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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