Med/Surg Nursing

Endocrine System-2009

Endocrinologist-specialist (MD) trained in the specialty of endocrine glands and hormones Endocrine disorders are caused by overproduction or underproduction of specific hormones

Dx TEST

Blood, urine tests CT's, xrays Indirect/direct observation (d/t

growth or appearance abnormalities)

Pituitary Function TestXrays, CT's, blood test, urine test

Thyroid Function Test Lab test Several different blood test may be

done Thryoid Scan (Radioscan or

Scintiscan)-client ingests radioactive iodine or IV. A scanogram is then done to determine the amount of radioactive activity in the body. If the thyroid absorbs most of the iodine, the thyroid is then said to be hyperactive. If the thyroid does not absorb the iodine it is then hypoactive

RAIU Test Measures thyroid gland activity A scan is done of the thyroid to

determine how much radioactive material it removes from the bloodstream and absorbs

Check for allergies to shellfish, or iodine

Test can be altered by the use of BCP's, anticoagulants, salicylates and propylthiouracil derivatives

Thyroid Ultrasound Determines the size of the thyroid

gland, its shape and position May be done to monitor the

effectiveness of therapy or evaluate thyroid function during pregnancy

Uses a gel to transmit sound waves that are then interpreted by radiologist or physician

Parathyroid Function Test Lab: serum PH, PTH, phosphate and

calcium levels Urinary calcium and serum alkaline

phosphatase  Other test: US, MRI, biopsy; this can

localize cysts, tumors and hyperplasia (abnormal increase in size)

PTH: increased calcium levels in blood aids in regulating calcium function

Adrenal Function Test Blood Tests: ACTH stimulation test, serum

ACTH test, plasma cortisol test Measured during the diurnal period (0800 and

1600) to determine if the ACTH and plasma cortisol levels are normal

Urine Tests: 24 hour urine specimen to test for vanillylmandelic acid a metabolite of catecholamines ~clonidine suppression test to determine

pheochromocytoma (catecholamine-secreting adrenal tumor)

phentolamine (Regitine) can be given to cause a hypotensive situation , the drop in BP is indicative of pheochromocytoma

Radiographic Evaluations Adrenal angiogram or venogram-

insertion of a catheter and injection of a contrast (dye) so that x-rays can be taken for studies

Complication-allergy to dye Premedicate with Benadryl or Inderal Contraindicated in unstable, pregnant

clients, hemophiliacs, bleeding disorders

General Pancreatic Function Tests

Pancreatic enzymes: lipase (fat digestion), amylase (CHO metabolism)

Elevations suggest pancreatitis

DM Tests Blood test: Fasting plasma glucose or

fasting blood sugar is used for diabetic screening

~Fasting elevation usually indicates DM

~Normal range is 65-115mg/dl (depends on source)

OGTT Timed test to confirm the Dx of

DM, can also diagnose functional hypoglycemia

Plasma glucose levels peak at 169-180 ml within 30 minutes to 1 hour after administration of oral glucose solutions and levels should return to normal in 2-3 hours

Glycosated Hemoglobin (Hb A1c)

Blood sugar reflection over the previous 6-10 weeks

Measurements detect the amount of glucose attached to a portion of the hgb in RBC's

Range should be between 5-8% out of a scale of 13%

Urine Tests

Glucose can spill over into the urine from the blood, acetone is a by-product of faulty metabolism

Most common test is for ketones if blood glucose level is consistently high

Monitor for readings in excess of 240 mg/dl

Keto-Diastix Measures for acetones (ketone

bodies) in urine Buildup of acetone ketones

acidosis Vomiting or excessive perspiration

can alter electrolytes

Pituitary Gland “The Master Gland”

Anterior lobe produces GH ACTH (stress situations) TSH Prolactin FSH LH All of the above are involved in growth,

maturation, and reproduction

Disorders of the Anterior Pituitary Gigantism – children Acromegaly – adults Cause – Overproduction of growth

hormone STH

Gigantism/Acromegaly S/S:

Thick lips Massive lower jaws Bulbous nose Enormous hands and feet Bulging forehead H/A Visual loss Impotence Amenorrhea Facial hair in females (hirsuitism)

Gigantism/Acromegaly Tx: Pituitary irritation

Drugs – parlodel, lowers STH levels Tx can stop progression of disease but can

not alter abnormal growth that has occurred

Posterior Pituitary Secretes: ADH – regulate the passage of H2O

through kidneys Vasopressin Oxytocin

Diabetes Insipidus Lack of production of ADH which regulates passage of water

through the kidneys S/S:

Huge urinary output (15-20 liters in 24 hrs.)

Thirsty Urine SG lowers 1.006 (very dilute

Normal = 1.030) Increased appetite Weakness Tx:

Vasopressin Subq, IM or nasally to control urine output Weigh every day

Disorders of the Posterior Pituitary SIADH

Increase secretion of ADH, unable to excrete dilute urine

Fluid retention and intoxication can occur Cause – CNS disorders, chemo, vasopressin overuse Tx – Monitor I & O

Fluid restriction Hypertonic IV solutions Meds: Declomyein or lithium carbonate

interfere antidiuretic action of ADH

SIADH S/S:

Concentrated urine Edema Decreased urine output HA Wt. gain Decreased LOC (lethargy) Confusion Hyponatremia diarrhea

Disorders of the Posterior Pituitary Pituitary Neoplasms

Gigantism – overgrowth of eosinophilic cells Cushing syndrome – hyperadrenalism from

basophilic tumor Hypopituitarism (pituitary can be destroyed

by chromophobic tumor) Change body temperature Scant, fine body hair Obese Slow movers

Hypophysectomy Surgical removal of the pituitary

To control pain in breast or prostate CaIf malignant tumor is presentDecrease diabetic retinopathy

Postop ICU admit

Pituitary and Adrenocortical Hormones

GH (somatotrophic hormone) Secrete by anterior pituitary and regulates growth Available as somatrem (Protropin) and somatropin

(Humatrope) Recombinant DNA origin and are identical to human GH

and produce skeletal growth in children GH is ineffective in clients with closed epiphysis (allow

for growth) because when the epiphyses close, growth cannot occur

Few adverse reactions – hypothyroidism or insulin resistance, swelling, joint pain and muscle pain may occur.

Contraindications Use caution with sensitivity to benzyl alcohol, clients

with thyroid disease or diabetes and during pregnancy.

Nursing Process Assessment Thorough physical exam Children may increase their growth rate from 3.5-

4 cm/year before treatment to 8-10 cm/year during the first year of treatment

GH is given IM or subq., swirl, don’t shake bottle Periodic testing of GH, thyroid levels may be

done

Patient with Diabetes If blood glucose levels increase or urine is

positive for glucose or ketones, the nurse notifies the primary health care provider. Some patients may have latent diabetes and corticosteroids may precipitate hyperglycemia.

Adrenal Gland Disorders Cushing’s syndrome (hyperadrenalism)

Cause: overproduction of hormones secreted form the adrenal cortex, excessive steroidal use, tumors of the adrenal glands

Steroids may cause hyperglycemia S/S: rounded “moon” face, heavy abdomen that hangs

down, thin arms and legs, backache as the disease worsens, edema, decreased urinary output, hypokalemia, hypernatremia, hyperglycemia, HTN, poor wound healing, ecchymosis, “Buffalo hump”, easy bruising

Lab – elevated cortisol level If develop during childhood, puberty begins early for boys

and the girls develop masculine traits.

Adrenal Gland Disorders (cont.) Tx: depend on cause, removal, of adrenal

gland, adrenocortical hormones are given. Nursing Considerations

Prevent injury and infection Monitor weight, v/s, labs: electrolytes,

glucose levels

Primary Aldosteronism Cause – excessive aldosterone secretion S/S-HTN, muscle weakness secondary to

low potassium levels.

Addison’s Disease Rare Cause-TB, CA, infection or the gland atrophies for

unknown reasons S/S-Decreased production of adrenal hormones

which results in fluid and electrolyte imbalances, hypoglycemia Darkening of the skin and mucosa Dehydration, anemia and wt. Loss BP decreases Thin hair Stress may cause adrenal shock (low BP, n/v/d, h/a,

restless

Addison’s Disease

Addisonian Crisis- function falls to a critically low point

Tx: IV hydrocortisone, IV Florinef to supply electolytes, vasopressors (raise BP), diet high in protein and low in potassium

Addison’s Disease Nursing Considerations

Replace fluid 5-6 small meals/day with snacks Monitor for decreased blood pressure of dizziness Protect from falls Accurate I & O’s including food Specific gravity of urine Daily wt’s Teach importance of follow up visits Protect from stressful situations

Adrenal Neoplasms Pheochromocytoma – benign tumor (usually)

originating from the adrenal medulla This tumor will increase epinephrine and

norepinephrine secretion that results in HTN, h/a, n/v, tremor, dizziness, increased urination.

Tx: surgical removal of tumor (dangerous d/t BP variations), IVP, CT scan may be used to locate the tumor, if a bilateral adrenalectomy of performed, the clients must be treated for Addison’s disease postop

Thyroid Gland Disorders Thyroid secretes T3 and T4

Hyperthyroidism Overproduction of T4 Graves’ disease Exopthalmic or toxic diffuse goiter is most

common Cause is unknown but it is thought to be

manifested by infection, physical or emotional strain, changes r/t puberty or pregnancy

Hyperthyroidism S/S: tremors, tachycardia, SBP elevated,

feel hot, lose weight despite eating, sensitivity to heat Exopthalmos noted in women with Graves’

disease, may lead to blindness, the neck is swollen use artificial tears (need MD order)

If left untreated, may cause nervousness, delirium and death

Hyperthyroidism Tx: medical or surgical

Antithyroid drugs: PTU or methimozole (inhibits synthesis of thyroid hormones) may be given daily over a long time and may have toxic effects.

RAI may be given to destroy the thyroid gland

Thyroidectomy may be done if all else fails

Nursing Considerations: Minimize overactivity, provide calm

environment Provide increased calories-proteins,

vitamin D and B complex, minerals, fluids

Hypothyroidism Deficiency of T4 which slows down the

metabolic process D/T removal of the thyroid gland or a

decrease in its activity Affects women more than men Congenital form of the deficiency is

cretinism; advanced from is myxedema

Hypothyroidism S/S: untreated results in dystrophy of bones and

soft tissues – the person is dwarfed with a large head, short arms and legs, puffy eyes, the skin is dry and movement is uncoordinated

If discovered early, can be treated with T4 replacement and continued for life

Myxedema in adults S/S: slowing physical and mental activity, mask

like expression, dry skin, hoarse and low voice, hair coarse and falls out, weight gain

RAIU uptake is normal and menorrhagia can occur

Hypothyroidism Tx:

Oral thyroid-Armour Thyroid or proloaid may be ordered

Synthetic thyroid hormones may be ordered; Levothroid or Cytomel to supply the deficiency and must be done gradually

Effective treatment will show an increased alertness and appearance will be normal

Hypothyroidism Nursing Considerations:

Focus on improvements in activity tolerance and independence, thyroid deficiency clients are a risk for respiratory depression

F/u visits to PCP If left untreated, may result in myxedema

coma, a medical emergency requiring immediate care

Avoid sedatives, narcotics as these drugs decrease HR and RR, with hypothyroidism, the HR and RR is already low.

Hashimoto's ThyroiditisAutoimmune hypothroidism disorder Simple Goiter-thyroid gland enlarges and fills

with colloid Affects women more than men and usually occurs

during pregnancy, infection or adolescence No harmful affects on health unless it enlarges and

obstructs breathing Diet is deficient in iodine which is needed to produce

thyroid hormones Toxic goiter occurs when there is too much T4

(hyperthyroidism) Tx: Iodine for 2-3 weeks, repeating tx 3-4x/year

Thyroid Neoplasms Liquid or semisolid cyst forming in the

thyroid Aspiration can be performed on a simple

cyst semisolid cyst is usually malignant and

must be removed if thyroid tumor is cancerous, it must be

treated with radioactive isotopes most often thyroid cancers grow slowly

Thyroidectomy Surgical removal of thyroid gland, client will

need thyroid supplements for life About 5/6 of the gland (subtotal thyroidectomy) Thyroid hormone levels must be normal prior to

surgery to reduce the risk of a thyroid storm (Thyroid crisis) Caused by sudden increase in T4; s/s:

tachycardia, anxiety, elevation in v/s, heart failure

Tx: Maintain 02 and glucose levels, reduce fever – place in semi- fowler’s

Lugol’s solution preop to decrease size and vascularity of the gland

Postop Complications Hemorrhage Hematoma Laryngeal nerve damage Edema of glottis Tetany; caused by accidental removal of the

parathyroid glands during surgery Chvostek’s sign-abnormal spasm of the facial muscles in

response to light taps on the facial nerve Trousseau’s sign-carpopedal spasm occuring after inflating

a sphygmomanometer cuff on the upper arm for 3 minutes Serum calcium levels may be low resulting in seizures

and cardiac arrhythmias

Nursing Considerations Avoid excessive physical activity Increase nutritional intake to ensure

adequate calories, vit. D and calcium Semi-fowlers Keep emergency trach set a bedside

Parathyroid Gland Disorders Parathyroid secretes PTH Vitamin D helps PTH regulate calcium and

phosphorous in the blood.

Hyperparathyroidism Excess PTH resulting in a rise of blood calcium

levels Bones are then soft and weak More susceptible to pathologic fractures Muscles become weaker and the client then feels

fatigue, nausea and constipation Kidney stones, UTI’s and uremia develops Dx: high blood level of PTH and by x-rays Diuretics (Lasix; furosemide), may be given to

prevent renal disorders which develop as a result of high blood calcium levels

Hyperparathyroidism Phosphates may be given to reduce the serum

calcium levels Thyroid lobectomy to remove part of the thyroid

gland containing the parathyroid may be done Encourage exercise to help the bones from releasing

some calcium (blood levels are high enough) Limit calcium Postop, tetany may occur and calcium gluconate can

be given Keep trach tray and IV calcium at bedside postop Avoid activities that may result in an injury so that

the bones do not break, they need time to be recalcified

Ca level >10.5

Hypoparathyroidism Deficiency of PTH resulting in lack of available

calcium in the body with phosphorous accumulating in the blood

Cause may be accidental removal of the parathyroid during a thyroidectomy.

Calcium deficiency causes tremors and tetany Cardiac output decreases + Trousseau’s sign or Chvostek’s sign S/S: hair loss, coarse skin, brittle nails,

arrhythmias, possible heart failure Tx: increase serum calcium level using calcium

gluconate (IV), large doses of Vitamin D, administer sedatives or anticonvulsants to prevent seizures.

THYROID AND ANTITHYROID DRUGS

T4 & T3-Iodine is an essential element for the manufacture of both of these hormones

Treat:Hypothroidism & Hyperthyroidism

THYROID AND ANTITHYROID DRUGS USES

Thyroid hormones are used as replacement therapy when the client is hypothyroid

By supplementing the decreased endogenous thyroid production and secretion with exogenous thyroid hormones, and attempt is made to create a euthyroid (normal thyroid)

THYROID AND ANTITHYROID DRUGS Adverse Reactions

During initial therapy, the most common adverse reactions are signs of overdose and hyperthyroidism

THYROID AND ANTITHYROID DRUGS Contraindications

Clients with a known hypersensitivity to the drug

After a recent MI Clients with thyrotoxicosis

Precautions Used carefully in clients with Addison’s

disease and during lactation

Antithyroid Drugs Used to treat hyperthyroidism Strong iodine solutions, radioactive iodine

or surgical removal of some or all of the thyroid gland may be done as well

Strong iodine solutions Adverse reactions-iodism; metallic taste in

the mouth, swelling and soreness of the parotid glands, burning of the mouth and throat, sore teeth and gums, symptoms of a head cold and GI upset

Antithyroid Drugs Nursing process: The nurse observes the client for a thyroid storm-high

fever, extreme tachycardia, AMS which can occur in clients whose hyperthyroidism is inadequately treated

Strong iodine solutions are measured in drops which are added to water or fruit juice (the drug has a strong, salty taste)

Iodine solutions should be drunk through a straw because they can cause tooth discoloration

Radioactive iodine is given by the PCP, orally as a single dose

If the client is hospitalized, radiation safety precautions identified by the hospital’s dept. of nuclear med are followed

When using radioactive iodine, thyroid hormone replacement therapy may be needed if hypothyroidism develops

Nursing Process S/S of hypothyroidism may be confused with

normal aging signs in the geriatric client depression, cold intolerance, weight gain, confusion or unsteady gait.

Full effects of thyroid hormone replacement therapy may not be apparent for several weeks of more, but can be seen in as little as 48 hours

Signs of a therapeutic response – weight loss, mild diuresis, sense of well-being, increased appetite, increased pulse rate, increased mental activity, and decreased puffiness of the face, hands, and feet.

Nursing Process The nurse will report signs of

hyperthyroidism-nervousness, anxiety, increase appetite, elevated body temp, tachycardia, etc.

The nurse monitors the client with diabetes during thyroids hormone replacement therapy for signs of hyperglycemia.

Replacement therapy for life - usually

Pancreatic Endocrine Disorders Hyperinsulinism Hypoinsulinism Diabetes Mellitus Type I and II Gestational diabetes Impaired glucose tolerance

Diabetes Mellitus Islets of Langerhans in the pancreas secrete

insulin If insulin is not available, glucose can’t

enter the body cells and this results in an increase in circulating blood glucose

Classification Type I (IDDM, or juvenile diabetes)

Onset age: under 30 Beta cells are not producing insulin Tx: diet, exercise, oral meds or insulin

Diabetes Mellitus Type II (NIDDM, adult onset diabetes)

Onset age: over 30 Tx: diet, exercise, oral meds or insulin

Gestational Diabetes Occurs during pregnancy only

Impaired fasting glucose (IFG and IGT) Risk factors for diabetes

S/S: most common is the 3 P’s Polyuria Polydipsia Polyphagia Classic sx: fatigue, blurred vision, mood changes, dry

skin, wt. loss, infections, numbness and tingling in extremities.

Diabetes Mellitus TYPE I DM 2 forms Immune mediated – results from an

autoimmune destruction of the pancreatic beta cells.

Idiopathic diabetes – Develops spontaneously, no cause

Type I DM = 5-10% of US cases

Diabetes Mellitus (cont) Will be on INSULIN!!! Goal of tx is to achieve metabolic stabilization,

relieve hyperglycemic symptoms, and restore body weight

Type II DM Usually occurs after age 30, overweight

Pancreas usually produces some insulin at time of diagnosis

May present with decreased tissue sensitivity to insulin known as insulin resistance

May require insulin injections

Diabetes Mellitus More prevalent in African Americans, Native Americans,

and Hispanics Seen more in Women Type II DM may be inherited, cause is unknown,

autoimmune destruction of pancreatic beta cells does not occur

The muscle cells of diabetics can’t take up glucose which leads to increased glucose concentration in the bloodstream (hyperglycemia)

Hyperglycemia gradually develops and symptoms are unnoticed

Increased risk for macrovascular and macrovascular complications

Diabetes Mellitus Goals for Tx: prevent vascular

complications, achieve metabolic control, meal planning, exercise program, wt. loss and medications.

Gestational Diabetes Mellitus Occurs during the 2nd or 3rd trimester of

pregnancy Screened between 24-28 wks gestation Disappears after birth; however,

Have a greater chance of having type II DM later in life

Impaired Glucose Homeostasis Glucose levels above normal but are not high

enough to have diabetes IFG occurs when the FPG is above 110 but less

than 126 mg/dl IGT means that the results of an OGTT are

greater than 140 but less than 200 mg/dl in the 2 hour sample

Client’s with IGH are at risk for diabetes development MI’s, strokes

Requires close glucose monitoring

Treatment Diabetics must maintain carefully planned and

balanced diet, exercise, and medications Goals of Tx:

Relieve sx Maintain normal wt. and activity Maintain glucose levels between 70-140 mg/dl Hgb A1C levels less than 7%

Prevent LT and ST complications Prevent hypo/hyperglycemic reactions

Nutrition Therapy Individualized Establish baseline-degree of diabetic

management, any complications?? Teach and encourage diet maintenance Obtain glucose levels before meals CHO counting-blood glucose levels are affected

by the CHO’s in foods, total amount of CHO is more important than the source

Nutrition Therapy The starch/breads, milk and fruits have been labeled as

CHO’s; these food groups can be interchanged in a single meal CHO counting diets – consult with dietician, 3 levels

involved Diabetes Food Guide Pyramid Diabetic Exchange List developed by the American diabetic

association and in conjunction with the American dietetic association Food in this group contains approximately equal contain

approximately equal amounts of kcal, CHO, protein, and fats

This means that any one food on a list can be substituted for any other food on a particular list

Nutrition Therapy Fiber can reduce the amount of insulin

needed because it lowers blood glucose levels by lowering the cholesterol and triglyceride levels Sucralose is the approved sweetener of the

FDA

Nutrition Therapy Exercise

Important for the diabetic Increases circulation Controls weight Decreases blood pressure Reduced stress Assists in blood glucose regulations by

increasing insulin receptor sites and stimulation glucagons production

Nutrition Therapy Diabetics who use medications to control

their glucose levels, need to know when and how often to exercise as exercise can cause HYPOGLYCEMIA

Also need to maintain proper hydration as dehydration can affect glucose levels

Insulin Available as purified extracts from beef

and pork pancreas (used infrequently) Synthetic insulins, such a human insulin and

insulin analogs Activates a process that helps glucose

molecules enter the cells Stimulates the liver glycogen synthesis

Insulin Onset – when insulin first begins to act in

the body Peak - when insulin exerts maximum

action Duration – the length of time the insulin

remains in the body.

Insulin When insulin is combined with protamine

(protein), the absorption of insulin from the injection site is slowed and the duration of action is prolonged.

The addition of zinc also modifies the onset and duration action of insulin.

Insulin is needed to control Type I DM.

Insulin Adverse Rxn’s

Allergy to the animal from which the incluin is obtained or to the protein or zinc added to the insulin

Human insulin or purified insulin is used to decrease the possibility of adverse reactions

Hypo/Hyperglycemia

Insulin Nursing Process:

Insulin doses are individualized Care must be taken to give the correct insulin

and dosage Insulin can be administered SubQ, or IV

(Humulin R only) Insulin lispro is given 15 minutes before a

meal or immediately after a meal.

Insulin When mixing insulin's, the short acting insulin is drawn

up first FYI – when mixing insulin, the insulin must be given

within 5 minutes of with drawing the two insulin from the vials

Liposdystrophy-atrophy of SubQ fat, appearance of pitting or dimpling of SubQ fat, interferes with the absorption of insulin from the injection site; insulin injection sites must be rotated.

Glycosylated hemoglobin (HbA1c) is used to monitor the average blood sugar over a 3-4 month period

Normal levels vary but generally you want the level to be between 2.5% and 6%, this level indicates a good control over diabetes

Insulin Storage of Insulin

Keep at room temp, away from heat and light if used in 1 month, keep in refrigerator for 3 months, vials not in use are stored in the refrigerator

Insulin Therapy Given subq-insulin is destroyed by

digestive enzymes What does insulin do?

Enables glucose to cross the cell membrane for use be the cell

Helps liver convert glucose to glycogen use of 02 by the cells

No 02? Increase confusion Lower ability to think

Insulin Therapy Types of Insulin

Rapid-acting Regular Clear Onset = ½ ° - 1 ° Peak action - 2 ° - 4 ° Duration = 5 ° - 7 ° Hypoglycemia reaction = before lunch Mixes with all other insulins Can be given IV

Insulin Therapy Intermediate – acting

NPHCloudyOnset= 1° - 2 °Peak action = 6 ° - 12 °Duration= 24 °Hypoglycemia reaction = night and early

a.m.

Insulin Therapy Long Acting

Humulin UCloudyOnset = 6 °Peak action = 16-18 °Duration = 36 °+Hypoglycemia reaction = night and early

a.m.

Insulin Therapy Care of insulin

RefrigerateAvoid excessive hear or lightDO NOT FREEZEMay mix Regular with all types of InsulinRoll vial – DO NOT SHAKECheck expiration dateCheck with another nurseDraw up regular THEN NPH

“clear to partly cloudy” If insulin clumpy – discard

Insulin Therapy Nursing Guidelines

Always get an order to give if pt. is NPODo FSBS before giving insulin

DO NOT USE a 3-cc syringe-use only insulin syringes

Give subq at 90° angle and withdraw needle at 90 ° angle

Document BS and insulinAssess for signs/symptoms of hypo-

hyperglycemia

Insulin Therapy Coverage

D.M. may be out of control during illnessSliding scale of regular insulin based on

B.S. Insulin requirements during illness and

stressUsually checked for coverage

AC lunch AC dinner HS

Insulin Therapy Insulin Pump

MechanicalInjects insulin automaticallyTries to maintain a constant blood

levelMay bolus prior to eatingBuffered insulin in used

Insulin TherapyComplications Hypoglycemia

(insulin shock) Too much

insulin in relation to the amount of available glucose

S/S Weak Cold Tired Hungry Nervous/

tingling/trembling

Perspiring HA N/V Blurred

vision Seizures LOC

decreased Death <70 mg/dl

blood glucose

Hypoglycemia Treatment and Nsg. Considerations

Develops rapidly CHO needed to counteract insulin reaction Client Conscious – give sugar – OJ, soft drink, honey,

candy Unconscious – give glucagons IV IM or 50% Dextrose IV Somogyi phenomenon – hypoglycemia followed by a

rebound hyperglycemia as the body attempts to correct the problem

Develops lat at night or early am Tx – reduce insulin dosage until glucose level achieved

DKA Hyperglycemia (Diabetic Ketoacidosis)

To little insulin available for use Glucose cannot enter muscle cells Fats and proteins are broken down into ketones as an

alternative energy source These ketones are sent to the cells for use If too many ketones accumulate (ketones), an

electrolyte imbalance will occur Ketoacidosis where acetone is also produced

DKA Ketone bodies are formatted in any

condition which interferes with the Storage of glycogen in the liver or Increase the body’s need to burn fat for

energy

DKA S/S

Slow onset Weakness, drowsiness Vomiting Thirst Dehydration Flushed cheeks Dry skin and mouth Sweet odor to breath Increase respirations

Without tx- Dizziness Confusion loss of

speech Blurred vision Seizures Loss of consciousness ^ BP ^ pulse Brain damage Death

DKA Tx:

IVF InsulinWarm blankets IV-regular insulinLower production of ketones> makes more

CHO’s available to tissues.

NKHOS – Nonketonic Hyperosmolar State Glucose 1,000/dl and above Occures in older adults most often Mortality rate high Causes include – age, stress undiagnosed

hyperosmolarity, coma Tx – continuous low – dose insulin infusion,

aggressive IVF Nsg. Care – administer IVF’s monitor I & O,

daily wt., monitor glucose levels frequently

NKHOS

Infections R/T vessel wall damage due to increased

blood sugar DM client susceptible to yeast and fungal

infections, colds, flu, carbuncles and furuncles

Nsg. role—injury prevention

NKHOS

Laboratory Evaluation of DKA vs NKH

DKA NKHPlasma Glucose Elevated Very HighpH Below 7.3 Above 7.3Bicarbonate <15 meq/1 >20mEq/LSerum ketones Present NegativeKetonuria Present NegativeOsmolarity Varies Very HighInsulin Levels Very Low Can be normal

NKHOS Post op – surgical risk

Difficulty regulating B.S. Circulatory Problems Decreased healing ability Increased infections

Diabetes Macrovascular complications

Increased glucose levels may increase arteriosclerosis in LE’s, vessels of heart and kidneys HTN, CAD, PVD, MI, stroke can result from

arteriosclerosis DM clients are 2-6 times more likely to have a

stroke and 2 times as likely to have an MI Assess for skin breakdown and teach clients to

assess for breakdown esp. on FEET!!

Diabetes Microvascular Complications

Diabetes causes changes in the capillary walls, resulting in decreased blood flow and poor 02 to highly vascular tissuesRetina and kidneys are primarily

affected

Diabetes Nephropathy-kidney disease that may

result in death caused by kidney failure Kidney infections or albumin or blood

in the urine are the first indications of nephropathy

Tx: slow approach, control BP, control blood sugar levels and diet

Diabetes Retinopathy – a leading cause of blindness

in this country caused by diabetes Loss of the functional retinal tissue d/t

microvascular damage Yearly eye exams Damage cannot be reversed

Diabetes Neuropathy – nerve damage

Long term complication of poorly controlled diabetes

Peripheral neuropathy Begins as tingling and numbness in the toes and

progresses gradually to the ankle and then leg. Can be painful or numb Tx-Elavil, Tegretol, Dilantin Autonomic neuropathy-can result in impotence

intestinal involvement, urinary retention, stomach involvement, orthostasis

These are treated based on the symptoms

Client Teaching Education is very important ! There is NO cure for diabetes!! Diabetes is only controlled or managed:

Person feels well Maintain balanced diet and normal wt. Blood glucose level 70-140 mg/dl Carry rapid – acting sugar with you at all

times

Client Teaching Long-term complications can be reduced

by controlling the blood glucose level Need regular care involving their feet,

hands, teeth, and eyes. Clients will be responsible for managing

foods, blood testing, exercise, and medication administration

Client Teaching Physician will plan a medication schedule,

exercise program and diet management Type 1 DM – clients will test their urine for

ketones Clients will notify MD if glucose level is above

240 mg/dl for 3 days Meal plans are individualized with assistance

from a dietician Foods containing sugar are not prohibited but

must be included in their CHO intake

Client Teaching Lifestyle factors – exercise lowers glucose

levels, be careful to make sure glucose level does not drop too much.

Smoking should be avoided d/t vasoconstrictor effect of nicotine

Insulin needs to be taught to the client; dosages, onset, peak and duration times, storage of the battle, etc. Rotate injection sites to keep skin healthy and

prevent lipodystophy

Diabetics Know the s/s of each!! Know how to manage them!! Encourage the client to carry CHO snacks with

them-hard candy, glucose tablets, cheese and peanut butter.

Glucagon/glucose emergency kit should be carried for those who receive insulin

Encourage client to wear a medic alert bracelet.

Diabetics Sexuality

Diabetic men may have erectile dysfunction

Cause is neurogenic May need to use penile implants or

prostheses, or oral meds - Viagra

Diabetics Exposure to Cold

Cold slows blood circulation Diabetics are at risk for hypothermia or

frostbite

Diabetics Vision Impairment

Annual eye exams Strategically place furniture to

avoid falls

Diabetics Dental Exam

Regular dental exams Dental caries can lead to infection

and alter glucose levels

Diabetics Foot Care

At risk d/t poor circulation and decreased sensation

Traveling Consult MD before traveling long distances Consider diet and exercise

Identification MedicAlert tags

Nursing Process: Observe client every 2-4 hours for symptoms of

hypoglycemia once therapy has been initiated Exposed to stress, infection, fever, surgery, or

trauma may increase the blood sugar levels requiring the use of insulin vs. oral drugs

Take the drug exactly as prescribed, at the same time/times each day, don’t skip meals, avoid alcohol

Client’s must monitor glucose before and after exercise, ingest extra CHO’s if glucose levels are under 100 mg/dl