{"id":1013,"date":"2015-06-18T15:14:47","date_gmt":"2015-06-18T19:14:47","guid":{"rendered":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/hypoglycemia-protocol\/"},"modified":"2019-09-30T14:32:16","modified_gmt":"2019-09-30T18:32:16","slug":"9-3-hypoglycemia-and-hyperglycemia","status":"publish","type":"chapter","link":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/chapter\/9-3-hypoglycemia-and-hyperglycemia\/","title":{"raw":"9.3 Hypoglycemia and Hyperglycemia","rendered":"9.3 Hypoglycemia and Hyperglycemia"},"content":{"raw":"The overlapping symptoms of hypo- and\u00a0hyperglycemia (e.g., hunger, sweating, trembling, confusion, irritability, dizziness, blurred vision) make the two conditions difficult to distinguish from one another (Pardalis, 2005). Since the treatment is different\u00a0for each condition, it is critical to test the patient's blood glucose\u00a0when symptoms occur. The\u00a0risk factors that may have led to the condition and the\u00a0recent medical history of the patient also help\u00a0to\u00a0determine the cause of symptoms.\r\n<h2>Hypoglycemia<\/h2>\r\nHypoglycemia is a condition\u00a0occurring in diabetic patients with\u00a0a blood glucose\u00a0of less than 4 mmol\/L.\u00a0If glucose continues to remain low and is not rectified through treatment, a change in the patient\u2019s mental status will result. Patients with hypoglycemia become confused and experience headache. Left untreated, they will\u00a0progress into semi-consciousness and unconsciousness, leading rapidly to brain damage. Seizures may also occur.\r\n\r\nCommon initial symptoms of hypoglycemia include:\r\n<ul>\r\n \t<li>Cold, clammy skin<\/li>\r\n \t<li>Weakness, faintness, tremors<\/li>\r\n \t<li>Headache, irritability, dullness<\/li>\r\n \t<li>Hunger, nausea<\/li>\r\n \t<li>Tachycardia, palpitations<\/li>\r\n<\/ul>\r\nThese symptoms will progress to\u00a0mood or behaviour changes, vision changes, slurred speech, and unsteady gait if the hypoglycemia is not properly managed.\r\n\r\nThe hospitalized patient with type 1 or type 2 diabetes is at an increased risk for developing hypoglycemia. Potential causes of hypoglycemia in a hospitalized diabetic patient include:\r\n<ul>\r\n \t<li>Receiving insulin and some oral antidiabetic medications (e.g., glyburide)<\/li>\r\n \t<li>Fasting for tests and surgery<\/li>\r\n \t<li><span style=\"line-height: 1.5\">Not following prescribed diabetic diet<\/span><\/li>\r\n \t<li>New medications or dose adjustments<\/li>\r\n \t<li>Missed snacks<\/li>\r\n<\/ul>\r\nHypoglycemia is a medical emergency that must be treated immediately. An initial blood glucose reading may confirm suspicion of hypoglycemia.\u00a0If you suspect that your patient is hypoglycemic, obtain a blood glucose level through skin puncture. A 15 g oral dose of glucose should be given to produce an increase in blood glucose\u00a0of approximately 2.1 mmol\/L in 20 minutes\u00a0(Canadian Diabetes Association, 2013). Table 9.2 outlines an example of a protocol that may be used in the treatment of hypoglycemia.\r\n<table>\r\n<tbody>\r\n<tr>\r\n<td style=\"border: 1px solid #000000\" colspan=\"4\">\r\n<h3 style=\"text-align: center\">Table 9.2 Hypoglycemia Treatment<\/h3>\r\n<h5 style=\"text-align: center\"><em>Disclaimer: This is one example of a hypoglycemia protocol. Always follow the protocol of your agency.<\/em><\/h5>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000;text-align: center\">\r\n<h4 style=\"text-align: center\">Capillary Blood Gas (CBG)<\/h4>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;text-align: center\">\r\n<h4 style=\"text-align: center\">Able to Swallow<\/h4>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;text-align: center\">\r\n<h4 style=\"text-align: center\">Patient Is Not Able to Swallow but Has<strong>\u00a0IV Access<\/strong><\/h4>\r\n<\/td>\r\n<td style=\"border: 1px solid #000000;text-align: center\">\r\n<h4 style=\"text-align: center\">Patient Is Able to Swallow\u00a0 but Has No IV Access<\/h4>\r\n<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000\">\u2265 4 mmol\/L<\/td>\r\n<td style=\"border: 1px solid #000000\">No treatment necessary<\/td>\r\n<td style=\"border: 1px solid #000000\">No treatment necessary<\/td>\r\n<td style=\"border: 1px solid #000000\">No treatment necessary<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000\">2.2 to 3.9 mmol\/L<\/td>\r\n<td style=\"border: 1px solid #000000\">Give 15 g of glucose in the form of:\r\n<ul>\r\n \t<li>3 to 5 dextrose\/glucose tabs (check the label) (best choice), OR<\/li>\r\n \t<li>175 ml of juice or soft drink (containing sugar), OR<\/li>\r\n \t<li>1 tablespoon of honey, OR<\/li>\r\n \t<li>3 tablespoons of table sugar dissolved in water<\/li>\r\n<\/ul>\r\n<div title=\"Page 3\" class=\"page\">\r\n<div class=\"section\">\r\n<div class=\"layoutArea\">\r\n<div class=\"column\">\r\n\r\n<strong>Note:<\/strong>\u00a0Milk, orange juice, and glucose gels increase blood glucose (BG) levels more slowly and are not the best\u00a0choice unless the above alternatives are not available.\r\n\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\nRepeat CBG every 15 to 20 minutes and repeat above if BG remains below 4 mmol\/L.\r\n\r\nOnce BG reaches 4 mmol\/L, give patient 6 crackers and 2 tablespoons of peanut butter. If meal is less than 30 minutes away, omit snack and give patient meal when it is available.<\/td>\r\n<td style=\"border: 1px solid #000000\">Notify physician.\r\n<div>Give 10 to 25 g (20 to 50 ml) of <strong>D50W<\/strong> (dextrose 50% in water) of glucose intravenously over 1 to 3 minutes,\u00a0OR\u00a0as per agency policy.<\/div>\r\nRepeat CBG every 15 to 20 minutes until\u00a04 mmol\/L.\r\n\r\nContinue with BG readings every 30 minutes for 2 hours.<\/td>\r\n<td style=\"border: 1px solid #000000\">Notify physician.\r\n\r\nGive glucagon 1 mg subcutaneously (SC) or intramuscularly (IM).\r\n\r\nPosition patient on side.\r\n\r\nRepeat CBG every 15 to 20 minutes. Give second dose of glucagon 1 mg SC or IM if BG remains below 4 mmol\/L.<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000\">\u2264 2.2 mmol\/L<\/td>\r\n<td style=\"border: 1px solid #000000\">Call lab for STAT BG\u00a0level.\r\n\r\nContinue as above.<\/td>\r\n<td style=\"border: 1px solid #000000\">Call lab for STAT BG level.\r\n\r\nContinue as above.<\/td>\r\n<td style=\"border: 1px solid #000000\">Call lab for STAT BG level.\r\n\r\nContinue as above.<\/td>\r\n<\/tr>\r\n<tr>\r\n<td style=\"border: 1px solid #000000\" colspan=\"4\">Data source: Canadian Diabetes Association, 2013; Pardalis, 2005; Rowe et al., 2015; Vancouver Coastal Health, 2009<\/td>\r\n<\/tr>\r\n<\/tbody>\r\n<\/table>\r\n<h2>Hyperglycemia<\/h2>\r\n<div title=\"Page 2\" class=\"page\">\r\n<div class=\"section\">\r\n<div class=\"layoutArea\">\r\n<div class=\"column\">\r\n\r\nHyperglycemia occurs when blood glucose values are greater than 7 mmol\/L in a fasting state or greater than 10 mmol\/L two hours after eating a meal (Pardalis, 2005).\u00a0Hyperglycemia is a serious complication of diabetes that\u00a0can result from eating too much food or simple sugar; insufficient insulin dosages; infection, illness, or surgery; and emotional stress. Surgical patients are particularly at risk for developing hyperglycemia due to the surgical stress response (Dagogo-Jack &amp; Alberti, 2002; Mertin et al., 2007). Classic symptoms of hyperglycemia include the three Ps: polydipsia, polyuria, and polyphagia.\r\n\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\n<\/div>\r\nThe common symptoms of hyperglycemia are:\r\n<ul>\r\n \t<li>Increased urination\/output (polyuria)<\/li>\r\n \t<li>Excessive thirst (polydipsia)<\/li>\r\n \t<li>Increased appetite (polyphagia), followed by lack of appetite<\/li>\r\n \t<li>Weakness, fatigue<\/li>\r\n \t<li>Headache<\/li>\r\n<\/ul>\r\nOther symptoms include\u00a0glycosuria, nausea and vomiting, abdominal cramps, and progression to diabetic ketoacidosis (DKA).\r\n\r\nPotential causes of hyperglycemia in a hospitalized patient include:\r\n<ul>\r\n \t<li>Infection<\/li>\r\n \t<li>Stress<\/li>\r\n \t<li>Increased intake\u00a0of calories (IV or diet)<\/li>\r\n \t<li>Decreased exercise<\/li>\r\n \t<li>New medications or dose adjustments<\/li>\r\n<\/ul>\r\nNote that testing blood glucose levels too soon after eating will result in higher blood glucose readings. Blood glucose levels should be taken one to two\u00a0hours after eating.\r\n\r\nIf hyperglycemia is not treated, the patient is at risk for developing DKA.\u00a0This is a life-threatening condition in which the body produces acids, called ketones, as a result of breaking down fat for energy. DKA occurs when insulin is extremely low and blood sugar is extremely high.\r\n<p class=\"features-content-body-copy-serif-body-copy\">DKA presents clinically with symptoms of hyperglycemia as above, Kussmaul respiration (deep, rapid, and laboured\u00a0breathing that is the result of the body attempting to blow off excess carbon dioxide to compensate for the metabolic acidosis), acetone-odoured breath, nausea, vomiting, and abdominal pain (Canadian Diabetes Association, 2013). Patients in DKA also undergo osmotic diuresis. They pass large amounts of urine because of the high solute concentration of the blood and the body\u2019s attempts to get rid of excess sugar.<\/p>\r\n<p class=\"features-content-body-copy-serif-body-copy\">DKA is treated with the administration of fluids and electrolytes such as sodium, potassium, and chloride, as well as insulin. Be alert for vomiting and monitor cardiac rhythm.\u00a0Untreated DKA can be fatal.<\/p>\r\n<p class=\"features-content-body-copy-serif-body-copy\">Patients with hyperglycemia may also exhibit a non-ketotic hyperosmolar state, also known as hyperglycemic hyperosmolar syndrome (HHS). This is a serious diabetic emergency that carries a mortality rate of\u00a010% to 50%. Hyperosmolarity is a condition in which the blood has a high sodium and glucose concentration, causing water to move out of the cells into the bloodstream.<\/p>\r\nFurther information on the treatment of DKA and HHS can be found\u00a0on the <a href=\"http:\/\/guidelines.diabetes.ca\/Browse\/Chapter15\" target=\"_blank\" rel=\"noopener\">Canadian Diabetes Association clinical guidelines website<\/a>.\r\n<div class=\"bcc-box bcc-info\">\r\n<h3 style=\"text-align: center\">Critical Thinking Exercises<\/h3>\r\n<ol>\r\n \t<li>At 0930 hours, your diabetic patient complains of feeling faint.\u00a0You\u00a0check his blood sugar and get a reading of 2.8 mmol\/L. What actions will you take?<\/li>\r\n \t<li>What blood glucose level range do you expect immediately post-operatively from your patient who has type 2 diabetes? Why?<\/li>\r\n<\/ol>\r\n<\/div>","rendered":"<p>The overlapping symptoms of hypo- and\u00a0hyperglycemia (e.g., hunger, sweating, trembling, confusion, irritability, dizziness, blurred vision) make the two conditions difficult to distinguish from one another (Pardalis, 2005). Since the treatment is different\u00a0for each condition, it is critical to test the patient&#8217;s blood glucose\u00a0when symptoms occur. The\u00a0risk factors that may have led to the condition and the\u00a0recent medical history of the patient also help\u00a0to\u00a0determine the cause of symptoms.<\/p>\n<h2>Hypoglycemia<\/h2>\n<p>Hypoglycemia is a condition\u00a0occurring in diabetic patients with\u00a0a blood glucose\u00a0of less than 4 mmol\/L.\u00a0If glucose continues to remain low and is not rectified through treatment, a change in the patient\u2019s mental status will result. Patients with hypoglycemia become confused and experience headache. Left untreated, they will\u00a0progress into semi-consciousness and unconsciousness, leading rapidly to brain damage. Seizures may also occur.<\/p>\n<p>Common initial symptoms of hypoglycemia include:<\/p>\n<ul>\n<li>Cold, clammy skin<\/li>\n<li>Weakness, faintness, tremors<\/li>\n<li>Headache, irritability, dullness<\/li>\n<li>Hunger, nausea<\/li>\n<li>Tachycardia, palpitations<\/li>\n<\/ul>\n<p>These symptoms will progress to\u00a0mood or behaviour changes, vision changes, slurred speech, and unsteady gait if the hypoglycemia is not properly managed.<\/p>\n<p>The hospitalized patient with type 1 or type 2 diabetes is at an increased risk for developing hypoglycemia. Potential causes of hypoglycemia in a hospitalized diabetic patient include:<\/p>\n<ul>\n<li>Receiving insulin and some oral antidiabetic medications (e.g., glyburide)<\/li>\n<li>Fasting for tests and surgery<\/li>\n<li><span style=\"line-height: 1.5\">Not following prescribed diabetic diet<\/span><\/li>\n<li>New medications or dose adjustments<\/li>\n<li>Missed snacks<\/li>\n<\/ul>\n<p>Hypoglycemia is a medical emergency that must be treated immediately. An initial blood glucose reading may confirm suspicion of hypoglycemia.\u00a0If you suspect that your patient is hypoglycemic, obtain a blood glucose level through skin puncture. A 15 g oral dose of glucose should be given to produce an increase in blood glucose\u00a0of approximately 2.1 mmol\/L in 20 minutes\u00a0(Canadian Diabetes Association, 2013). Table 9.2 outlines an example of a protocol that may be used in the treatment of hypoglycemia.<\/p>\n<table>\n<tbody>\n<tr>\n<td style=\"border: 1px solid #000000\" colspan=\"4\">\n<h3 style=\"text-align: center\">Table 9.2 Hypoglycemia Treatment<\/h3>\n<h5 style=\"text-align: center\"><em>Disclaimer: This is one example of a hypoglycemia protocol. Always follow the protocol of your agency.<\/em><\/h5>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000;text-align: center\">\n<h4 style=\"text-align: center\">Capillary Blood Gas (CBG)<\/h4>\n<\/td>\n<td style=\"border: 1px solid #000000;text-align: center\">\n<h4 style=\"text-align: center\">Able to Swallow<\/h4>\n<\/td>\n<td style=\"border: 1px solid #000000;text-align: center\">\n<h4 style=\"text-align: center\">Patient Is Not Able to Swallow but Has<strong>\u00a0IV Access<\/strong><\/h4>\n<\/td>\n<td style=\"border: 1px solid #000000;text-align: center\">\n<h4 style=\"text-align: center\">Patient Is Able to Swallow\u00a0 but Has No IV Access<\/h4>\n<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000\">\u2265 4 mmol\/L<\/td>\n<td style=\"border: 1px solid #000000\">No treatment necessary<\/td>\n<td style=\"border: 1px solid #000000\">No treatment necessary<\/td>\n<td style=\"border: 1px solid #000000\">No treatment necessary<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000\">2.2 to 3.9 mmol\/L<\/td>\n<td style=\"border: 1px solid #000000\">Give 15 g of glucose in the form of:<\/p>\n<ul>\n<li>3 to 5 dextrose\/glucose tabs (check the label) (best choice), OR<\/li>\n<li>175 ml of juice or soft drink (containing sugar), OR<\/li>\n<li>1 tablespoon of honey, OR<\/li>\n<li>3 tablespoons of table sugar dissolved in water<\/li>\n<\/ul>\n<div title=\"Page 3\" class=\"page\">\n<div class=\"section\">\n<div class=\"layoutArea\">\n<div class=\"column\">\n<p><strong>Note:<\/strong>\u00a0Milk, orange juice, and glucose gels increase blood glucose (BG) levels more slowly and are not the best\u00a0choice unless the above alternatives are not available.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<p>Repeat CBG every 15 to 20 minutes and repeat above if BG remains below 4 mmol\/L.<\/p>\n<p>Once BG reaches 4 mmol\/L, give patient 6 crackers and 2 tablespoons of peanut butter. If meal is less than 30 minutes away, omit snack and give patient meal when it is available.<\/td>\n<td style=\"border: 1px solid #000000\">Notify physician.<\/p>\n<div>Give 10 to 25 g (20 to 50 ml) of <strong>D50W<\/strong> (dextrose 50% in water) of glucose intravenously over 1 to 3 minutes,\u00a0OR\u00a0as per agency policy.<\/div>\n<p>Repeat CBG every 15 to 20 minutes until\u00a04 mmol\/L.<\/p>\n<p>Continue with BG readings every 30 minutes for 2 hours.<\/td>\n<td style=\"border: 1px solid #000000\">Notify physician.<\/p>\n<p>Give glucagon 1 mg subcutaneously (SC) or intramuscularly (IM).<\/p>\n<p>Position patient on side.<\/p>\n<p>Repeat CBG every 15 to 20 minutes. Give second dose of glucagon 1 mg SC or IM if BG remains below 4 mmol\/L.<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000\">\u2264 2.2 mmol\/L<\/td>\n<td style=\"border: 1px solid #000000\">Call lab for STAT BG\u00a0level.<\/p>\n<p>Continue as above.<\/td>\n<td style=\"border: 1px solid #000000\">Call lab for STAT BG level.<\/p>\n<p>Continue as above.<\/td>\n<td style=\"border: 1px solid #000000\">Call lab for STAT BG level.<\/p>\n<p>Continue as above.<\/td>\n<\/tr>\n<tr>\n<td style=\"border: 1px solid #000000\" colspan=\"4\">Data source: Canadian Diabetes Association, 2013; Pardalis, 2005; Rowe et al., 2015; Vancouver Coastal Health, 2009<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n<h2>Hyperglycemia<\/h2>\n<div title=\"Page 2\" class=\"page\">\n<div class=\"section\">\n<div class=\"layoutArea\">\n<div class=\"column\">\n<p>Hyperglycemia occurs when blood glucose values are greater than 7 mmol\/L in a fasting state or greater than 10 mmol\/L two hours after eating a meal (Pardalis, 2005).\u00a0Hyperglycemia is a serious complication of diabetes that\u00a0can result from eating too much food or simple sugar; insufficient insulin dosages; infection, illness, or surgery; and emotional stress. Surgical patients are particularly at risk for developing hyperglycemia due to the surgical stress response (Dagogo-Jack &amp; Alberti, 2002; Mertin et al., 2007). Classic symptoms of hyperglycemia include the three Ps: polydipsia, polyuria, and polyphagia.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n<p>The common symptoms of hyperglycemia are:<\/p>\n<ul>\n<li>Increased urination\/output (polyuria)<\/li>\n<li>Excessive thirst (polydipsia)<\/li>\n<li>Increased appetite (polyphagia), followed by lack of appetite<\/li>\n<li>Weakness, fatigue<\/li>\n<li>Headache<\/li>\n<\/ul>\n<p>Other symptoms include\u00a0glycosuria, nausea and vomiting, abdominal cramps, and progression to diabetic ketoacidosis (DKA).<\/p>\n<p>Potential causes of hyperglycemia in a hospitalized patient include:<\/p>\n<ul>\n<li>Infection<\/li>\n<li>Stress<\/li>\n<li>Increased intake\u00a0of calories (IV or diet)<\/li>\n<li>Decreased exercise<\/li>\n<li>New medications or dose adjustments<\/li>\n<\/ul>\n<p>Note that testing blood glucose levels too soon after eating will result in higher blood glucose readings. Blood glucose levels should be taken one to two\u00a0hours after eating.<\/p>\n<p>If hyperglycemia is not treated, the patient is at risk for developing DKA.\u00a0This is a life-threatening condition in which the body produces acids, called ketones, as a result of breaking down fat for energy. DKA occurs when insulin is extremely low and blood sugar is extremely high.<\/p>\n<p class=\"features-content-body-copy-serif-body-copy\">DKA presents clinically with symptoms of hyperglycemia as above, Kussmaul respiration (deep, rapid, and laboured\u00a0breathing that is the result of the body attempting to blow off excess carbon dioxide to compensate for the metabolic acidosis), acetone-odoured breath, nausea, vomiting, and abdominal pain (Canadian Diabetes Association, 2013). Patients in DKA also undergo osmotic diuresis. They pass large amounts of urine because of the high solute concentration of the blood and the body\u2019s attempts to get rid of excess sugar.<\/p>\n<p class=\"features-content-body-copy-serif-body-copy\">DKA is treated with the administration of fluids and electrolytes such as sodium, potassium, and chloride, as well as insulin. Be alert for vomiting and monitor cardiac rhythm.\u00a0Untreated DKA can be fatal.<\/p>\n<p class=\"features-content-body-copy-serif-body-copy\">Patients with hyperglycemia may also exhibit a non-ketotic hyperosmolar state, also known as hyperglycemic hyperosmolar syndrome (HHS). This is a serious diabetic emergency that carries a mortality rate of\u00a010% to 50%. Hyperosmolarity is a condition in which the blood has a high sodium and glucose concentration, causing water to move out of the cells into the bloodstream.<\/p>\n<p>Further information on the treatment of DKA and HHS can be found\u00a0on the <a href=\"http:\/\/guidelines.diabetes.ca\/Browse\/Chapter15\" target=\"_blank\" rel=\"noopener\">Canadian Diabetes Association clinical guidelines website<\/a>.<\/p>\n<div class=\"bcc-box bcc-info\">\n<h3 style=\"text-align: center\">Critical Thinking Exercises<\/h3>\n<ol>\n<li>At 0930 hours, your diabetic patient complains of feeling faint.\u00a0You\u00a0check his blood sugar and get a reading of 2.8 mmol\/L. What actions will you take?<\/li>\n<li>What blood glucose level range do you expect immediately post-operatively from your patient who has type 2 diabetes? Why?<\/li>\n<\/ol>\n<\/div>\n","protected":false},"author":397,"menu_order":3,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":"cc-by"},"chapter-type":[],"contributor":[],"license":[50],"class_list":["post-1013","chapter","type-chapter","status-publish","hentry","license-cc-by"],"part":993,"_links":{"self":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/1013","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/users\/397"}],"version-history":[{"count":21,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/1013\/revisions"}],"predecessor-version":[{"id":5158,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/1013\/revisions\/5158"}],"part":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/parts\/993"}],"metadata":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapters\/1013\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/media?parent=1013"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/pressbooks\/v2\/chapter-type?post=1013"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/contributor?post=1013"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.bccampus.ca\/clinicalproceduresforsaferpatientcaretrubscn\/wp-json\/wp\/v2\/license?post=1013"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}