Endocrine System Review for Nursing Module PDF

NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*MEDTECH LET*PSYCHOMET*RESPIRATORY THERAPY*CIVIL SERVICE*NAPOLCOM NCLEX*DHA*HAAD* PROMETRIC* UK-CBT ENDOCRINE SYS...

NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*MEDTECH LET*PSYCHOMET*RESPIRATORY THERAPY*CIVIL SERVICE*NAPOLCOM NCLEX*DHA*HAAD* PROMETRIC* UK-CBT ENDOCRINE SYSTEM MAJOR COMPONENTS Glands- secrete their products directly into the chemical substances secreted by the endocrine glands. Hormones- chemical substances secreted by the endocrine glands. Target cells/ receptor FUNCTIONS OF HORMONES Regulates and integrates body’s metabolic activities. Functions together with the nervous system. ENDOCRINE GLANDS HYPOTHALAMUS Produce and secrete pro- hormones (hormones that stimulate or inhibit production/ release of pituitary hormones.) Hormones: Releasing and inhibiting hormones o Corticotropin- releasing hormone (CRH) o Thyrotropin- releasing hormone (TRH) o Growth hormone- releasing hormone (GHRH) o Gonadotropin- releasing hormone (GnRH) Action: Controls the release of pituitary hormones. PITUITARY GLAND v Hypophysis o Commonly referred to as the master gland because of the influence it has on secretion of hormones by other endocrine glands. v Anterior Pituitary Somatostatin/ Growth hormone (GH) o Inhibits growth hormone and thyroid- stimulating hormone. o Stimulates growth of bone and muscle, promotes protein synthesis and fat metabolism, decreases carbohydrate metabolism. Adrenocorticotropic hormone (ACTH) o Stimulates synthesis and secretion of adrenal cortical hormones. Thyroid-stimulating hormone (TSH) o Stimulates synthesis and secretion of thyroid hormones. Follicle- stimulating hormone (FSH)/ Sertoli cell-stimulating hormone (males) o Female: stimulates growth of ovarian follicle, ovulation. o Male: stimulates sperm production Luteinizing hormone (LH) / Leydig cell-stimulating hormone (males) o Female: stimulates development of corpus luteum, release of oocyte, production of estrogen and progesterone. o Male: stimulates secretion of testosterone, development of interstitial tissue of testes Prolactin o Prepares female breast for breast- feeding. Melanocyte- stimulating hormone v Posterior Pituitary Antidiuretic Hormone (ADH)/ Vasopressin o Increases water reabsorption by kidney Oxytocin o Stimulates contraction of pregnant uterus, milk ejection from breasts after child birth 1 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*MEDTECH LET*PSYCHOMET*RESPIRATORY THERAPY*CIVIL SERVICE*NAPOLCOM NCLEX*DHA*HAAD* PROMETRIC* UK-CBT ADRENAL CORTEX v The outer portion of the adrenal gland; stimulated by ACTH to produce corticosteriods. v Hormones: Mineralocorticoids (aldosterone) o Increase sodium absorption, potassium loss by kidney. Glucocorticoids (cortisol) o Affect metabolism of all nutrients; regulates blood glucose levels, affects growth, has anti- inflammatory action, and decreases effects of stress Adrenal androgens o Have minimal intrinsic androgenic activity; they are converted to testosterone and dihydrotestosterone in the periphery ADRENAL MEDULLA v The center of the adrenal gland that reacts to autonomic nervous system signals to release catecholamines. v Hormones: Epinephrine/Adrenaline o Serve as neurotransmitters for the sympathetic nervous system. o Prepares the body for the fight or flight response by converting glycogen, stored in the liver, to glucose and increasing cardiac output. Norepinephrine/Noradrenaline o Serve as neurotransmitters for the sympathetic nervous system. o Produces effect similar to epinephrine and produces extensive vasoconstriction THYROID GLAND v Butterfly- shaped organ located in the lower neck, anterior to the trachea. Thyroid hormones: triiodothyronine (T3), Thyroxine (T4) o Increase the metabolic rate; increase protein and bone turnover. o Regulate cellular metabolic activity. o T3 is produced predominantly from peripheral conversion of T4. o T3- Metabolism o T4- Heat Calcitonin o Lower blood calcium and phosphate levels. o Secreted in response to high blood calcium levels. o Inhibits bone resorption. PARATHYROID GLANDS v Small glands, usually four, surround the posterior thyroid tissue; they are often difficult to locate and may be removed accidentally during thyroid or other neck surgeries. v Hormones: Parathormone (PTH, parathyroid hormone) o Regulates serum calcium. o Raise blood calcium levels by increasing calcium resorption from kidney, intestines and bones. PANCREATIC ISLET CELLS v A slender, elongated organ lying horizontally in the posterior abdomen behind the stomach which function as an exocrine and an endocrine gland. v Hormones: Glucagon (alpha cells) o Increases blood glucose concentration by stimulation of glycogenolysis and gluconeogenesis. o Glycogenolysis- breakdown of stored glucose. o Gluconeogenesis- production of new glucose from amino acids and other substances. Insulin (beta cells) Lower blood glucose by facilitating glucose transport across cell membranes of muscle, liver, and adipose tissue Somatostatin (delta cells) o Delays intestinal absorption of glucose. 2 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*MEDTECH LET*PSYCHOMET*RESPIRATORY THERAPY*CIVIL SERVICE*NAPOLCOM NCLEX*DHA*HAAD* PROMETRIC* UK-CBT KIDNEY v Paired organs located on either side of the vertebral column. They are between the 12th thoracic and 3rd lumbar vertebrae in the posterior abdomen behind the peritoneum. 1,25- Dihydroxy vitamin D o Stimulates calcium absorption from the intestine. Renin o Activates renin- angiotensin-aldosterone system. Erythropoietin o Increases red blood cell production TESTES Male gonads Two almond-shaped organs suspended inside the scrotum; primary function is for reproduction. Steroid Hormone: Androgen (Testosterone) o Affect development of male sex organs and secondary sex characteristics; aid in sperm production. OVARIES v Female gonads v Two almond-shaped organs located at the anterior pelvis; primary function is for reproduction. v Steroid Hormones: Estrogen Ø Affect development of female sex organs and secondary sex characteristics Progesterone o Regulates the endometrium of the uterus o Maintains pregnancy DISORDERS OF ANTERIOR PITUITARY GLAND GIGANTISM v Description: Oversecretion of GH results in gigantism in children; a person may be 7 or even 8 feet tall. Noticed at puberty. Epiphyseal plate still open. Enlargement of bones of head, hands & feet. v Causes: Tumor of somatotrophs (signs of increased ICP) v Diagnostic Tests: CT and MRI. Serum levels of pituitary hormones. v Clinical Manifestations: More than 7 feet tall. Weak and lethargic. Severe headaches. Visual disturbance. Diplopia. Loss of color discrimination. Decalcification of the skeleton. v Management: Pharmacological Management o Bromocriptine (Parlodel) ü A dopamine antagonist o Octreotide (Sandostatin) Ø A synthetic analogue of GH Surgical Management o Hypophysectomy. 3 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*MEDTECH LET*PSYCHOMET*RESPIRATORY THERAPY*CIVIL SERVICE*NAPOLCOM NCLEX*DHA*HAAD* PROMETRIC* UK-CBT Stereotactic Radiation Therapy o Requires use of a neurosurgery- type stereotactic frame, may be used to deliver external beam radiation therapy precisely to the pituitary tumor with minimal effect on normal tissue. Nursing Interventions ü Record height and head circumference. ü Provide nursing care when receiving radiation therapy, perioperative care. ü Prepare the client for surgical removal of a pituitary tumor. ü Assist child in interacting normally with peers. ACROMEGALY v Description: An excess of Growth hormone in adults, results in bone and soft tissue deformities and enlargement of the viscera without an increase in height. ü Closed epiphyseal plate. v Diagnostic Tests: CT and MRI. Serum levels of pituitary hormones. v Clinical Manifestation: Transverse enlargement of bones Broad skull Protruding jaw Prognathism Broadening of hands and feet Thickening heel pads Lips become heavier Enlarged tongue Soft tissue enlargement ( brain, heart, internal organs) Coarse features v Management: Pharmacological Management ü Bromocriptine (Parlodel) - a dopamine antagonist. ü Ocreotide (Sandostatin) - a synthetic analogue of GH Surgical Management ü Hypophysectomy Stereotactic Radiation Therapy Nursing Management ü Prepare the client for pituitary irradiation and hypophysectomy if indicated. ü Monitor post- surgical clients for signs of complications: Hemorrhage Transient diabetes insipidus Rhinorrhea, which may indicate cerebrospinal leak. Adrenal insufficiency Thyroid insufficiency Infection, particularly meningitis (marked by fever, nuchal rigidity, headache) Visual disturbances, decreased visual field ü Monitor for hyperglycemia, cardiovascular and neurologic problems. v What is Hypophysectomy? ü Partial / complete removal of pituitary gland. ü Approaches may include transfrontal, subcranial, oronasal transphenoidal. Nursing care: ü Insulin therapy ü Medication to treat peptic ulcer ü Blood glucose monitoring ü Assessment of stools for blood ü Deep breathing is taught before the surgery ü Head of bed is raised for at least 2 weeks to decrease pressure on the sella turcica and to promote drainage ü Observe for post-nasal drip and check for glucose ü Patient is cautioned against engaging in activities that increases ICP ü Measure I & O, daily weight 4 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*MEDTECH LET*PSYCHOMET*RESPIRATORY THERAPY*CIVIL SERVICE*NAPOLCOM NCLEX*DHA*HAAD* PROMETRIC* UK-CBT ü Warm saline mouth rinses DWARFISM v Description: Generalized limited growth resulting from insufficient secretion of growth hormone during childhood. v Diagnostics Tests: X-ray Computed tomography and MRI Blood sample v Clinical Manifestation: Overweight for height Underdeveloped jaw Abnormal teeth position High voice Delayed puberty v Management: Pharmacological Management ü Somatrem (Protropin) ü Somatropin (Humatrope) Nursing Interventions ü Provide psychologic support and acceptance for alteration of body image. ü Assist in ambulation; avoid high impact activities. HYPERPROLACTINEMIA v Female: Prolactin-secreting tumors Amenorrhea Galactorrhea v Male: Gynecomastia Decreased sex drive Impotence DISORDERS OF POSTERIOR PITUITARY GLAND SYNDROME OF INAPPROPRIATE ANTI-DIURETIC HORMONE (SIADH) v Description: Excessive ADH secretion from the pituitary gland even in the face of subnormal serum osmolality. Patients cannot excrete dilute urine, retain fluids, and develop a sodium deficiency known as dilutional hyponatremia. v Causes: Bronchogenic carcinoma Severe pneumonia Pneumothorax Malignant tumors Head injury Brain surgery or tumor Infection Some medications v Diagnostic Tests: Decreased serum osmolality ( 45 yrs. Old Hypertension HDL cholesterol level 250 mg/dl v Classification of DM: Type 1 diabetes Type 2 diabetes Gestational diabetes Diabetes mellitus associated with other conditions or syndromes v Diagnostic tests and findings: Fasting plasma glucose Random plasma glucose Oral Glucose Tolerance Test (OGTT) v Criteria of the diagnosis of Diabetes Mellitus: 1. Symptoms of diabetes plus casual plasma glucose concentration equal to or greater than 200 mg/dl (11.1mmol/L). Casual is defined as any time of day without regard to time since last meal. The classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss. Or 2. Fasting plasma glucose greater than or equal to 126 mg/dl (7.0 mmol /L). Fasting is defined as no caloric intake for at least 8 hours or 3. Two-hour postprandial glucose equal to or greater than 200 mg/dL (11.1 mmol/L) during an oral glucose tolerance test. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved win water. TYPE 1 DIABETES MELLITUS v Description: Characterized by destruction of the pancreatic beta cells. Abnormal response in which antibodies are directed against normal tissues of the body, responding to these tissues as if they were foreign. 15 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*MEDTECH LET*PSYCHOMET*RESPIRATORY THERAPY*CIVIL SERVICE*NAPOLCOM NCLEX*DHA*HAAD* PROMETRIC* UK-CBT Destruction of the beta cells results in decreased insulin production, unchecked glucose production by the liver, and fasting hyperglycemia. Glucose derived from food cannot be stored in the liver but instead remains in the bloodstream and contributes to postprandial (after meals) hyperglycemia If the concentration of glucose in the blood exceeds the renal threshold for glucose, usually 180 to 200 mg/dl (9.9 to 11.1 mmol/L), the kidneys may not reabsorb all of the filtered glucose; the glucose then appears in the urine (glycosuria). When excess glucose is excreted in the urine, it is accompanied by excessive loss of fluids and electrolytes. This is called osmotic diuresis. Fat breakdown occurs, resulting in an increase production of ketone bodies, which are the byproducts of fat breakdown. Ketone bodies are acids that disturb the acid-base balance of the body when they accumulate in excessive amounts. The result is diabetic ketoacidosis (DKA). TYPE 2 DIABETES MELLITUS v Description: The two main problems: ü Increased Insulin resistance ü Decreased Insulin sensitivity ü Impaired insulin secretion. Idiopathic This is called metabolic syndrome, which includes hypertension, hypercholesterolemia, and abdominal obesity. Despite the impaired insulin secretion that is characteristic of type 2 diabetes, there is enough insulin present to prevent the breakdown of fat and the accompany production of ketone. v Management: v Nutritional Therapy To promote a 1-to-2-pound weight loss per week, 500 to 1000 calories are subtracted from the daily total. The caloric distribution currently recommended is higher in carbohydrates than in fat and protein. Foods high in carbohydrates, such as sucrose are not totally eliminated from the diet but should be eaten in moderation because they are typically high in fat and lack vitamins, minerals, and fiber. Additional recommendations include limiting total intake of dietary cholesterol to less than 300 mg/day. Increase fiber in the diet may improve blood glucose levels, decrease the need the exogenous insulin, and lower total cholesterol and low-density lipoprotein levels in the blood Alcohol is absorbed before other nutrients and does not require insulin for absorption. Large amounts can be converted to fats, increasing the risk for DKA It is important that patients read the labels of “health foods” especially snacks because they often contain carbohydrates and saturated fats, which may be contraindicated in people with elevated blood lipid levels v Exercise Exercise lower blood glucose levels by increasing the uptake of glucose by body muscles and by improving insulin utilization Exercise at the same time (preferable when blood glucose levels are at their peak) and in the same amount each day. Regular daily exercise Walking is a safe and beneficial. Eat 15-g carbohydrate snack before engaging in moderate exercise to prevent unexpected hypoglycemia. Use proper footwear. Avoid exercise in extreme heat or cold. Inspect feet daily after exercise. Avoid exercise during periods of poor metabolic control v Self- Monitoring of Blood Glucose This allows for detection and prevention of hypoglycemia and hyperglycemia and plays a crucial role in normalizing blood glucose levels, v Glycated hemoglobin (also referred to as glycosylated hemoglobin, HgbA1C, or A1C) is a blood test that reflects average blood glucose levels over a period of approximately 2 to 3 months. v Testing for Ketone ü Ketone in the urine signal that there is adeficiency of deficiency of insulin and control of type 1 diabetes is deteriorating. The risk of DKA is high. 16 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*MEDTECH LET*PSYCHOMET*RESPIRATORY THERAPY*CIVIL SERVICE*NAPOLCOM NCLEX*DHA*HAAD* PROMETRIC* UK-CBT v Pharmacologic Therapy ü Insulin Therapy ü In type 1 diabetes, exogenous insulin must be administered for life because the body loses the ability to produce insulin. TIME COURSE AGENT ONSET PEAK DURATION INDICATION Rapid-acting Lispro (Humalog) 10-15 min 1h 2-4 h Used for rapid reduction of glucose Aspart (Novolog) 5-15 min 40-50 min 2-4 h Level, to treat postprandial Glulisine (Apidra) 5-15 min 30-60 min 2h Hyperglycemia, and/or to prevent noctumal hypoglycemia Short-acting Regular (Humalog R, ½-1 h 2-3 h 4-6 h Usually administered 20-30 min Novolin R, Iletin II before a meal; may be taken Regular alone or in combination with longer-acting insulin Can be incorporated to an IV infusion Intermediate NPH (neutral 2-4 h 4-12 h 16-20 h Usually taken after food - acting protamine Hagedorn) (Humulin N, Iletin II 3-4 h 4-12 h 16-20 h Lente, Iletin II NPH) Novolin L [Lente], Novolin N [NPH] Long-acting Glargine (Lantus) 1h Continuous 24 h Used for basal dose Determir (Levemir) (no peak) ü Human insulin preparations have a shorter duration of action than insulin from animal sources because the presence of animal protein triggers an immune response that results an in the binding of animal insulin. ü Short-acting insulins are called regular insulin (marked R on the bottle). Regular insulin is a clear solution and is usually administered 20 to 30 minutes before a meal. Regular insulin is the only insulin approved for IV use. ü Intermediate-acting insulins are called NPH insulin (neutral protamine Hagedorn) or lente insulin. Intermediate-acting insulins. ü “Peakless” basal or very long-acting insulins that’s is, the insulin is absorbed very slowly over 24 hours and can be given once a day. Complications of Insulin Therapy ü Local Allergic Reactions. Ø Redness, swelling, tenderness, and induration or 2- to 4-cm wheal) may appear at the injection site 1 to 2 hours after the insulin administration. ü Systematic Allergic Reactions. Ø When they do occur, there is an immediate local skin reaction that gradually spreads into generalized urticaria (hives). Ø These rare reactions are occasionally associated with generalized edema or anaphylaxis. ü Insulin Lipodystrophy Ø Lipodystrophy refers to a localized reaction, in the form of either lipoatrophy of lipohypertrophy, occurring at the site of insulin injections. Ø Lipoatrophy is loss of subcutaneous fat; it appears as slight dimpling or more serious pitting of subcutaneous fat ü Resistance to Injected Insulin Ø Most patients have some degree of insulin resistance at one time or another. The most common being obesity, which can be overcome by weight loss ü Morning hyperglycemia Ø An elevated blood glucose level on arising in the morning is caused by an insufficient level of insulin, which may be caused by several factors: the dawn phenomenon, the Somogyi effect, or insulin waning 17 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*MEDTECH LET*PSYCHOMET*RESPIRATORY THERAPY*CIVIL SERVICE*NAPOLCOM NCLEX*DHA*HAAD* PROMETRIC* UK-CBT Oral antidiabetic agents ü Sulfonylureas Ø Stimulate beta cell of the pancreas to secrete insulin; may improve binding between insulin and insulin receptors of increase the number of insulin receptors or increase the number of insulin receptors ü Biguanide Ø Inhibits production of glucose by the liver Ø Increase body tissues sensitivity to insulin Ø Decrease hepatic synthesis of cholesterol Ø The only biguanide in the market: Metformin ü Alpha-glucosidase inhibitors Ø Delay absorption of complex carbohydrates in the intestine and slow entry of glucose into systemic circulation. ü Non-sulfonylureas Secretagogues (Meglitinides and phenylalanine derivatives) Ø Stimulate pancreas to secrete insulin ü Thiazolidinediones (Glitazone) Ø Sensitized body tissue to insulin; stimulate receptor sites to lower blood glucose and improve action of insulin ü Dipeptide-pepidase-4 (DDP-4) Inhibitors Ø Increase and prolongs the action of incretin, a hormone that increases insulin release and decreases glucagon levels, with the result of improved glucose control CAUSE OF MORNING HYPERGLYCEMIA Characteristic Treatment Insulin Waning Increase evening (predinner or bedtime) dose Progressive rise in blood glucose from bedtime of intermediate acting or long-acting insulin, or to morning institute a dose of insulin before the evening meal if one is not already part of the treatment regimen. Dawn Phenomenon Change time of injection of evening Relatively normal blood glucose until about 3 intermediate-acting insulin from dinnertime to am, when the level begins to rise bedtime. Somogyi Effect Decrease evening (predinner or bedtime) dose Normal or elevated blood glucose at bedtime, a of intermediate acting insulin, or increase decrease at 2-3 am to hypoglycemic levels, and bedtime snack. a subsequent increase caused by the production of counterregulatory hormones ü Storing Insulin Ø Vials not in use, including spare vials. should be refrigerated. Ø Insulin should not be allowed to freeze and should not be kept in direct sunlight Ø The insulin vial in use should be kept at room temperature to reduce local irritation at the injection site Ø The patient should be instructed to always have a spare vial of the type or types of insulin he or she uses. Ø Cloudy insulins should be thoroughly mixed by gently inverting the vial or rolling it between the hands before drawing the solution into a syringe or a pen Ø Bottles of intermediate-acting insulin should also be inspected for flocculation, which is a frosted, whitish coating ü Mixing Insulins. Ø Longer-acting insulin must be mixed thoroughly before drawing into the syringe. Ø Regular insulin should be drawn up first. ü Withdrawing Insulin Ø Inject air into the bottle of insulin equivalent to the number of units of insulin to be withdrawn ü Selecting and Rotating the Injection Site. Ø The four main areas for injection are the abdomen, upper arms (posterior surface) thighs (anterior surface), and hips. 18 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*MEDTECH LET*PSYCHOMET*RESPIRATORY THERAPY*CIVIL SERVICE*NAPOLCOM NCLEX*DHA*HAAD* PROMETRIC* UK-CBT Ø The speed of absorption is greatest in the abdomen and decreases progressively in the arm, thigh, and hip, respectively. Ø Systematic rotation of injection sites within an anatomic area is recommended to prevent localized changes in fatty tissue (lipodystrophy). Ø Administer each injection 0.5 to 1 inch away from the previous injection. Another approach to rotation Ø Patient should try not to use the same site more than once in 2 to 3 weeks. Ø Insulin should not be injected into the limb that will be exercised because this will cause the drug to be absorbed faster, which may result in hypoglycemia. ü Preparing the Skin. Ø They should be cautioned to allow the skin to dry after cleansing with alcohol. Ø The alcohol may be carried into the tissues, resulting in a localized reddened area and a burning sensation. ü Inserting the Needle. Ø For a normal or overweight person, a 90- degree angle is the best insertion angle. Ø Aspiration is generally not recommended with self-injection of insulin. ü Disposing of Syringes and Needles. Ø Used sharps should be placed in a puncture-resistant container. COMPLICATIONS OF DIABETES MELLITUS HYPOGLYCEMIA v Occurs when the blood glucose falls to less than 50 to 60 mg/dL (2.7 to 3.3 mmol/L), because of too much insulin or oral hypoglycemic agents, too little food, or excessive physical activity. v Clinical Manifestation: Mild hypoglycemia ü Sweating ü Tremor ü Tachycardia ü Palpitation ü Nervousness ü Hunger. Moderate hypoglycemia ü Inability to concentrate ü Headache ü Lightheadedness ü Confusion ü Memory lapses ü Numbness of the lips and tongue ü Slurred speech ü Impaired coordination ü Emotional changes ü Irrational or combative behavior ü Double vision ü Drowsiness. Severe hypoglycemia ü Patient needs the assistance of another person for treatment of hypoglycemia. ü Disoriented behavior ü Seizures ü Difficulty arousing from sleep ü Loss of consciousness. 19 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*MEDTECH LET*PSYCHOMET*RESPIRATORY THERAPY*CIVIL SERVICE*NAPOLCOM NCLEX*DHA*HAAD* PROMETRIC* UK-CBT v Emergency measures: Injection of glucagon 1mg (subcutaneously or intramuscularly.) A concentrated source of carbohydrate followed by a snack should be given to the patient on awakening In hospitals and emergency departments, for patients who are unconscious or cannot swallow, 25 to 50 mL of 50% dextrose in water (D5OW) may be administered IV. Assuring patency of the IV line because (D5OW) is very irritating to veins. Taking additional food when physical activity is increased Routine blood glucose tests are performed Wear an identification bracelet or tag stating that they have diabetes. Learn to carry some form of simple sugar with them at all times Refrain from eating high-calorie, high-fat dessert foods (eg, cookies, cakes, doughnuts, ice cream). DIABETES KETOACIDOSIS v Caused by an absence or markedly inadequate amount of insulin. This deficit in available insulin results in disorders in the metabolism of carbohydrate, protein, and fat. The three main clinical features of DKA are: Hyperglycemia Dehydration and electrolyte loss Acidosis v Pathophysiology: v Clinical Manifestations: Polyuria Polydipsia Blurred vision Weakness Headache Orthostatic hypotension Weak and rapid pulse Anorexia Nausea and vomiting Abdominal pain Acetone breath Kussmaul’s respiration – rapid, deep breathing v Diagnostic Tests and Findings: Blood glucose levels may vary between 300 and 800 mg/dL Serum bicarbonate (0 to 15 mEq/L) Low pH (6.8 to 7.3) A low partial pressure of carbon dioxide (PCO2; 10 to 30 mm Hg) Increased levels of creatinine 20 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*MEDTECH LET*PSYCHOMET*RESPIRATORY THERAPY*CIVIL SERVICE*NAPOLCOM NCLEX*DHA*HAAD* PROMETRIC* UK-CBT Increased blood urea nitrogen (BUN) Increased hematocrit v Management: Rehydration ü 0.9% Sodium chloride (normal saline solution) 0.65 to 1 Uh for2-3 hours ü Half strength normal saline (0.45%)- hypernatremia ü Monitoring fluid volume status ü Vital signs ü Lung assessment ü Intake and output ü Plasma expanders-severe hypotension ü Monitor for signs of overload Restoring Electrolytes ü Serum potassium level must be monitored frequently. ü As much as 40 mEq/h may be needed for several hours. ü Frequent (every 2 to 4 hours initially) ECGs and laboratory. measurements of potassium are necessary. ü Because a patient's serum potassium level may drop quickly as a result of rehydration and insulin treatment, potassium replacement must begin once potassium levels drop to normal. Reversing Acidosis ü Insulin is usually infused intravenously at a slow, continuous rate ü Bicarbonate infusion to correct severe acidosis is avoided during treatment of DKA because it precipitates further, sudden decreases in serum potassium levels. ü When mixing the insulin drip, it is important to flush the insulin solution through the entire IV infusion set and to discard the first 50 mL of fluid. ü Insulin molecules adhere to the inner surface of IV infusion sets; therefore, the initial fluid may contain a decreased concentration of insulin. HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC SYNDROME (HHNS) v Serious condition in which hyperosmolarity and hyperglycemia predominate, with alterations of the sensorium (sense of awareness) v Ketosis is usually minimal or absent v Persistent hyperglycemia causes osmotic diuresis, which results in losses of water and electrolytes v Clinical manifestations: Hypotension Profound dehydration (dry mucous membranes, poor skin turgor) Tachycardia Alteration in sensorium Seizures Hemiparesis v Diagnostic tests and Findings: Blood glucose- 600 to 1200mg/dL Osmolality exceeds 350 mOsm/kg v Management Fluid replacement Correction of electrolyte imbalances Insulin administration Fluid treatment is started with 0.9% or 0.45%NS Central venous or hemodynamic pressure monitoring Potassium is added to IV fluids Insulin plays a less important role in the treatment of HHNS because it is not needed for reversal of acidosis 21 TOPRANK REVIEW ACADEMY- NURSING MODULE  NURSING*RADTECH*DENTISTRY*CRIMINOLOGY*MIDWIFERY*MEDTECH LET*PSYCHOMET*RESPIRATORY THERAPY*CIVIL SERVICE*NAPOLCOM NCLEX*DHA*HAAD* PROMETRIC* UK-CBT Characteristic DKA HHNS Patients most commonly Can occur in type 1 or type 2 diabetes; More common in type 2 diabetes, affected more common in type 1 diabetes. especially elderly patients with type 2 diabetes Precipitating event Omission of insulin; physiologic stress PHYSIOLOGIC STRESS (infection surgery, (infection, surgery, CVA,MI CVA, MI) Onset Rapid (250 mg/dL (>3.9mmol/L) Usually >600 mg/dL (>33.3 mmol/L Arterial pH level 7.3 Normal Serum and urine ketones Present Absent Serum osmolality 300-350 mOsm/L >350 mOsm/L Plasma bicarbonate level