly. I always tell new nurses, “Trust the symptoms.” Sweaty and shaky? Hungry and pale? Don’t overthink it—assume it's a hypo until proven otherwise. The phrase “better safe than sorry” fits perfectly here.

Dr Kat Riley

Okay, but now let’s flip to hyperglycemia. I feel like it’s the neglected cousin. You know, until things hit the extreme end like DKA or HHS.

RN Tom

Totally agree. Hyperglycemia pops up when glucose levels go above 15. The catch is it develops gradually, so it’s often overlooked. But when we get those elevated levels alongside red flags—like Kussmaul respirations or altered consciousness—well, that’s where protocols like Adult ECAT kick in.

Dr Kat Riley

Oh, Kussmauls. That deep, laboured breathing. It’s such a tell, isn’t it?

RN Tom

It really is. It practically screams, “This patient’s heading into diabetic ketoacidosis!” And that’s why quick identification means everything. The protocol details are clear: get that BGL, check ketones, and escalate if they’re over 3. It’s step by step, but every second counts.

Dr Kat Riley

And let’s not forget monitoring dehydration. Sunken eyes, dry mucous membranes, those physical signs are your bread and butter. But I’m curious, Tom, do you think nurses get too focused on numbers and miss these clinical cues?

RN Tom

Sometimes, yes. Numbers matter, but so does the whole picture—vital signs, history, even just looking at how unwell someone appears. For severe hyperglycemia, it’s only with a full A- G assessment, including monitoring for things like fever or possible infection triggers, that you can really tackle the underlying cause. So remember to escalate your concerns early.

Dr Kat Riley

Such a vital point. Nurses listening, this is where your acute care instincts kick in. Protocol adherence is key, yes, but you’re trained to catch what the protocols might miss. Symptoms evolve—so our interventions have to as well.

RN Tom

Absolutely. And as we manage BGLs, let’s not forget the risks of overshooting our interventions—like inducing hypoglycemia during aggressive insulin therapy. We’re walking a tightrope here, from stabilization to prevention of severe complications.

Dr Kat Riley

Prevention might just be the word of the day, Tom. Know the red flags, work the protocols, stay vigilant. That way, we’re not just reacting, we’re preventing those worst-case scenarios from becoming reality.

Dr Kat Riley

Alright, Tom, we’ve covered the challenges and nuances of monitoring blood glucose levels. Now, let’s move into the practical side—insulin administration. It’s a cornerstone skill for nurses, but also one of the most high-risk, wouldn’t you say?

RN Tom

Absolutely. Insulin isn’t just another medication. It’s a hormone, and the way we manage it can go from life-saving to life-threatening if we aren’t meticulous. Starting with basics: storage. Insulin must be refrigerated until it’s in use. But once it’s opened, room temperature's okay, as long as it's used within 28 days and kept out of sunlight.

Dr Kat Riley

And that's where the little things matter. Like labeling the insulin vial as soon as it’s opened—I can’t stress enough how crucial that is. Same goes for keeping it in a patient-specific tray, yeah?

RN Tom

Exactly. It’s not just good practice; it’s policy. Missteps like mixing up a patient’s pen or forgetting to rotate injection sites? They’re so avoidable but can cause real harm such as dosing errors, lipodystrophy. For Glargine and Detemir, these are clear insulins with specific protocols. You can’t mix them with anything else, and they need their own devices.

Dr Kat Riley

Oh, Tom, mixing insulins incorrectly—it’s almost like creating a dangerous cocktail with no party at the end, isn’t it?

RN Tom

Couldn’t have said it better myself! And even drawing insulin out of a pen—can you believe people still do this? It risks contamination and dosing errors. It’s a no-go, plain and simple.

Dr Kat Riley

Good shout. And let’s not forget dosing checks. Insulin is time-critical, and skipping the independent double-check with a second nurse feels like playing roulette with patient safety. Any memorable cases where you’ve seen protocols save the day?

RN Tom

Oh, plenty. One that sticks was a middle-aged man admitted for hyperglycemia. His insulin orders were vague—just “units before meals.” Thanks to a careful nurse who questioned it, we found he was meant to receive individualized doses based on his BGLs. A quick check with the doctor prevented what could’ve been a serious hypo, and it reinforced how important clear, time-specific orders are.

Dr Kat Riley

See? Protocols aren’t just rules—they’re life savers. But we haven’t even touched on common errors yet, like skipping basal insulin in Type 1 patients. That’s a big no-no, right?

RN Tom

Massive. Basal insulin is critical to keep glucose levels steady between meals and overnight. Missing even one dose can risk ketoacidosis—talk about a slippery slope!

Dr Kat Riley

And then there's the communication side. I mean, unclear orders, illegible handwriting—it’s like we’re setting traps for ourselves. Writing “units” in full rather than “U” exists for a reason. Mistaking “10U” for “100 units” is terrifyingly easy, don’t you think?

RN Tom

Oh, absolutely. That’s why electronic prescribing with mandatory fields is such a game changer. But Kat, what really helps is creating those small teaching moments—for example, why insulin withdrawal timing is tied to meals or how using cloudy insulins requires proper mixing. You teach those nuances, and it sticks.

Dr Kat Riley

And it boils down to vigilance, too. Keep an eye on patients’ symptoms beyond the numbers. Trust me, if their patterns don’t match up, there’s usually an underlying issue we missed— dehydration, even a smear of vaseline on a sensor!

RN Tom

That’s spot-on. It’s about catching the small things early, which, like you said, are often preventable. And when those challenges pop up, simulation training is brilliant. Let’s say a patient’s BGL and insulin timing are mismatched, and their BGL levels crash late afternoon. A safe simulated environment is where we want students to explore that.

Dr Kat Riley

Totally agree. There’s something empowering about being able to mess up in an academic setting, so it doesn’t happen on the floor. Nurses, if you’re listening, take these simulated challenges—and real scenarios, like Tom’s story—as golden opportunities to refine your instincts and technique.

RN Tom

Couldn’t agree more. Making mistakes here prepares you for when the stakes are sky-high with a real patient. And Kat, let’s not sugarcoat it—literally and figuratively. Insulin’s power comes with responsibility. It’s a high-risk medicine, but managed well, it’s transformational for patients.

Dr Kat Riley

And on that note, thanks for listening, everyone. This episode’s been a dive into the ins and outs of diabetes care in acute settings, and I hope you now feel ready to manage those challenging scenarios. Tom, an absolute pleasure chatting with you.

RN Tom

The feeling’s mutual, Kat. Until next time, everyone, stay sharp, stay safe, and keep learning. See you soon!