HYPOGLYCEMIA: Prevention, Recognition and Treatment in Residential and Acute Care Self Learning Plan

Transcription

1 Diabetes Management HYPOGLYCEMIA: Prevention, Recognition and Treatment in Residential and Acute Care Self Learning Plan Developed by: Melanie Wiebe RD, CDE - Regional Knowledge Coordinator CDM & PHC Nicole Seyl RN, BN - Clinical Practice Educator, Residential Services FINAL: April 29, 2013

2 Self Learning Package Table of Contents Backgrounder... 3 Introduction... 3 Learning Objectives... 3 Pre-Test... 4 Pre Test Answer Key... 6 Scope of Practice and Competency... 7 Definitions and Abbreviations... 8 Pathophysiology of Hypoglycemia... 9 Prevention Signs and Symptoms of Hypoglycemia Underlying factors Treatment and Rationale Post Test Post Test Answer Key References Self Learning Package Evaluation Self Learning Plan April 29, 2013 Page 2 of 19

3 Backgrounder This education resource was developed through a collaborative effort of the Interior Health medical director for Diabetes, Community Integration Services, Acute and Residential Nurse Educators, Interior Health (IH) front line nurses and the Professional Practice Office. The goal of the collaborative effort is to provide nurses with a standardized evidence based approach to treating hypoglycemia in adults in the acute and residential care setting, in accordance with the BC Health Professions Act (HPA), the Nurses (Registered) and Nurse Practitioners Regulations and the standards, limits and conditions on RN practice set out by CRNBC and IH limits and conditions. Introduction The IH HYPOGLYCEMIA: Prevention, Recognition and Treatment in the Residential and Acute Care Self Learning Plan is designed to be an independent study module for nurses to increase their knowledge base and competency level in providing treatment of hypoglycemia in adults. The learning resource provides basic information about hypoglycemia and includes information on how to recognize, treat and prevent the condition. Education and clinical decision support tool (CDST) resources should be reviewed on a regular basis as needed, in order to maintain clinical competence in hypoglycemia treatment. Learning Objectives To guide nursing (RN, RPN and LPN) staff within the residential and acute care environment with consistent best practice for prevention, recognition and treatment of hypoglycemia. Once the Self Learning Package has been completed the learner should be able to: understand the pathophysiology of hypoglycemia identify possible causes of hypoglycemia describe hypoglycemia signs and symptoms recognize and diagnose the condition of hypoglycemia understand asymptomatic hypoglycemia and when this is most likely to occur understand implications of available treatment pathways understand medication side effects and actions contribute to review and revisions of a care plan in order to prevent hypoglycemia initiate the appropriate treatment plan for patients and residents who can swallow and those who cannot understand professional accountability, responsibility and scope or practice (LPN, RPN and RN) with regards to acting with or without an order and the administration of glucagon and IV dextrose provide/plan for appropriate follow up care for the patient including consultations with most appropriate care providers document the hypoglycemia event Self Learning Plan April 29, 2013 Page 3 of 19

4 Pre-Test 1. The hypoglycemic patient/resident will always show signs of hypoglycemia such as shakiness, sweating etc? True or False 2. The following are signs of hypoglycemia: a. diaphoresis and impaired consciousness b. tremors and aggression c. hunger and tachycardia d. all of the above 3. In the event that a patient/resident becomes unconscious you can still treat them orally? a. Never treat an unconscious patient orally b. Yes if you have glucose gel available c. Yes so long as you use thickened juice 4. LPNs can give glucagon without a physician order? True or False 5. In the Acute Care environment, it is within the RN scope to give the IV dextrose 50% injectable without a physician order? True or False 6. How many grams of fast acting carbohydrate are needed to treat moderate-severe hypoglycemia orally? a grams b grams c grams d grams e grams 7. Which statement is true? a. Glucagon cannot be repeated the patient can only receive one glucagon 1mg injection b. You can give a total of 2 treatments of glucagon 1mg c. Glucagon 1mg can be repeated as many times as needed Self Learning Plan April 29, 2013 Page 4 of 19

5 8. In the Acute Care environment, when a VAD and an RN are immediately available the unconscious hypoglycemic patient should be treated with dextrose 50% injectable by the RN True or False 9. You should never feed the hypoglycemic patient/resident until their blood sugar is above 4 mmol/l True or False 10. The typical follow up snack for your patient/resident should include a. only carbohydrate such as crackers b. only protein such as cheese c. fat and carbohydrate such as crackers and butter d. carbohydrate and protein such as crackers and cheese Self Learning Plan April 29, 2013 Page 5 of 19

6 Pre Test Answer Key 1. False 2. (d) all of the above 3. (a) never treat an unconscious patient orally 4. False LPNs require a physician order to administer glucagon 5. True 6. (c) grams of carbohydrate 7. (b) you can give a total of 2 treatments 8. True 9. False 10. (d) carbohydrate and protein such as crackers and cheese Self Learning Plan April 29, 2013 Page 6 of 19

7 Scope of Practice and Competency Scope of Practice: Registered Nurses (RN), Registered Psychiatric Nurses (RPN) and Licensed Practical Nurses (LPN) are required to work within their scope of practice and competency level. Registered Nurse Scope: Whenever a physician s order is available, the RN will follow the order and is accountable for the CRNBC standards for acting with an order (CRNBC, 2012, pg 22). When a physician order is not available, RNs can administer dextrose 50% (D50W) and glucagon without an order in the emergency treatment of hypoglycemia. When acting without an order the RN is solely accountable for the decision to act as well as the activity. The RN is accountable for practicing within the CNRBC standard for Acting without an Order. (CRNBC, 2012, pg 11). As soon as possible, the client shall be transferred to a physician / nurse practitioner for assessment and orders. LPN Scope: LPNs can be assigned as primary nurse when the known nursing care needs of the patient/resident assigned are within LPN scope of practice and the individual competencies of the LPN. Reassignment of the patient/resident to an RN as primary nurse is required in the care of the unstable patient/resident. LPNs are required to collaborate closely with an RN/RPN and transfer primary care responsibility to an RN as soon as possible in the event of glucagon administration or an unstable patient/resident. LPNs require a physician or Nurse Practitioner (NP) order to administer glucagon SC/IM (refer to Interior Health Pre Printed Insulin Orders or other documented patient specific Physician/NP order). It is not within the scope of LPNs to administer intravenous medications (e.g. prefilled 50 ml syringe of dextrose 50%; D50W). RPN Scope: It is within the entry level competency for RPNs to make a nursing diagnosis of suspected hypoglycemia and to follow the order of physician/np in the medical management of hypoglycemia. At this time, the Regulation governing Registered Psychiatric Nurse practice, scope, limits and conditions with respect to restricted activities without an order has not been enacted. Once the RPN scope of practice has been defined in legislation, this section will be reviewed and amended. (Refer to RPN Competency Profile, p. 64). Self Learning Plan April 29, 2013 Page 7 of 19

8 In life threatening emergencies, the Registered Psychiatric Nurses are ethically obliged to provide the best care they can, given the circumstances and their individual competency. (Refer to CRPNBC Interim Clarification Statement, Dec ) Competency: It is the professional responsibility of all registered health care providers who are expected to respond to hypoglycemia to maintain competency. This will include self- assessment of competency initially and as the Professional deems necessary thereafter in order to maintain competency. It is recommended that the professional complete a self assessment at least annually. A self assessment will include, but not necessarily be limited to, completion of an IH Personal Practice review. The IH Personal Practice Review guides the nurse to IH resources for review of their professional scope, the supporting Acute and Residential Clinical Decision Support Tools (CDST), corresponding IHA Acute (# )or Residential (# ) Hypoglycemia Protocol, along with completion of this IHA Hypoglycemia: Prevention, Recognition and Treatment in Residential and Acute Care Self Learning Plan. It is the responsibility of all health care providers to develop and complete a learning plan to address any personal knowledge or competency deficits that are revealed during their Personal Practice Review/Self Assessment. Definitions and Abbreviations Dextrose: Fast Acting Carbohydrate: Glucose: Hypoglycemia: Hypoglycemia Severity: Another name for glucose. Dextrose/glucose tablets are often used to treat mild or moderate hypoglycemia A form of carbohydrate (glucose, dextrose, fructose, sucrose etc.) which results in a rapid increase in blood glucose levels (15 minutes) once ingested A simple form of sugar that acts as fuel for the body. It is produced during digestion of carbohydrate Low blood glucose level (less than 4 mmol/l) Commonly associated with the development of autonomic or neuroglycopenic symptoms (latter more common in elderly) Symptoms responding to the administration of carbohydrate Mild: Blood glucose less than 4 mmol/l but above 2.8 mmol/l. Autonomic symptoms are present. Individual able to consume oral treatment Moderate: Blood glucose less than 4 mmol but above 2.8 mmol/l. Autonomic and neuroglycopenic symptoms are present. Individual is able to consume oral treatment Severe: Blood glucose typically less than 2.8 mmol/l. Individual requires assistance; unconsciousness may occur. Persons with dementia, or on psychotropic medications may show confusion, stroke-like symptoms and unawareness of symptoms when blood glucose is low. Neuroglycopenic symptoms may occur at blood glucose values higher than 2.8 mmol/l in the elderly Self Learning Plan April 29, 2013 Page 8 of 19

9 Insulin Secretagogues: RN Initiated Activity: Sucrose Oral medication which simulates the pancreatic beta cells to produce insulin. This medication can be associated with hypoglycemia Actions taken by an RN without an order from a Physician or Nurse Practitioner. The RN is solely accountable and responsible for the decision to act and for the act itself. The RN is accountable for practicing within the CNRBC standard for Acting without an Order. (CRNBC, 2012, pg 11). A common type of sugar derived from sugar cane or sugar beets. Abbreviations CDST FP IM LPN MRP NP NPH PPO PRN RN RPN SC VAD Clinical Decision Support Tool Family Practitioner Intramuscular Licensed Practical Nurse Most responsible physician Nurse Practitioner Intermediate-acting human basal insulin added to prolong absorption from the subcutaneous space; named neutral protamine Hagedorn. Pre-printed Order As needed Registered Nurse Registered Psychiatric Nurse Subcutaneous Vascular Access Device; Commonly referred to as an VAD Pathophysiology of Hypoglycemia Hypoglycemia is defined as blood glucose less than 4 mmol/l. If the blood glucose is less than 4 mmol/l there is an imbalance in the insulin to glucose ratio resulting in a blood glucose deficit. When hypoglycemia occurs, the body responds by releasing the hormone epinephrine, which in turn stimulates the liver to release stored glucose into the blood stream. The release of epinephrine results in many common symptoms of hypoglycemia; such as, sweating, anxiousness, confusion, and hunger, among many others. Despite the release of glucose from the liver, the glucose deficit often remains and the person must receive treatment for the condition. Hypoglycemia can be treated with carbohydrate ingestion, glucagon or IV dextrose (treatment is discussed later in this document). If left untreated the patient/resident will experience autonomic and neuroglycemic symptoms, impaired consciousness and even death. Self Learning Plan April 29, 2013 Page 9 of 19

10 Hypoglycemia is common in patients/residents with diabetes, particularly those being treated with insulin or insulin secretagogues. Patients/residents on other oral medication or no medication at all may still experience episodes of hypoglycemia especially if meals are missed or exercise is increased. Mild Hypoglycemia Mild hypoglycemia occurs when the blood glucose is less than 4 mmol/l with autonomic symptoms and the patient/resident is able to self treat by ingesting oral carbohydrates, such as, juice, glucose tablets, etc. Moderate Hypoglycemia Moderate hypoglycemia is characterized by autonomic and neuroglycemic symptoms; the patient/resident is not able to self treat and will need prompting to treat or requires assistance. Moderate hypoglycemia may need to be treated with oral carbohydrate or in some cases glucagon or IV dextrose. Severe Hypoglycemia Finally severe hypoglycemia results in unconsciousness and/or seizures; if left untreated severe hypoglycemia may cause death. Severe hypoglycemia is treated with glucagon or IV dextrose if Vascular Access Device (VAD) is immediately available. Autonomic Symptoms Shaking/trembling, sweating, hunger, tingling, anxiety, palpitations, and/or nausea. Neuroglycopenic Symptoms Confusion, drowsiness, dizziness, vision changes, difficulty speaking, headache, trouble concentrating, weakness, and/or tiredness. Pseudo Hypoglycemia Patients/residents who have had an extended period of elevated blood glucose may feel the symptoms of hypoglycemia as their blood glucose lowers to the target range. Despite blood glucose being above 4 mmol/l the patient/resident may feel shaky, sweaty, unwell, dizzy etc. It is acceptable to treat the patient/resident with a small amount of carbohydrate (approximately 7-10grams) to help alleviate symptoms. With time and good glucose control, pseudo hypoglycemia typically resolves itself. Hypoglycemia Unawareness This condition occurs when the autonomic nervous system fails to alert the patient/resident that blood glucose is below 4 mmol/l. Hypoglycemia unawareness tends to be more common in long-term diabetics or in patients/residents who have had a recent episode of hypoglycemia. Patients/residents with hypoglycemia unawareness are more likely to advance from mild to severe hypoglycemia as there are no symptoms to warn the patient/resident of the low blood glucose. More frequent blood glucose monitoring is required for patients/residents with this condition. Self Learning Plan April 29, 2013 Page 10 of 19

11 Prevention Prevention of hypoglycemia lies largely on the recognition of symptoms and an understanding of the underlying factors which cause the condition. Regular blood glucose monitoring plays a critical role in the prevention and treatment of hypoglycemia as well. Assessment of risk factors for hypoglycemia which include, but are not limited to: Those on insulin or secretagogues, Those with hypoglycemia on day prior, Nutritional interruption, Renal or liver impairment, Heart failure and/or Cognitive impairment. Assessment of risk factors for severe hypoglycemia, which include but are not limited to: Prior episodes of severe hypoglycemia; Current low A1C; <6.5% Hypoglycemic unawareness, Long duration of diabetes and Autonomic neuropathy. With physician and interdisciplinary staff, develop a proactive prevention plan to avoid hypoglycemia, including: Increased monitoring effort, Proactive medication adjustment and Plan for treatment. All patients/residents at risk of hypoglycemia should, if possible, have access to their own glucose meter. Nurse should be made aware if patient/resident is using own meter and employ clinical judgment in validating capillary blood sugar results with hospital meter) and a ready source of oral fast acting carbohydrate (i.e. glucose tabs). Patients/residents should be advised to inform nurse if they are feeling symptoms of hypoglycemia. All patients/residents at risk of hypoglycemia going for a procedure should have a ready source of oral fast acting carbohydrate. NPH can be related to nocturnal hypoglycemia and prevention measures such as increased monitoring should be implemented. For patients/residents identified as at risk, obtain Physician/Nurse Practitioner (NP) order for treatment of potential hypoglycemic episode. (refer to Interior Health Pre-Printed Insulin Orders or other patient specific documented orders) Self Learning Plan April 29, 2013 Page 11 of 19

12 Signs and Symptoms of Hypoglycemia Blood glucose level less than 4 mmol/l, with or without symptoms Typical autonomic symptoms include: shaking/trembling, sweating, hunger, tingling, anxiety, palpitations, and/or nausea. Typical neuroglycopenic symptoms include: confusion, drowsiness, dizziness, vision changes, difficulty speaking, headache, trouble concentrating, weakness, and/or tiredness. Hypoglycemia in the elderly may be asymptomatic or present more often as neuroglycopenic symptoms. Underlying factors Possible underlying factors contributing to hypoglycemia include, but are not limited to: Decreased oral intake Increased physical activity Excessive dose of diabetes medications or a change in medications Alcohol consumption Underlying Kidney Disease complications Recent weight loss Liver impairment Treatment and Rationale Recognition All patients/residents with autonomic or neuroglypenic symptoms require a nursing assessment. If blood glucose is less than 4 mmol/l (as determined by blood glucose meter) with or without symptoms the IH Adult Hypoglycemia Protocol for Acute Care (# ) or Residential (# ) must be followed. If the blood glucose is equal to or greater than 4 mmol/l DO NOT follow the IH Adult Hypoglycemia Protocol for Acute Care or the Residential Adult Hypoglycemia Protocol as it is not hypoglycemia. The client or resident should be assessed for underlying factors and causes of any symptoms they may be experiencing and the physician must be notified. Oral Treatment If the patient/resident is stable and able to swallow safely, treat orally with 20 grams of fast acting carbohydrate, 15 grams of fast acting carbohydrate will produce a rise in blood glucose of 3.6 mmol/l within 20 minutes. The Canadian Diabetes Association (CDA) guidelines recommend 15 grams fast acting carbohydrate for mild to moderate hypoglycemia and 20 grams for severe. However, in an acute or residential situation it is reasonable to treat the patient/resident with 20 grams for mild, moderate and severe so long as swallowing is deemed safe. Self Learning Plan April 29, 2013 Page 12 of 19

13 If patient/resident is on alpha-glucosidase inhibitor (Acarbose ) preferred treatment is honey (4 tsp) or glucose tablets (20 grams). Sucrose (common form table sugar also found in some sweetened juice and pop) absorption is delayed by alpha-glucosidase inhibitor (Acarbose ). Absorption of glucose should be apparent 15 minutes post administration. Assess blood glucose 15 minutes post oral glucose administration. If blood glucose remains below 4 mmol/l and patient/resident remains able to consume oral treatment, repeat oral fast acting carbohydrate 20 grams 2 more times, allowing for 15 minutes between doses for assessment of effect. If the blood glucose continues to remain less than 4 mmol/l, the LPN must collaborate closely with an RN/RPN. LPN and RN/RPN are to determine if RN will take over patient/resident care. Do not feed the patient/resident food until the blood glucose is above 4 mmol/l. Food may delay the rise in blood glucose following the hypoglycemic event. If patient/resident at anytime becomes unable to consume oral treatment proceed to 4.2 Procedure A (if no VAD immediately available) or B of Acute Hypoglycemia protocol; or Unable to Consume Oral Pathway for Residential Protocol. Assess for underlying factors to determine cause. (Refer to previous Section titled: Possible Underlying Factors Contributing to Hypoglycemia). Glucagon (IM or SQ) Treatment; No VAD Immediately Available LPNs require an order to administer glucagon. RNs can administer glucagon without an order to treat the condition of hypoglycemia. Patients/residents on insulin with IH Pre-printed Insulin orders (PPO) have orders in place for the administration of glucagon within the PPO. The preferred injection site for glucagon is the thigh. Vomiting is a side effect of glucagon administration, therefore the patient/resident should be in the side lying position with suction available. Treatment with glucagon should be apparent within 15 minutes post administration. Typically 1mg of glucagon will produce a rise in blood glucose of 3-12 mmol/l in 60 minutes. Do not administer subsequent doses of glucagon if post administration blood glucose is greater than or equal to 4 mmol/l. Assess for underlying factors to determine cause. (Refer to previous Section titled: Possible Underlying Factors Contributing to Hypoglycemia). Dextrose Treatment; VAD Immediately Available (Acute Care ONLY) If Venous Access is immediately available in acute care follow Procedure B (Acute Protocol Only). LPN immediately transfers care to an RN/MD/NP. LPNs do not administer intravenous medications. Dextrose is administered through a VAD using a prefilled 50mL syringe of dextrose 50% injectable (25 grams/50ml). The effects of VAD dextrose 50% are immediate; if there is no immediate response, monitor blood glucose every 15 minutes. If blood glucose remains less than 4 mmol/l, continue to repeat dextrose 50% injectable administration steps 4.21 to 4.24 (acute protocol only) until physician gives new orders. Assess for underlying factors for symptoms and monitor neuro-vital signs. (Refer to Section titled: Possible Underlying Factors Contributing to Hypoglycemia.) Self Learning Plan April 29, 2013 Page 13 of 19

14 Follow-Up LPNs can continue to provide care to the patient/resident independently with oral management and in collaboration with an RN/RPN if IM/SC glucagon management is required, with transferrance of care as soon as possible to RN/NP thereafter. Transfer care to RN/NP if VAD management becomes necessary. Once blood glucose is equal to or greater than 4 mmol/l and the patient/resident is able to eat; feed a protein and carbohydrate snack. If patient/resident is given food before blood glucose is above 4 mmol/l this will delay the effectiveness of the hypoglycemia treatment. Ensure physician is notified before next insulin dose for severe cases requiring treatment via glucagon or IV dextrose, and within 24 hours for mild cases requiring treatment orally, as per IH Insulin Administration and Blood Glucose Monitoring Record protocol. Support patient/resident and/or family with education and resources as appropriate to prevent future hypoglycemic events. Charting and Documentation All patient s/resident s with a completed and signed Pre-Printed Insulin Order must have an addressographed Acute or Residential Hypoglycemia protocol added to chart at time of order, and also whenever protocol is enacted. All blood glucose results must be recorded in the IH Insulin Administration and Blood Glucose Monitoring Record as per IHA protocol. Nurses are required to document all assessments, actions, and interventions on the patient/resident chart. All medications administered must be recorded per protocol in the MAR. If RN administers medications without an order, the RN documentation shall include a statement indicating that the activity was RN initiated using the IH hypoglycemia protocol to guide the activity. CONGRATULATIONS! You have just completed the Residential and Acute Care Hypoglycemia Protocol Self Learning Module. All that you now need to do is to complete the post test and the evaluation form. Self Learning Plan April 29, 2013 Page 14 of 19

15 Post Test 1. What level of blood glucose defines hypoglycemia? 2. What are three autonomic signs and symptoms of hypoglycemia? 3. What are three neuroglycopenic sign and symptoms of hypoglycemia? 4. It is possible to have hypoglycemia with no signs and symptoms? True or False 5. Name three factors that might contribute to hypoglycemia. 6. What is the chief feature of severe hypoglycemia? 7. What are the treatment options for a hypoglycemic patient/resident who can consume oral treatment? Provide three examples 8. What is the preferred treatment for the dysphasic patient/resident? 9. What should be done 15 minutes after oral treatment? 10. Why is it not a good idea to feed patient/resident before seeing the rise in glucose from the fast acting carbohydrate? Self Learning Plan April 29, 2013 Page 15 of 19

16 11. What is the treatment for a patient/resident who is not able to consume oral treatment or is unconscious? 12. What should be done after hypoglycemia is treated successfully? Self Learning Plan April 29, 2013 Page 16 of 19

17 Post Test Answer Key 1. Less than 4 mmol/l 2. Shaking/trembling, sweating, hunger, tingling, anxiety, palpitations 3. Confusion, drowsiness, dizziness, vision changes, difficulty speaking, headache, trouble concentrating, weakness, and/or tiredness. 4. True 5. Decreased oral intake, increased physical activity, excessive dose of diabetic medication (glyburide/ gliclazide/insulin) or a change in medications, alcohol consumption, underlying Kidney disease complications, recent weight loss, or liver impairment 6. Patient is unable to self treat grams fast acting carbohydrate, 200 ml juice, 5 X 4 grams glucose tablets, 4 packets (4 tsp) sugar dissolved in 60mL water or 20 ml (4 tsp) honey 8. Thickened juice or honey 9. Re- check blood glucose 10. Food may delay the rise of blood glucose 11. a) Without vascular access? i.) Administer glucagon 1 mg SC / IM first, then consider VAD ii.) Notify physician STAT b) With vascular access? i.) Administer dextrose 50% injectable 10 grams (20 ml) IV over 2 to 3 minutes ii.) Notify physician STAT iii.) If no immediate response, administer dextrose 50% injectable 15 grams (30 ml) over 2 to 3 minutes 12.) 1.Feed patient if meal is more than 1 hour away (protein/ carbohydrate snack) 2. Evaluate cause 3. Notify physician if not already done 4. Document Self Learning Plan April 29, 2013 Page 17 of 19

18 References Canadian Diabetes Association. (2008) Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes, 2008:32 (suppl1): [S62-S64; S71-S74] Canadian Diabetes Association. (2013) Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada. Can J Diabetes, 2013:37 (suppl1): [S69-S71] College of Registered Nurses of British Columbia. (February 2013) Scope of Practice for Registered Nurses: Standards Limits and Conditions. pp 11-12, 18, 20-22, Retrieved from College of Registered Psychiatric Nurses of BC. (December 15, 2010). Clarification Regarding the Current Scope of Practice of Registered Psychiatric Nurses in BC. Retrieved from Maynard G, Huynh M, Renvall M (2008). Iatrogenic inpatient hypoglycemia: risk factors, treatment, and prevention: analysis of current practice at an academic medical center with implications for improvement efforts. Diabetes Spectrum. 21: Registered Psychiatric Nurses of Canada. (2001). Registered Psychiatric Nurses: Competency Profile for the Profession in Canada. pp 64. Retrieved from Umpierrez, G.E., Hellman, R., Korytkowski, M.T., Kosiborod, M. Maynard, G.A., Seley, J.J., VandenBerghe, G. (2012). Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab, 2012, Jan. 97(1) Self Learning Plan April 29, 2013 Page 18 of 19

19 Self Learning Package Evaluation Your feedback is very important, so please fill out. 1. What did you like about the learning module? 2. What did you not like about the learning module? 3. In your opinion, what could be done to improve it? 4. What was your overall impression of this learning module? (Circle only one) Poor Excellent Do you have any further comments? Thank you for taking the time to complete this survey! Please scan and to either: Niocole.Seyl@InteriorHealth.ca - Residential Services Clinical Practice Educator Melanie.Wiebe@InteriorHealth.ca Regional Knowledge Coordinator, CDM Self Learning Plan April 29, 2013 Page 19 of 19