Category: Advancing Modules

In this case it is expected you will now have an understanding of:

• The potential and pathophysiological harm of hyperglycaemia in acute stroke patients
• Recognising the high incidence of increased glucose in acute stroke patients.
• The method and frequency of blood glucose monitoring
• The urgency of rapid intervention to correct hypoglycaemia

Six months after his stroke Bob is feeling much better and during a routine check up at his local surgery he mentions that he’s keen to return to driving. Bob’s GP refers him for a formal driving assessment, which he passes. Bob is now busy making plans to go and visit his sister who lives in Thurso. Bob has also found it very helpful to work through the CHSS self management resource: Selfhelp4stroke. 

 

 

• You would give Bob a discharge patient information secondary prevention sheet
• You would explain that as part of your coordinated discharge planning you had already referred Bob to the diabetic nurse specialist who would be visiting him before he went home
• You inform Bob of the benefits of maintaining normal glucose, and offer a referral to the dietitian to plan a weight loss control programme
• You could also provide Bob with CHSS essential guide: Type 2 Diabetes (PDF)

Over the next few days Bob improved and his glucose was controlled with oral hypoglycaemics. He is due to leave the acute stroke unit and announces “nobody has told me anything about diabetes“.

What information and explanation would you give Bob? Think and list some of things you would do before turning to the next page for some answers.

You come on shift the next morning and notice that Bob is pale and sweaty, dizzy, shaky and appears confused with a GCS of 14/15.

 

On day three after his admission Bob has a large hospital meal, plus a large box of chocolates, despite the nurses previously giving him some dietary advice. The next routine BM stix shows his glucose to be even higher at 16mmol/l. The doctors decide that this needs to be better controlled and decide to start Bob on an insulin sliding scale.

Example of a Diabetic Control Table. NB: These will vary so please refer to your local charts.

Patient name:	Bob Ferguson	DOB: 23/03/62	Consultant:	Dr Ross
Date	21/11/2020	21/11/2020	21/11/2020	21/11/2020	21/11/2020
Time	07:30	09:30	11:30	13:30	15.30
Insulin Name and Units
Actrapid
as per BM	4	3	3	2	2
Signature: D. Ross	D Ross	D Ross	D Ross	D Ross	D Ross
BM results (mmol/L	16.0	13.8	12.2	10.7	10.2
Ketones

Insulin sliding scale prescription

Drug/Dose Actrapid 100units in 100ml 0.9% Saline		BM result (mmol/L)	Insulin rate (ml/hr)
		0 – 4	0
ROUTE Intravenous		5 – 7	1
		8 – 10	2
Start Date 21/11/2020	Doctors Signature Doug Ross	11 – 15	3
		16 – 20	4
Disc. Date	Doctors Signature	21 – 28	6
		>28	Inform Dr

 

An insulin sliding scale is a temporary measure to control glucose levels in acute stroke patient with very high blood glucose (>15 mmol/L). It involves intravenous administration of a standard insulin to tightly regulate blood glucose levels. Blood glucose levels are monitored using bedside, finger-prick capillary glucose monitoring machines. The rate of infusion of insulin is titrated according to the glucose which is ideally monitored every 1-2 hours. Insulin given intravenously has a short half-life of a few minutes.

Q. How common is abnormal glucose and diabetes in acute stroke patients? Answer Yes or No to each of the questions below:

For more details on quiz answers see additional information

You look at the computer and notice that Bob’s HbA1C level is over 48mmol/mol (over 6.5%).

Q. What does this indicate? Answer Yes or No to each of the questions below:

 

As Bob’s capillary blood glucose (CBG/BM) was 10.8 mmol/l.  what would you do next? Select Yes or No for each question. Correct answer in Bold