Effect of Nursing-directed Protocol on the Occurance of Hypoglycemic Episodes among Patients at Medical Intensive Care Unit

Background: Hypoglycemia is a well-recognized complication among patients with type 1 diabetes, and it is the most common diabetes-related emergency. It is a complication of diabetes that cannot be ignored because it will increase morbidity and mortality in diabetic patients. thus, coordinated nursing care of the hypoglycemia patient results in improved outcomes, decreased lengths of hospital stay and minimize complications. The aim of the study: - Evaluate the effect of nursing-directed protocol on the occurance of hypoglycemic episodes among patients at Medical Intensive Care Unit. Study design: - Quasi-experimental research design . Study setting: This study was conducted at Medical Intensive Care Unit of Tanta Main University Hospital. Study subjects: Purposive sampling of 60 adult patients with hypoglycemia and meeting all inclusion criteria, were divided into two equal groups; each group consisted of 30 patients. Tools of data collection: - Three tools were used . Tool (I): Patients Structured Assessment Tool; Socio-demographic data of the patients, Patient`s Clinical Data. Tool (II): Blood Glucose Measurements Flow Sheet tool. Tool (III): Monitoring of Hypoglycemic manifestation and its complications among critically ill Patients. Result : The main results revealed a significant improvement in relation to vital signs, level of consciousness, blood glucose measurements among study group. Statically significant difference was observed related to hypoglycemic manifestation and complication among the control and study group with P<0.05. conclusion : the nursing-directed protocol had positive effect on decreasing hypoglycemic episode by improving blood glucose level, reducing hypoglycemic manifestations and complications. Recommendation : Replication of the same study on larger probability sample at different geographical locations for data generalizability.


Introduction
Hypoglycemia is the commonest medical emergency in diabetic patients and perceived as the most important obstacle to tight glucose control using intensive insulin therapy in medical critically ill patients.It requires prompt recognition and treatment to prevent organ and brain damage (1) .Critical illness associated hypoglycemia in nondiabetic patients generally occurs as a result of kidney, liver disorders, insufficient nutritional intake, side effect of some medications as antibiotics that is seen frequently in critically ill patients.Hypoglycemia is common in insulin and non-insulin-dependent diabetic patients who require an action plan because it is common, clinically significant, measurable, and preventable (1,2) .Vol. 31.No. 4 (Suppl 1) ,November 2023 Hypoglycemia always represents an emergency that signals the inability of the brain to meet its energy needs.When hypoglycemia is left untreated, it can result in permanent brain damage and ultimately death.In the context of critical illness that limits endogenous glucose production and increases glucose utilization, inadequate nutrition, or insufficient provision of glucose and intensive insulin therapy is the most frequent cause of hypoglycemia ( 3) .Hypoglycemia is induced by many causes as liver disorders, over-dose of insulin or oral hypoglycemic agents in diabetic subjects.In such as case, hyperinsulinemic hypoglycemia is usually observed (4,5) .On the other hand, it is difficult to diagnose hypoinsulinemic hypoglycemia, which is sometimes observed in non-diabetic patients (5)   .The other contributory factors leading hypoglycemia may include imbalance between the anti-diabetic regimen, longer time intervals between meals or impaired counter-regulator mechanisms.In addition, failure to detect warning symptoms of hypoglycemia due to reduced autonomic response during sleep may also aggravate the development of hypoglycemia (6,7) .According to the world health organization,Worldwide,the incidence of severe hypoglycemia event was 4.800 per 100.000patient per year and moderate events was 13.100 per 100.000patient per year.The reported incidence of hypoglycemia varies considerably among studies, however in general patients with type I diabetes have an average of two episodes of symptomatic hypoglycemia per week and one episode of severe hypoglycemia once a year (8) .The occurrence of hypoglycemia and sensitization to the unpleasant symptoms has been shown to result in fear of future hypoglycemia and avoidance of low blood glucose, particularly among insulin-treated patients.In these patients, mild or moderate and severe hypoglycemia have been reported as the most common adverse effects associated with intensive insulin therapy and have been estimated to occur annually in 5 to 20% of patients taking oral antihyperglycemic agents.Severe hypoglycemia can result in seizures and coma, which may be complicated by irreversible brain damage (8) .The spectrum of symptoms of hypoglycemia depends on duration and severity of hypoglycemia and varied from autonomic activation to behavioral changes to altered cognitive function to seizures or coma.Thus, close and reliable monitoring of the glycemic level is crucial in detecting hypoglycemia (9) .The development of medical intensive care had a huge impact on improving outcome and reducing mortality in patients with critical medical conditions (9)   .Insulin dosing and glucose monitoring rules, response to impending hypoglycemia, use of computerization and attention to modifiable factors extrinsic to insulin algorithms may affect the risk for hypoglycemia.Recurring use of intravenous (IV) bolus doses of insulin in insulinresistant cases may reduce reliance upon higher IV infusion rates (10,11) .Critical care nurses, on the front lines, that can screen patients for early hypoglycemia identification, recognize and initiate corrective measures for inadequate treatment regimens, help patients set and achieve therapeutic goals, and assess diabetes-related complications as they arise (8)   .Moreover, critical care nurses can prevent hypoglycemic episodes by conveying Vol. 31.No. 4 (Suppl 1) ,November 2023 appropriate instructions for meal timing and medication administration, heightening awareness of medical conditions that influence glucose control, and, if appropriate, encouraging patient self-care (12,13) .Patient's self-management whose diabetes is well controlled as outpatients and who possess the capability of managing their insulin regimen in the hospital, such as those who wear an insulin pump or who use multiple daily injections of glargine, can be a means to reduce hypoglycemia.Often, capable patients can match their required needs in respect to timing and amount of carbohydrate better than most nurses or physicians (14) .

Significance of the study
Based on clinical observations, patients in medical intensive care unit especially who had liver disorders are at risk for hypoglycemia because of their critical health status and altered mental status (15) .The prevalence of hypoglycemia is reported as 50% in patients of liver cirrhosis (5) .The threat of hypoglycemia requires the inpatient team to be vigilant in detecting signs and symptoms, preventing episodes without compromising glycemic control for adequate healing, and treating hypoglycemia episodes appropriately.So, the aim of the present study is to evaluate the effect of nursing-directed protocol on the occurance of hypoglycemic episodes among patients at medical intensive care unit.The aim of this study was to: -Evaluate the effect of nursing-directed protocol on the occurance of hypoglycemic episodes among patients at medical intensive care unit.

Research hypotheses
Patients who were exposed to nursingdirected protocol on hypoglycemic episodes occurance will exhibit early detection of hypoglycemia, decreasing its episodes and complications compared to control group who does not exposed.

Subjects and method Study Design
nd modified by the researcher.It was used to asses and compare different blood glucose control algorithms and evaluation of blood glucose (BG) control in the intensive care unit (ICU).(16) and modified by the researcher.4-The study tools were tested for content validity by the developed and translated tools were tested for content validity by five experts in the Critical Care and Emergency Nursing Department and medical field professors.Modifications were carried out accordingly before conducting the study.

5-A pilot study
It was conducted before the actual study on 10% of the patients, to test the clarity, feasibility, and applicability of the different items of the tools.Modifications and some additional terms were done by the researcher before the main study, according to the experience gained from the pilot study.
-Data obtained from those patients were excluded and not included in the current study.

Validity of the tools
The developed tool I part a and b were tested for content validity by seven experts in the Medical-Surgical and Critical Care Nursing and accordingly needed modifications were done.6-Reliability of the study tools was done by Cronbach's Alpha for tool I is 0.826 for 21 items applied on 6 patients, Cronbach's Alpha for tool II is 0.951 for 2 items applied on 6 patients.Cronbach's Alpha for tool III is 0.802 for 21 items applied on 6 patients.Cronbach's Alpha for the studied sheet in total is 0.881 for 6 patients.

7-Actual study
Data were collected over a period of months, started from march 2022 to September 2022.The researcher used to start the interview by introducing herself after providing an explanation for the purpose and the nature of the study.The researcher started with the control group first then the study group to prevent data contamination.Each nurse and each patient was individually interviewed in medical intensive care unit to fulfill the sheet questions.Each interview for the nurse lasted for about 20-30 minutes to complete the tools and 15-20 minutes for each patient.The questionnaire was filled by the researcher according to the answers of diabetic elderly.The average number of each diabetic elderly per day ranged from 3-5 cases.The average time spent for collecting data from each elderly ranged from 30-45 minutes.

Table (1):
Illustrates percentages distribution of the studied patients regarding their sociodemographic characteristics.This table showed that about two third (60 %) of the control group and near half (46.67%) of the study group had age ranged from (50-60) years old with mean SD(52.577.380) in control group and (48.6310.447 ) in the study group .Regarding gender, it was found that about more than half (56.67%) of both control group and study group were males respectively.Concerning marital status, it was observed that more than two third (66.67%) of the control group and (60%) of the patients in the study group were married.Regarding educational level, more than one third (40 %, 36.67 %) of the control and study group were read and write respectively.Concerning occupation, the result showed that about two third (60 %) of the patients in control group and more than two third (66.67 %) of the study group were worked respectively.Also, it was found that no statistically significant difference among the control and the study group regarding age, sex, marital status, educational level and occupation were observed as P value equal (0.354, 0.606, 0.118, 0.953 and 1.00 respectively).Table (2): Show percentage distribution of the studied patients regarding their diagnosis and past history.Regarding diagnosis, the result showed that near half (43.33%,46.67%) of the control and study group had acute kidney injury (AKI).Also, near half (40%) of both control and study group had hepatic failure respectively.Also, it was found that more than half (53.33%) of both control and study group had renal disease.On the other hand, it was found that (50%) of both control and study group had heart disease.Also, near half (46.67%, 40%) of the control group and study group had hepatic failure Regarding past surgical history, it was found that about less than one quarter (16.67%) of the control group and more than one third (36.67%) of the study group had appendectomy respectively.Concerning the patient's drug history, the result showed that more than two third (63.33%) of the control group and about half (50.00%) of the study group had received glibenclamid drug.Also, one third (30%)of the control group and more than half (56.67%)of the study group had received pentamidine.Table (3): Show percentage distribution of the studied patients regarding their clinical data.Regarding duration of diabetes, the results showed that the mean of the control group was 8.806.088year, and the study group was 10.405.170year.It was found that more than three quarter (80.00%) of both control and study group had past family history of diabetes mellitus.Also, it was found that about more than two third (66.67%) of the control group and less than three quarter (70.00%) of the study group respectively had episodes of sever hypoglycemia before.Concerning the number of hypoglycemia episodes, the results showed that the mean of the control group was 1.431.569episodes, and the study group was 2.132.129episode.Also , Glaciated hemoglobin AIc,the results showed that the mean of the control group was 6.4830.706and the study group was 6.1630.576.Concerning the risk factors associated with hypoglycemia, the result showed that more than two third (66.67%,63.33%) of both control and study group had risk factors as delay in the timing of meals.Also, more than half (53.33 ,56.67%)of the control and study group had heavy stress and near half (40%, 43.33%)of the control and the study group were heavy exercise.

Table (4): present percentage distribution of the studied patients regarding level of consciousness throughout periods of study.
This table showed that less than one quarter (20%) of the control group and one third (30%) of the study group were alert on admission.On the other hand, it was found that near half (46.67 %) of the control group and (100%) of the study group were alert on post 2 weeks.Moreover, there was a statistically significant difference between patients in the study group on admission, Vol. 31.No. 4 (Suppl 1) ,November 2023 post a week, post 2 weeks where P-value=0.00.

Table (5): illustrate distribution of the studied patients regarding blood glucose measurements throughout periods of study.
The results showed that about less than one quarter (20%) of the control group and near half (46.67 %) of the study group had normal capillary blood glucose level on admission.On the other hand, it was found that more than two third (63.33 %) of the control group and equal (100%) of the study group were normal capillary blood glucose on post 2 weeks.Also, it was found that more than three quarter (80%) of the control group compared to (53.33 %) of the study group were hypoglycemia on admission.On the other hand, it was found that more than one third (36.67 %) of the control group had hypoglycemia post 2 weeks while no patient in study group had hypoglycemia post 2 weeks.Moreover, there was a statistically significant difference between patients in the control and study group on admission, post a week, post 2 weeks where P-value=0.000.Concerning glycemic Penalty Index (GPI), the results showed that less than one quarter (20%) of the control group and near half (46.67 %) of the study group were normoglycemia of glycemic penalty index on admission.On the other hand, it was found that about two third (63.33 %) of the control group and compared to (100%) of the study group were normoglycemia of glycemic penalty index on post 2 weeks.Also, it was found that one third (33.33%) of the control group and less than one quarter (10.00 %) of the study group had sever hypoglycemia on admission.On the other hand, it was found that less than one quarter (13.33 %) of the control group had hypoglycemia on post 2 weeks.On the other hand, there was no evidence of hypoglycemia among study group post 2 weeks.Moreover, there was a statistically significant difference between patients in the control and study group on admission, post a week, and post 2 weeks where P-value=0.000.This table shows that the highest mean score for the hypoglycemic manifestation assessment in the control group was ranged from (0-6) where the mean  SD was (2.271.48)post 2 weeks respectively.While mean scores for the hypoglycemic manifestation in the study group was ranged from (0-2) where the mean  SD was (0.570.63) of the study group post 2 weeks respectively.
. Concerning complication assessment, the result shows that the highest mean score for the hypoglycemic complication assessment was seen in the control group ranged from (0-4) where the mean  SD was (1.570.97)post 2 weeks respectively.While mean scores for the hypoglycemic complication assessment was seen in the study group ranged from (0-1) where the mean  SD was (0.330.48) of the study group post 2 weeks respectively.Also, the study showed that, there was a statistically significant difference among patients of the control and study group on admission, post a week, and post 2 weeks at P-value =0.000.

Table (7): Present Correlation between monitoring of hypoglycemic manifestation and complications of the studied patients among the studied groups.
This table illustrates that there was a high positive correlation was observed among the control group regarding the total monitoring of hypoglycemic manifestation and total monitoring of hypoglycemic complications on admission as R = 0.44 with P value= 0,014respectively of hypoglycemic manifestation.also, a high negative correlation was observed among the study group regarding the total monitoring of hypoglycemic manifestation and total monitoring of hypoglycemic complications post 2 weeks as R= -0.077 with P value= 0.688 respectively.In addition, it was found that there was a significant positive correlation between monitoring of hypoglycemic manifestations and complications score of control group on the admission with p value = .027andalso , there was a significant positive correlation between monitoring of hypoglycemic manifestation and complications score of control group on the admission as R=0.445 with p value =0.014

Discussion
Hypoglycemia is a well-known complication in patients with diabetes mellitus.It has been associated with poorer hospital outcomes, including increased Intensive Care Unit (ICU) and mortality (23) .Nursing-directed protocol (NDP) for hypoglycemic episodes resulted in a sustained reduction in hypoglycemia as well as improvement in other glucose metrics (24) .So, the aim of the current study was to evaluate the effect of nursing-directed protocol on the occurance of hypoglycemic episodes among patients at medical Intensive Care Unit.To fulfill this aim one research hypothesis were stated as following: Study subjects who will be exposed to nursingdirected protocol on hypoglycemic episodes occurance will exhibit early detection of hypoglycemia, decreasing its episodes and complications compared to control group who did not exposed.
In  (27) who found that more than two thirds of the studied patients were males Also, this study was agreed with Bakar et al., (2020) (28) .who stated that about two thirds of the studied patients were males.This could be related to that, male patients with longstanding type 2 diabetes mellitus (T2DM) have a higher incidence of hypoglycemia than female (Li et al., 2018) (29) .The current study represented that, more than two third of the control group and the study group were married, in the researcher point of view, this might be related to emotional distress in the partners of type 1 diabetes adults and change in hormones.This result was similar to a study conducted in United States of America (USA) by Long & Dungan, (2020) (30) .who mentioned that more than half of the studied patients were married.
The present study found that, more than one third of the control and study group read and write, in the researcher point of view, this might be related to patients' knowledge of reading and writing makes it easier for them to understand the application of the protocol and take treatment on time.This study was in agreement with a study carried out in Singapore by Shi Min Ko et al., (2022) (31) in their recent study titled A crosssectional study on risk factors for severe hypoglycemia among insulin-treated elderly type 2 diabetes mellitus (T2DM) patients in Singapore and stated that one quarter of the studied patients were not educated but read and write.The present study reported that, there was no statically significant difference between the control and the study group regarding sociodemographic data, in the researcher point of view, this might be related to that, there were inclusion criteria for current study.This indicated to homogeneity between two group.This finding was similar to Alghamdi et al., (2020) (32) who found that there was no statistically significant difference among control and experimental group regarding their characteristics.Contrariwise, this study was dissimilar to Baretic & Lang, (2020) (33) .who stated that there was a statistically significant difference between control and study group regarding their gender and educational level.Concerning diagnosis and past history of the studied patients, the current study found that, near half of the control and study group had acute kidney injury (AKI) and hepatic failure, in the researcher point of view; this might be related to that the diabetes mellitus is a risk factor for kidney and liver diseases (Adiga, 2016) (34).This result was supported by Sakane et al., (2022) (35) .whorevealed that one quarter of the studied patients had kidney disorders .Also, this finding was agreed with a study conducted in India by Sankar & Jayakrishnan, (2023) (36) in their recent study titled risk factors for hypoglycemia requiring medical assistance in patients with type 2 diabetes and found that most of sample of the studied patients had liver diseases.Concerning past medical history, the present study represented that, more than half of both control and study group had renal disease.this could be related to that Its incidence is higher due to a decrease in the process of gluconeogenesis that 40% of it occurred in the kidney, decreased insulin degradation in peripheral tissues, decreased insulin clearance through the kidneys.
On the other hand, it was found that half of both control and study group had heart disease and hepatic failure.This could be related to that, the liver plays a role in carbohydrate metabolism, gluconeogenesis and glycogenolysis.Impaired liver function ultimately contributes to an increased risk of hypoglycemia.This study was on the same line with Uemura et al., (2022) (37) .who reported two thirds of study patients had renal diseases.Also, this finding was supported by a study carried out a study in India by Samya et al., (2019) (38) who study Prevalence of hypoglycemia among patients with type 2 diabetes mellitus in a rural health center and found that most of sample of the studied patients had liver diseases.Contrariwise, this result was disagreed with a study in Poland by Agrawal et al., (2022) (39) in their recent study the impact of hypoglycemia on patients with diabetes mellitus and stated that more than one third of the studied patients had cardiovascular diseases.Regarding past surgical history, the current study revealed that, about less than one quarter of the control group and more than one third of the study group had appendectomy.This finding was in agreement with Tiruneh et al., (2019) (40) .who mentioned that more than one quarter of the studied patients had past surgeries as appendectomy Concerning the patient's drug history, the result of the current study reported that, more than two third of the control group and about half of the study group had received glibenclamid drug.Also, one third of the control group and more than half of the study group had received pentamidine.In the researcher point of view this might related to that, all study sample had diabetes mellitus so could be some of them treated by glibenclamid that hypogycemia is typically the result of the interplay of therapeutic insulin excess and compromised physiological and behavioral defenses against falling glucose levels.and about less than one quarter of the control group and more than one third of the study group had appendectomy so could be received pentamidine drug as antibiotic postsurgery.This result was similar to a study in United States of Arabia by Mahgoub et al., (2023) (41) in their study titled "An update on the molecular and cellular basis of pharmacotherapy in type 2 diabetes mellitus and revealed that more than half of the studied patients were on glibenclamid drug for management of diabetes mellitus.Contrariwise, this finding was in disagreement with Yang et al., (2022) (26) who found that most of the studied patients didn't take other medications rather than oral hypoglycemic medication.Regarding duration of diabetes, the present study revealed that, the mean score of the control group was 8.806.088year, and the study group was 10.405.170year, this could be related to that for a long period of time, diabetic patients may be exposed to more complications .This finding was similar to Olamoyegun et al., (2020) (42) .who found that majority of the studied patients had diabetes mellitus for more than 5 years with mean years of duration 9.573.09.Contrariwise, this result was dissimilar to Switzer et al., (2021)(27)who represented that more than half of the studied patients had diabetes mellitus for less than 2 years with mean 1.910.88.
Concerning previous family history of diabetes, the current study reported that, more than three quarter of both control and study group had past history of diabetes mellitus, this might be related to that diabetes mellitus is hereditary disease.This study was on the same line with a study in Saudi Arabia by AlTowayan et al., (2023) (43) in their recent study titled Awareness level of hypoglycemia among diabetes mellitus type 2 patients and revealed that most of the studied patients had family history for diabetes mellitus .The present study found that, about more than two third of the control group and less than three quarter of the study group had episodes of sever hypoglycemia before, this could be related to that, more than half of the studied patients had risk factors of diseases.This result was on the same line with Pratley et al., (2020) (44) who mentioned that more than half of the studied patients had episodes of severe hypoglycemia in the last 12 months.Also, this study was supported by Yun et al., (2021) (45) who stated that more than half of the studied patients had episodes of sever hypoglycemia for two times before.Concerning number of hypoglycemia episodes in ICU, the current study represented that, the range of the control group had episodes of hypoglycemia for 0-5 times, and the study group had episodes of hypoglycemia for 0-7 times, this could be related to that, for a long period of time, diabetic patients may be exposed to more complication and episodes of hypoglycemia.This finding was in agreement with a study conducted in Korea by Yun et al., (2019) (46) who studied severe hypoglycemia and the risk of cardiovascular disease and mortality in type 2 diabetes and found that more than half of the studied patients had episodes of hypoglycemia for ≥ 2 times and less than two thirds of control group had episodes of hypoglycemia for 1-2 times.Regarding Glaciated hemoglobin A1c, the present study reported that, the mean of the control group was 6.4830.706and the study group was 6.1630.576,this might be related to that the studied patients had diabetes mellitus.This study was similar to Popoviciu et al., (2019)  who revealed that more than two thirds of the studied patients had mean HA1c 6.75±0.834.Also, this finding was on the same line with Samya et al., (2019) (38) .who represented that less than two thirds of the studied patients their HAIc were 6.9.this could be related to that blood testing of glucose is useful for daily management of diabetes.However, a different blood test is used to achieve an objective measure of blood glucose over an extended period.The glycated hemoglobin test, also known as glycosylated hemoglobin (HbA1C or A1C) provides information about the average amount of glucose that has been present in the patient's bloodstream over the previous 3 to 4 months.Typically, 4% to 6% of hemoglobin contains the glucose group A1C.A normal A1C value is less than 5.4%, with an acceptable target level for diabetic patients below 6.5% (48) .Concerning the risk factors associated with hypoglycemia, the present study revealed that, more than two third of both control and study group had risk factors as delay in the timing of meals.Also, more than half of the control and study group had heavy stress and near half of the control and the study group were heavy exercise, this could be related to that, more than two thirds of the studied patients were worker so they are busy, delay their meals, stress and heavy exercise which leads to hypoglycemia.This result was similar to Bakar et al., (2020) (28) .who reported that most of the studied patients their predisposing factor for hypoglycemia were delay meals after insulin or oral hypoglycemic medication administration and emotional stress.Also, this study was on the same line with Sankar & Jayakrishnan,(2023)(36) who mentioned that less than one quarter of the studied patients had heavy exercise post taking insulin or oral medication .
In relation to level of consciousness throughout periods of study, the current study revealed that, less than one quarter of the control group and one third of the study group were alert on admission.On the other hand, it was found that near half of the control group and of the study group was alert on post 2 weeks.Moreover, there was a statistically significant difference between patients in the study group on admission, post a week, post 2 weeks, this could be related to that, the study group were more alert more control group because of effect of nursing-directed protocol on the occurance of hypoglycemic episodes among patients.This result was similar to Lee et al., (2022) (48) in their recent study titled "Predictors of consciousness improvement in patients with hypoglycemic encephalopathy" and reported that less than one quarter of the studied patients were alert on admission and more than three quarters of them showed the improvement on Glasgow Outcome Scale (GOS) after 2 weeks of treatment .Contrariwise, this study was dissimilar to Saikawa et al., (2019) (49) who mentioned that more than half of the studied patients were alert on admission.Regarding blood glucose measurements throughout periods of study, the present study found that, more than one third of the control group had hypoglycemia post 2 weeks while no patient in study group had hypoglycemia post 2 weeks.In the researcher point of view this might be related to that, positive effect of implementing current nursing protocol of this study on adjusting blood glucose measurements post 2 weeks.This finding was on the same line with a study carried out in Saudi Arabia by Abdalla et al., (2019) (50) .whostudied "The Association between Hypoglycemia Requiring Emergency Medical Intervention and Patient Health Outcomes" and found that most of the studied patients had abnormal blood glucose level as a result of presence of hypoglycemia on admission which improved on treatment post admission within one to two weeks .Also, this result was supported by Shea et al., (2019) (51) who conducted a study entitled "Reducing hypoglycemia in critical care patients using a nurse-driven root" and mentioned that there was a statistically significant improvement in blood glucose level pre and post implementation of nursing driven root.Concerning glycemic Penalty Index (GPI), the results showed that about more than two third of the control group and compared to all of the study group were normoglycemia of glycemic penalty index on post 2 weeks.Also, it was found that less than one quarter of the control group had hypoglycemia on post 2 weeks.On the other hand, there was no evidence of hypoglycemia among study group post 2 weeks.Moreover, there was a statistically significant difference between patients in the control and study group on admission, post a week, post 2 weeks.This study was in agreement with Lou et al., (2021) (52) who represented that more than three quarters of the studied patients had abnormal HgA1c on admission which was improved post two to three weeks post admission.Also, this finding was agreed with Wu et al., (2021) (53) .who found that there was highly statistically significant difference between the studied patients' blood glucose level pre and post program.In the researcher point of view this might be related to that, positive effect of implementing current nursing protocol of this study on adjusting blood glucose measurements post 2 weeks.Moreover, there was a statistically significant difference between monitoring of hypoglycemic manifestations and complications assessment among patients in the control and study group on admission, post a week, and post 2 weeks.This study was on the same line with Santoso & Setyowati, (2019) (54) who revealed that there was a statistically significant improvement among the studied patients pre and post educational program implementation.In the researcher point of view; this could be due to the effectiveness of nursedirected protocol on improving patients' condition.This finding was supported by Veintramuthu et al., (2019) (55) who mentioned that there was a statistically significant improvement in glycemic control compliance and life style of the studied patients with hypoglycemia..This result was on the same line with Purwanti et al., (2021) (56) who revealed that there was a highly statistically significant difference between pre and post educational program among the studied hypoglycemic patients .Moreover, There are no significant differences of relation between sociodemographic characteristics of the studied patients and hypoglycemic manifestation and complication assessment among the studied groups.This study was similar to a study conducted in Saudi Arabia by Almigbal, (2021) (57) who studies " Association between knowledge of hypoglycemia and likelihood of experiencing hypoglycemia among patients with insulin-treated diabetes mellitus" and revealed that there was no statistically significant relation between the studied patients' demographic characteristics and their clinical manifestation of hypoglycemia with age mean±SD 39.54 ± 15.20 years.This result was agreed with Samya et al., (2019) (38) who mentioned that there was no statistically significant relation between the studied patients' gender and their hypoglycemia level and reported that highest mean scores for the hypoglycemic manifestation among male patients where the meanSD was 5.843.21.This study was disagreed with Kahsay et al., (2019) (58) who mentioned that there was a statistically significant association between the studied patients' age, gender and their hypoglycemic events .This finding was in agreement with AlTowayan et al., (2023) (43) who stated that there was no statistically significant difference between the studied patients' marital status and their Vol.31.No. 4 (Suppl 1) ,November 2023 hypoglycemia This finding was in disagreement with Gilmore et al., (2022) (59) who studied "Evaluation of the efficacy of a hypoglycemia protocol to treat severe hypoglycemia" and represented that there was a statistically significant difference between control group and the studied patients' age and their hypoglycemic prognosis.This study was agreed with Shea et al., (2019) (51) .who mentioned that there was no statistically significant relation between the studied patients' gender and their hypoglycemia outcome .This result was supported by Hasse et al., (2020) (60) who carried out a study entitled "Nurse-driven intervention using real-time data to improve hypoglycemia rates in a respiratory care unit" and reported that there was no statistically significant difference between the studied patients' and control group's marital status and their hypoglycemic rates and outcomes.Regarding correlation between monitoring of hypoglycemic manifestation and complications of the studied patients among the studied groups, the current study revealed that, there was a high positive correlation among the control group regarding the total monitoring of hypoglycemic manifestation and total monitoring of hypoglycemic complications.Also, a high negative correlation was observed among the study group regarding the total monitoring of hypoglycemic manifestation and total monitoring of hypoglycemic complications post 2 weeks.In addition, it was found that there was a significant positive correlation between monitoring of hypoglycemic manifestation and complications score of control group on the admission.Also, it was a significant positive correlation between monitoring of hypoglycemic manifestation and complications score of control group on the admission as and also, it was monitoring of hypoglycemic complications on admission, post a week, post 2 weeks.In the researcher point of view; monitoring of hypoglycemic manifestation helping for preventing to hypoglycemic complication; The greater the relationship between monitoring hypoglycemic manifestation, the less hypoglycemic complications will be occurring.This study was in agreement with Mattathil, (2022) (61) who mentioned that there was positive correlation between hypoglycemia episodes and hypoglycemia, consequences and outcomes among study group post 4 weeks of bundle implementation.Also, this finding was supported by Gilmore et al., (2021) (59) who there was positive correlation between hypoglycemia severity, complications and outcomes of hypoglycemia pre hypoglycemia protocol .

Conclusion
Based on findings of the present study, it can be concluded that: The present study showed that, there was no significant difference among patients of the control group and the study group regarding heart rate and blood pressure on admission, post a week, post 2 weeks.While, there was a statistically significant difference between patients in the study group regarding level of consciousness, blood glucose measurements on admission, post a week, post 2 weeks.Also, there was a statistically significant difference between patients in the control and study group regarding present hypoglycemic manifestation and complications assessment on admission, post a week, post 2 weeks.Additionally, there was positive correlation between hypoglycemic manifestation and complications on admission.Finally, concluded that, the nursing-directed protocol had positive effect on decreasing hypoglycemic episode by improving blood glucose level, reducing hypoglycemic manifestations and complications.

Recommendations
Based on the findings of the present study, the following can be recommended: Vol. 31.No. 4 (Suppl 1) ,November 2023 -Studying hypoglycemic episodes more broadly in the nursing specialty.-Replication of the same study on larger probability sample at different geographical locations for data generalizability.-Future studies should target diverse populations in order to test whether similar factors are similarly important for occurrence of hypoglycemic episodes.

# More than one answer was chosen Table (3): Distribution of the studied patients regarding their clinical data .
# More than one answer was chosen.

): Mean scores of monitoring of hypoglycemic manifestations and complications of the studied patients throughout period of study. Monitoring of Hypoglycemic manifestation and complications The studied patients (n=60) Range Mean  SD Study group F P Control group F P On Admissio n Post a week Post 2 weeks On admission Post a week Post 2 weeks
* Significant