Endocrine System - NRSG311 - PowerPoint PDF

Endocrine System NRSG311 – Week 3 R. Stent Winter 2025  What is the Endocrine System? Critical communication and coordination system Hormones regulate a...

Endocrine System NRSG311 – Week 3 R. Stent Winter 2025  What is the Endocrine System? Critical communication and coordination system Hormones regulate activities and communicate Interconnected with nervous and immune systems: Bidirectional immune-neuroendocrine communication Regulate responses to internal and external environments R. Stent Winter 2025 NRSG 311 2  General Roles and Functions of Endocrine System Reproductive and CNS development in the fetus Stimulating growth and development during childhood and adolescence Sexual reproduction Maintaining homeostasis Responding to emergency demands R. Stent Winter 2025 NRSG 311 3  What are some common endocrine disorders, diseases, or conditions? R. Stent Winter 2025 NRSG 311 4  Learning Objectives Identify endocrine glands and their locations Describe role and function of thyroid, parathyroid, and pancreas Describe hormone transport, regulation, and secretion and pathophysiology of insulin and glucagon secretion Explain subjective and objective data related to assessment of the endocrine system Hypo- and hyperthyroidism and hypo- and hyperparathyroidism: Differentiate between these conditions and understand their clinical manifestations Understand nursing interventions, multidisciplinary collaboration, and rationales for management of these conditions Discuss patient and family teaching Diabetes Mellitus: Differentiate between Type 1 and Type 2, explain the etiology, pathology, and clinical manifestations Explain prediabetes and subsequent development into Type 2 DM Understand nursing interventions, multidisciplinary collaboration, and rationales for management of these disorders, including patients newly diagnosed with diabetes Describe different insulin regimens, the role of nutritional therapy, exercise, and blood sugar monitoring Discuss patient and family teaching, including discussion strategies for patients who have difficulty adhering to treatment plans Explain chronic complications of diabetes and clinical manifestations; explain pathology, care, and management of DKA Discuss and HHSdiabetes insipidus and gestational diabetes R. Stent Winter 2025 NRSG 311 5  Endocrine Glands Hypothalam Pineal body / Pituitary Thyroid us pineal gland gland gland Parathyroid Thymus Adrenal Pancreas glands gland glands Ovary Testes R. Stent Winter 2025 NRSG 311 6 FIG. 50.1 Locations of some major endocrine glands. Source: Patton, K. (2019). Anatomy and physiology (10th ed., Figure 25-  Structures and Functions of the Endocrine System: Glands Produce hormones which control and regulate specific target tissues E.g. Thyroid gland: synthesizes thyroxine which affects many target tissues Two types of glands: Exocrine glands: secrete substances into ducts that empty into a body cavity or onto a surface (e.g. salivary glands produce saliva, secreted through salivary ducts into the mouth) Endocrine glands: ductless, secrete substances directly into blood (e.g. adrenal glands produce epinephrine and norepinephrine, release into bloodstream, regulate body’s response to stress) R. Stent Winter 2025 NRSG 311 7  Role and Function of the Thyroid Glands Located in Two encapsulated lateral lobes connected by narrow isthmus anterior neck, midline, straddle Highly vascular trachea: Function: Production, storage, and release of hormones: Thyroxine (T4), Triiodothyronine (T3), and Calcitonin Hormones exert effects on nearly every organ system, stimulating cell metabolism and activity Regulated by Low circulating levels of thyroid hormone  hypothalamus releases TRH  negative anterior pituitary gland releases TSH feedback cycle: High circulating levels of thyroid hormone  inhibitory effect of TRH from hypothalamus and TSH from anterior pituitary gland R. Stent Winter 2025 NRSG 311 8  Role and Function of the Parathyroid Glands Located behind Four small, oval structures each thyroid lobe: Usually found in pairs Function: Secretes parathyroid hormone (PTH or parathormone), regulates blood level of calcium Acts on bone and kidneys and indirectly on GI tract Regulated by Low serum calcium or magnesium levels  PTH secretion increases negative feedback cycle: High serum calcium or active Vitamin D levels  PTH secretion decreases R. Stent Winter 2025 NRSG 311 9  Role and Function of the Pancreas Located behind Anterior to 1st and 2nd lumbar vertebrae stomach Long, tapered, lobular, soft gland Islets of Langerhans: Hormone-secreting portion of the pancreas Functions: Exocrine function: produce enzymes important for digestion Endocrine function: regulate level of glucose in the blood 4 types of hormone- Alpha (α) cells: produce and secrete Glucagon secreting cells: Beta (β) cells: produce and secrete insulin and amylin Delta (D) cells: produce and secrete somatostatin Gamma (F or PP) cells: secrete pancreatic polypeptide (PP) R. Stent Winter 2025 NRSG 311 10 Structures and Functions of the Endocrine System: Hormones Chemical substances synthesized and secreted by endocrine glands Paracrine action: act locally on nearby cells (e.g. action of sex steroids on ovary) Autocrine action: act on cell that produced it (e.g. insulin secreted from pancreas inhibits further insulin release from same cells) Common characteristics: Secretion in small amounts at variable but predictable rates Regulation by feedback systems Able to bind to specific target cell receptors Control varied physiological activities: E.g. reproduction; response to stress/injury; electrolyte balance; energy metabolism; growth, maturation, aging; regulating nervous/immune systems R. Stent Winter 2025 NRSG 311 11  T3 and T4 Calcitonin Thyrotropin-releasing hormone Produced in response to (TRH) released by hypothalamus  high circulating calcium Functions pituitary makes thyroid-stimulating hormone (TSH) TSH tells thyroid to capture iodine levels Inhibits calcium resorption (i.e. loss) from bone of Thyroid from blood to synthesize, store, and release thyroxine (T4) Increases calcium storage in bone Hormones: T4 reaches target cells  converted to triiodothyronine (T3) Increases renal excretion of calcium and phosphorous, T3, T4, T4 reaches adequate circulating lowering serum calcium and level  hypothalamus and pituitary phosphate levels reduce output of TRH and TSH Counter-mechanism to PTH and If T4 levels drop  hypothalamus and pituitary resume output of TRH (does not play critical role in calcium balance) Calcitonin and TSH Effects: metabolic rate, caloric requirements, oxygen consumption, carbohydrate and lipid metabolism, growth and development, brain function, nervous system activity R. Stent Winter 2025 NRSG 311 12  Target Tissues Functions Bone: resorption of Regulates calcium and calcium, inhibits bone phosphorus blood Functions of formation, release of calcium and phosphate levels Promotes bone Parathyroid into the blood Kidneys: increase demineralization and increases intestinal Hormone calcium reabsorption absorption of Ca2+ and phosphate Increases serum Ca2+ (PTH) or excretion, stimulate levels renal conversion of Parathormon Vitamin D to most e active form Intestine: Indirect action on GI tract  Vitamin D in active form enhances intestinal absorption of calcium R. Stent Winter 2025 NRSG 311 13  Glucagon Insulin Increases blood Essential hormone: glucose principal regulator of Functions of Provides fuel for metabolism, storage of ingested carbohydrates, Pancreatic energy during fasting states, fats, and proteins Hormones: when ingested Facilitates glucose glucose is not transport across cell Glucagon and readily available membranes in most Insulin tissues Responsible for how ingested nutrients are used for energy and stored (anabolism) R. Stent Winter 2025 NRSG 311 14  Pathophysiology of Insulin and Glucagon Secretion Reciprocal negative feedback loop: Maintain normal blood glucose levels Low blood glucose, protein ingestion, and/or exercise  glucagon synthesized and released from pancreatic α cells Blood glucose increased through catabolism  fuel/energy during fasting when ingested glucose not readily available, by stimulating: Glycogenolysis: breakdown of glycogen into glucose Gluconeogenesis: formation of glucose from noncarbohydrate molecules Ketogenesis: breakdown of fatty acids and amino acids to produce ketone bodies Mechanisms carefully modulate insulin secretion to prevent hypo and hyperglycemia: Increased blood glucose  stimulates insulin synthesis and secretion Decreased blood glucose and glucagon  inhibit insulin secretion Insulin: essential hormone Principal regulator of metabolism and storage of ingested carbohydrates, fats, and proteins Facilitates glucose transport across cell membranes in most tissues R. Stent Winter 2025 NRSG 311 15  Tabl e of E 50.1 fo nd o focu crin r full ra s stu e Horm nge d cove ying on ones: red toda ones y R. Stent Winter 2025 NRSG 311 16  Endocrine System Assessment: Health History and Subjective Data Assessment predominantly captured through health history Personal/family Overall health Eyes, ears, nose, history: conditions, status: change Musculoskeletal mouth, throat: Cardiovascular: surgeries, in appetite, : shaky hands, blurred/double vision, heart hospitalizations, weight, difficulty difficulty swallowing, palpitations treatments, activities, holding things enlarged neck medications fatigue Neurological: Genitourinary: Integumentary: Gastrointestinal increased nocturia, Endocrine: change in hair : bowel nervousness, stress, kidney stones, temperature distribution, changes, anxiety, memory, water at regulation skin constipation concentration bedside colour/texture changes Female reproductive: ADLs: activity, mobility, menarche, menstrual cycle, Male reproductive sleep/rest, relationships, fertility, children health: change in coping/stress, born/weight, gestational ability to have occupational health, self diabetes, breastfeeding, erection, fertility care, health promotion menopause R. Stent Winter 2025 NRSG 311 17  Endocrine System Assessment: Objective Data Effects every body system: Clinical manifestations vary significantly depending on gland involved Mental/emotional status: Integumentary: orientation, alertness, colour/texture of skin, hair, Vital signs, memory, affect, nails; hair distribution; height/weight personality, anxiety, pigmentation, ecchymosis; appropriateness of dress, palpate for moisture speech pattern Thorax: shape, skin; Head/face: Size, contour, facial Neck: position, gynecomastia in men; symmetry; eye position, swallowing, trachea auscultate lung and symmetry, shape, movement, midline; symmetry; heart sounds; signs of edema; buccal mucosa, teeth, bulging over thyroid fluid overload or heart tongue size and movements failure Abdomen: contour, Extremities: size, shape, symmetry, Genitalia: hair symmetry, colour; proportion of hands/feet; skin; distribution; skin condition; lesions/edema; muscle strength; palpation of testes; auscultate bowel deep tendon reflexes; tremors in clitoral sounds upper extremities enlargement R. Stent Winter 2025 NRSG 311 18  Laboratory and Diagnostics: Blood and Urine TSH: usually first diagnostic test for thyroid dysfunction; most sensitive method T4 Total: total serum level of T4, useful in evaluating thyroid function and monitoring thyroid therapy Free T4: active component of total T4, better indication of thyroid function (level remains constant) T3: serum levels of T3, helpful to diagnose hyperthyroidism if T4 levels are normal PTH: evaluates hypercalcemia or hypocalcemia, results interpreted with serum calcium level Total serum calcium: helps detect bone and parathyroid disorders Cortisol (blood): amount of total cortisol in serum, evaluates status of adrenal cortex function Cortisol (urine): free (unbound) cortisol with suspected hyper- or hypofunction of adrenal gland, evaluates hypercortisolism ACTH: plasma level of ACTH, determine if under-/overproduction of cortisol caused by adrenal or pituitary dysfunction Calcitonin: serum calcitonin, helpful with diagnosis of medullary thyroid cancer CBC (RBC, WBC, platelets, Hg, hematocrit, MCV), Electrolytes, BUN, Cr Thyroid peroxidase antibodies may suggest autoimmune origin of hypothyroidism disorder Elevated cholesterol and triglyceride levels, anemia, increased creatine kinase level may be related to hypothyroidism R. Stent Winter 2025 NRSG 311 19  Laboratory and Diagnostics: Imaging MRI: visualize CNS, bony spine, joints, extremities, breasts CT scan with contrast: detect presence of tumour Ultrasonography: evaluate thyroid nodules, determine if fluid filled (cystic) or solid tumour Thyroid Scan: evaluate nodules; radioactive isotopes given PO/IV, scanner passes over thyroid, records radiation emitted; benign nodules appear as warm spots (take up radionuclide), malignant tumours appear as cold spots (tend not to take up radionuclide) Radioactive iodine uptake (RAIU): measures thyroid activity/function, useful for evaluation of solitary thyroid nodules; radioactive iodine taken PO/IV, scanner measures uptake by thyroid gland at several time intervals (i.e. 2- and 4-hour intervals and at 24 hours) R. Stent Winter 2025 NRSG 311 20 Disorders of the Thyroid Gland Thyroid hormones regulate energy metabolism, growth, and development Disorders of thyroid gland include: Enlargement (Goitre) Benign and malignant nodules Inflammation (Thyroiditis) Hyperfunctioning and hypofunctioning states R. Stent Winter 2025 NRSG 311 21  Hyperthyroidism vs. Hypothyroidism Hyperthyroidism: Hyperactivity of the thyroid gland, increased synthesis and release of thyroid hormones Hypothyroidism: Hypoactivity of the thyroid gland, insufficient circulating thyroid hormones R. Stent Winter 2025 NRSG 311 22  Critical Thinking A 45-year-old woman presents with complaints of fatigue, weight gain, dry skin, and feeling cold even in warm environments. On examination, you note bradycardia, coarse hair, and slight swelling around her neck. 1) What do you suspect the diagnosis may be? 2) What subjective data supports this diagnosis? 3) What objective findings support this diagnosis? 4) Which diagnostic test is most relevant for confirming the diagnosis? 5) What is the primary treatment for this condition? R. Stent Winter 2025 NRSG 311 23  Hyperthyroidism Graves’ disease Causes of Hyper- Toxic nodular goitres and Thyroiditis Hypothyroidism Hypothyroidism can Hypothyroidism: be: Iodine deficiency (most common worldwide) Primary: destruction of Atrophy of thyroid gland (most common in thyroid tissue or defective hormone synthesis Canada) Secondary: pituitary Amiodarone or lithium use disease with decreased Treatment for hyperthyroidism (e.g. surgical TSH secretion or removal) hypothalamic dysfunction Discontinuing thyroid hormone therapy Transient: factors such Destruction of thyroid gland: autoimmune as thyroiditis, disease (e.g. Hashimoto’s thyroiditis, Graves’ discontinuing thyroid disease) hormone therapy, R. Stent etc. Winter 2025 NRSG 311 24  Clinical Manifestations of Hyper- and Hypofunction of the thyroid: (Table 51.6) Symptoms vary depending on severity, duration, age Hyperfunction of the thyroid Hypofunction of the thyroid Effects of excess circulating hormones: Effects of decreased circulating hormones: increased metabolism and tissue sensitivity to insidious, nonspecific slowing of body processes SNS Stimulation Cardiovascular: angina; atrial fibrillation, Cardiovascular: anemia; cardiac hypertrophy; palpitations, dysrhythmias; bounding, rapid decreased rate and force of cardiac pulse; cardiac hypertrophy; increased cardiac contractions; decreased cardiac output; distant output; increased rate and force of cardiac heart sounds; increased capillary fragility; contractions; systolic hypertension; systolic greater risk of heart failure, angina, and MI; murmurs varied changes in blood pressure Respiratory: dyspnea on mild exertion, Respiratory: decreased breathing capacity, increased respiratory rate dyspnea R. Stent Winter 2025 NRSG 311 25  Clinical Manifestations of Hyper- and Hypofunction of the thyroid: Continued Hyperfunction of the thyroid Hypofunction of the thyroid Gastrointestinal: diarrhea, frequent Gastrointestinal: celiac disease; constipation; defecation; hepatomegaly; increased appetite, decreased appetite; distended abdomen; thirst; increased bowel sounds, increased weight gain; enlarged, scaly tongue; nausea peristalsis; splenomegaly; weight loss and vomiting Integumentary: clubbing of fingers; Integumentary: decreased sweating; dry, diaphoresis; fine, silky hair; premature greying sparse, coarse hair; dry, thick, inelastic, cold (men), hair loss; palmar erythema; thin, brittle skin; generalized interstitial edema; pallor; poor nails detached from nail bed; warm, smooth, turgor of mucosa; puffy face; thick, brittle nails moist skin Musculoskeletal: dependent edema; fatigue, Musculoskeletal: arthralgia; fatigue, muscular muscle weakness; osteoporosis; proximal aches and pains, slow movements, weakness muscle wasting R. Stent Winter 2025 NRSG 311 26  Clinical Manifestations of Hyper- and Hypofunction of the thyroid: Continued Hyperfunction of the thyroid Hypofunction of the thyroid Nervous: personality changes, lability of Nervous: personality and mood changes, mood, nervousness, irritability; depression, anxiety, depression, apathy, lethargy, fatigue; apathy, fatigue, insomnia, exhaustion; hyper- delayed relaxation of deep tendon reflexes; reflexia of tendon reflexes; difficulty focusing hoarseness; paresthesias; polyneuropathy; eyes; fine tremor (fingers, tongue); inability to slow, slurred speech; forgetfulness, slowed concentrate; agitation, restlessness, delirium, mental processes, stupor, coma, stupor, coma Reproductive: amenorrhea, decreased Reproductive: decreased libido, infertility, fertility, decreased libido, erectile dysfunction prolonged menstrual periods or amenorrhea in men, gynecomastia in men, menstrual irregularities Other: goitre; elevated basal temperature, Other: hearing impairment; goitre; intolerance intolerance of heat; increased sensitivity to of cold; increased sensitivity to opioids, stimulant medications; exophthalmos, eyelid barbiturates, anaesthetics; increased lag, stare, eyelid retraction; rapid speech R. Stent Winter 2025 susceptibility to infection; sleepiness NRSG 311 27  Hyperthyroidism: Interprofessional Care Interprofessional care goal: block adverse effects of thyroid hormones, stop over-secretion Diagnostics: history, physical exam, electrocardiography, lab tests, ophthalmological examination, RAIU Radiation therapy: radioactive iodine Surgical therapy: subtotal thyroidectomy Nutritional therapy: frequent meals, high-calorie diet, high-protein diet Medication therapy: antithyroid medications, methimazole, propylthiouracil, iodine, β-Adrenergic blockers (e.g., propranolol) R. Stent Winter 2025 NRSG 311 28 Hyperthyroidism: Nursing Interventions Assessment: Health history and physical examination Identify Nursing Diagnoses: E.g. Reduced stamina resulting from physical deconditioning Planning – Goals related to: Relieving symptoms Avoiding serious complications related to disease or treatment Maintaining nutritional balance Encouraging adherence to therapeutic plan Implementation: Patients often treated in outpatient settings Require acute care for thyroidectomy or acute thyrotoxicosis Evaluation: Assess if goals have been met FIG. 51.6 Exophthalmos and goitre of Graves’ disease. R. Stent Winter 2025 NRSG 311 29  Thyroidectomy Indications: Large goitre causing tracheal compression Condition not responding to antithyroid therapy Thyroid cancer Not a candidate for RAI Subtotal thyroidectomy: preferred, removes significant portion (90%) of thyroid gland Endoscopic thyroidectomy: minimally invasive, less scarring, less pain, faster recovery Postoperative complications: Hypothyroidism; damage or inadvertent removal of parathyroid; hemorrhage; injury to nerves; thyrotoxic crisis; infection R. Stent Winter 2025 NRSG 311 30  Thyroidectomy: Nursing Interventions Ensure O2, suction equipment, and tracheostomy tray available in case of airway obstruction Assess q2 hrs for 24 hrs: Signs of hemorrhage or tracheal compression (e.g. irregular breathing, neck swelling, frequent swallowing, sensation of fullness at incision site, choking, blood on dressings) Semi-Fowler’s position, support head with pillows, avoid flexion of neck and tension on suture lines Monitor vital signs, signs of hypocalcemia and tetany (e.g. tingling in toes, fingers, or around mouth; muscular twitching; apprehension) Assess for difficulty speaking or hoarseness Control postoperative pain and nausea Ambulate within hours after surgery, take fluids as soon as tolerated, eat soft foods day after surgery R. Stent Winter 2025 NRSG 311 31 Thyroidectomy: Patient/Family Teaching Comfort/safety measures, deep breathing and coughing, leg exercises Appearance of incision may be distressing, may have difficulty speaking after surgery Routine post-operative care (e.g. IV infusion) Thyroid hormone balance monitoring: ensure normal function returns Avoid overexertion, gently support wound when coughing, support head while turning, range-of-motion exercise Watch for difficulties swallowing or breathing; infection; tingling or numbness in mouth/fingers, progressive pain or nausea (return immediately to hospital) Adequate fluid intake, reduce caloric intake to prevent weight gain, ensure sufficient iodine intake Avoid constipation Regular gentle/light exercise to stimulate thyroid gland Avoid high environmental temperature Regular follow-up needed: biweekly for a month, then at least semi-annually Complete thyroidectomy: lifelong thyroid replacement needed; watch for signs of progressive thyroid failure (fatigue, weight gain, sensitivity to cold, muscle weakness) R. Stent Winter 2025 NRSG 311 32 Critical Thinking A client reports pain at the incision site 8 hours after a thyroidectomy. Which nursing intervention is most appropriate? Select all that apply. a) Administer prescribed analgesics as needed b) Provide an ice pack to be applied to the next for 30 minutes c) Elevate and support the client’s head to reduce strain on the incision d) Encourage the client to perform neck stretches R. Stent Winter 2025 NRSG 311 33  Critical Thinking Which laboratory value is most important to monitor in a client post-thyroidectomy? a) Serum calcium b) Serum sodium c) Blood glucose d) White blood cell count R. Stent Winter 2025 NRSG 311 34  Critical Thinking What is the best position for a client post- thyroidectomy? a) Supine with the neck in a neutral position b) High-Fowler’s position with the neck supported c) Side-lying with the head slightly elevated d) Flat with the head turned to one side R. Stent Winter 2025 NRSG 311 35  Hyperthyroidism Complication: Thyrotoxic Crisis or Thyrotoxic Storm Rare, acute condition: Life-threatening emergency Hyperthyroid manifestations intensify Cause: Stressors on the body Infection, trauma, surgery in patient with pre-existing hyperthyroidism Clinical Manifestations: Severe tachycardia, heart failure, shock, hyperthermia, restlessness, agitation, seizures, abdominal pain, nausea, vomiting, diarrhea, delirium, coma R. Stent Winter 2025 NRSG 311 36  Acute Thyrotoxicosis: Treatment and Management, Nursing Implications Treatment and Management: Reduce circulating thyroid hormone levels with appropriate medication therapy Reduce manifestations with appropriate medication therapy Supportive therapy to manage respiratory distress, reduce fever, replace fluids Eliminate or manage initiating stressor Nursing Implications Monitor for cardiac dysrhythmias and decompensation Ensure adequate oxygenation IV fluids to replace fluid and electrolyte loss Adequate rest: calm, quiet, cool room; change linens regularly if diaphoretic Exercise large muscle groups Supportive, trusting relationship to cope with aggravating events and lessen anxiety Exophthalmos: relieve eye discomfort, prevent corneal ulceration (artificial tears, salt restriction to reduce edema, elevate head, dark glasses, exercise intraocular muscles) R. Stent Winter 2025 NRSG 311 37  Hypothyroidism: Interprofessional Care Goal: restore euthyroid state as safely and rapidly as possible with hormone replacement Diagnostics: history, physical exam; serum T3 and T4 levels; serum TSH and free T4 levels; thyroid peroxidase antibodies; TRH stimulation test Monitor thyroid hormone levels and adjust dosage (if needed) Nutritional therapy: promote weight loss Patient and caregiver teaching Thyroid hormone replacement (e.g. levothyroxine): take regularly, monitor for angina and cardiac dysrhythmias R. Stent Winter 2025 NRSG 311 38  Assessment: Health history and physical examination Identify Nursing Diagnoses: Hypothyroidis E.g. Constipation resulting from decrease in GI motility m: Nursing Planning – Goals related to: Interventions Relieving symptoms Maintaining euthyroid state Maintaining positive self-image Encouraging adherence to lifelong thyroid replacement therapy regimen Implementation Monitor for myxedema coma: requires acute care Monitor skin integrity, assess for skin breakdown Avoid sedatives Assess for/prevent constipation, avoid enemas due to vagal stimulation Notify physician of signs of overdose: orthopnea, dyspnea, rapid pulse, palpitations, nervousness, insomnia Evaluation: Assess if goals have been met R. Stent Winter 2025 NRSG 311 39  Hypothyroidism: Patient/Family Teaching Provide written instructions, frequent repetition, assess comprehension regularly Nature of thyroid hormone deficiency Self-care to prevent complications Understand thyroid replacement therapy Need for lifelong replacement, take medication continually, regular follow-up care Need for comfortable, warm environment Measures to prevent skin breakdown Caution to avoid use of sedatives, and monitor mental status, LOC, and respirations if needed Measures to minimize constipation (diet, stool softeners, maintenance) and avoidance of enemas due to vagal stimulation Signs of overdose, when and how to contact provider R. Stent Winter 2025 NRSG 311 40  Hypothyroidism Complication: Myxedema Coma Medical emergency Gradual or sudden progression to hypothermia Notable impairment of consciousness, coma Cause: Infection, medications (opioids, tranquilizers, barbiturates), exposure to cold, trauma Clinical Manifestations: Subnormal temperature, hypotension, hypoventilation R. Stent Winter 2025 NRSG 311 41  Myxedema Coma: Treatment and Management, Nursing Implications Treatment and management: Support vital functions Draw and analyze serum T4, TSH, and cortisol Treat aggressively with IV thyroid hormone replacement and high-dose glucocorticoid therapy until adrenal insufficiency excluded Nursing Implications: Mechanical respiratory support Cardiac monitoring Hypertonic saline (e.g., 3% NaCl) if hyponatremic Monitoring of core temperature and vital signs, weight, I&O Assessment of edema, cardiovascular response to hormone, energy level, mental alertness R. Stent Winter 2025 NRSG 311 42  Hyperparathyroidism vs. Hypoparathyroidism Hyperparathyroidism: Characterized by inappropriately normal or increased secretion of parathyroid hormone (PTH), resulting in hypercalcemia Hypoparathyroidism: Characterized by hypocalcaemia resulting from lack of PTH to maintain serum calcium levels, or PTH resistance at cellular level R. Stent Winter 2025 NRSG 311 43  Clinical Manifestations of Hyper- and Hypofunction of the Parathyroid (Table 51.12) Can by asymptomatic or have overt symptoms Hyperfunction of the parathyroidism Hypofunction of the parathyroidism Effects related to hypercalcemia Effects are related to hypocalcemia Cardiovascular: dysrhythmias; hypertension; Cardiovascular: decreased cardiac output and shortened Q-T interval on ECG contractility of heart muscle, dysrhythmias, prolonged Q-T and ST intervals on ECG Gastrointestinal: anorexia, cholelithiasis, nausea, Gastrointestinal: abdominal cramps, fecal vomiting, constipation, pancreatitis, peptic ulcer incontinence, malabsorption disease, vague abdominal pain, weight loss Integumentary: moist skin, skin necrosis Integumentary: brittle nails; transverse ridging; changes in developing teeth, lack of tooth enamel; dry, scaly skin; hair loss on scalp/body R. Stent Winter 2025 NRSG 311 44  Clinical Manifestations of Hyperparathyroidism and Hypoparathyroidism Hyperparathyroidism Hypoparathyroidism Musculoskeletal: backache, osteoporosis, Musculoskeletal: skeletal radiograph changes, compression fractures of spine, pain on weight osteosclerosis; soft tissue calcification; difficulty bearing, pathological fractures of long bones, walking, fatigue, painful muscle cramps, weakness skeletal pain; decreased muscle tone, muscle atrophy; weakness, fatigue Neurological: delirium, confusion, memory Neurological: disorientation, confusion, memory impairment, coma; emotional irritability, impairment; personality changes, irritability, personality disturbance, psychosis, depression; depression, anxiety, psychosis; headache; headache; hyperactive deep tendon reflexes; hyperactive deep tendon reflexes; paresthesias of paresthesias; poor coordination, abnormalities of perioral areas, hands, and feet; Positive gait, psychomotor retardation Chvostek’s or Trousseau’s sign; seizures; tremor Renal: hypercalciuria, kidney stones, polyuria, Renal: urinary frequency, urinary incontinence urinary tract infections Other: corneal calcification Other: eye changes, including lenticular opacities, R. Stent Winter 2025 NRSG cataracts, 311 papilledema 45  Conservative approach when asymptomatic/mild symptoms Hyperparathyroidis Annual examination: m: Serum calcium, creatinine clearance Evaluation of bone density Interprofessional Continued ambulation, avoidance of immobility Care Dietary measures High fluid intake, moderate calcium intake Supplement phosphorus if not contraindicated Medications lower calcium levels, do not treat underlying condition: Bisphosphonates, estrogen or progestin, oral phosphate, calcimimetic agents Surgical interventions are most effective Parathyroidectomy: partial or complete – outpatient, endoscopy Autotransplantation of normal parathyroid tissue (forearm/sternocleidomastoid)  continued PTH secretion R. Stent Winter 2025 NRSG 311 46  Parathyroidectomy patients receive similar care Hyperparathyroidism: to thyroidectomy patients Assess for signs of tetany post-operatively Neuromuscular hyperexcitability associated with sudden decrease in calcium levels Nursing Interventions Tingling in hands and around mouth, muscular spasms, laryngospasms Provide IV calcium if tetany occurs Monitor intake and output to evaluate fluid status Assess calcium, potassium, phosphate, and magnesium levels frequently Assess for Chvostek’s and Trousseau’s signs Encourage mobility to promote bone calcification R. Stent Winter 2025 NRSG 311 47  Primary goals: Treat acute complications (e.g. tetany) Hypoparathyroidis Maintain normal serum calcium levels m: Correct low magnesium levels Prevent long-term complications Emergency treatment of tetany: Interprofessional care Administer IV calcium Infuse slowly to avoid hypotension, cardiac dysrhythmias, or cardiac arrest Monitor ECG when calcium administered Nutrition: Oral calcium supplements usually prescribed High calcium meal plan, avoid foods containing oxalic acid (reduces calcium absorption) PTH replacement not recommended: expensive, need for parenteral administration Vitamin D to enhance intestinal calcium absorption and bone resorption Monitor calcium level 3-4 times a year R. Stent Winter 2025 NRSG 311 48  Hypoparathyroidism: Nursing Interventions Ensure IV patency IV calcium can cause venous irritation, inflammation, and extravasation May cause cellulitis, necrosis, and tissue sloughing Instruct to breath in and out of paper bag or breathing mask Rebreathing may partially alleviate acute neuromuscular symptoms associated with hypocalcemia R. Stent Winter 2025 NRSG 311 49  Hyper- and Hypoparathyroidism Patient and Family Teaching Educate about meal plans and lifestyle Refer to dietitian if needed Importance of exercise program: immobility can aggravate bone loss Encourage to keep regular appointments and adherence to treatment Inform patient of need for lifelong treatment and follow-up care Explain tests being performed Instruct about symptoms of hypocalcemia or hypercalcemia and to report if they occur R. Stent Winter 2025 NRSG 311 50  Break 9/4/20XX Presentation Title 51  Prediabetes Type 1 and 2 Diabetes Mellitus Hypoglycemia Diabetic Ketoacidosis Diabetes Hyperosmolar Hyperglycemic Syndrome Diabetes Insipidus Gestational Diabetes R. Stent Winter 2025 NRSG 311 52  Intermediate stage between normal glucose homeostasis and Diabetes Mellitus Fasting or 2-hour plasma glucose level Pre-Diabetes: higher than normal, lower than diagnostic Impaired level for DM Risk for developing DM and its complications Glucose Long-term damage to body (e.g. heart, blood Tolerance vessels) can begin with prediabetes (IGT) or Often no symptoms Impaired Regular blood glucose and A1C testing, self- monitor for signs of DM Fasting If action taken, can delay or prevent type 2 Glucose DM Maintain healthy weight, regular exercise, healthy diet, medications when required R. Stent Winter 2025 NRSG 311 53  Normally: Insulin produced by β cells (Islets of Langerhans) and released continuously into bloodstream Small increments with larger amounts released after food to stabilize blood glucose range to 4-6mmol/L Diabetes Mellitus: Diabetes Chronic disease affecting multiple systems, related to abnormal insulin production and/or impaired insulin Mellitus: utilization May be caused by genetic, autoimmune, viral, and/or environmental factors Type 1 Diabetes Mellitus: Etiology and Pancreas does not make insulin Pathophysiology Body’s immune system attacks islet cells Type 2 Diabetes mellitus: Pancreas makes less insulin than it used to Body becomes resistant to insulin R. Stent Winter 2025 NRSG 311 54  Critical Thinking A 55-year-old man with a BMI of 32 kg/m² reports increased thirst, frequent urination, and fatigue for the past month. He has a family history of diabetes. Blood tests reveal a fasting blood glucose level of 8.5 mmol/L and an HbA1c of 7.5%. 1. What symptoms suggest diabetes mellitus? 2. Based on the lab values, how would you classify this patient’s condition? 3. Name one non-pharmacological and one pharmacological intervention for this condition. R. Stent Winter 2025 NRSG 311 55 Diabetes Mellitus: Clinical Manifestations Type 1 DM Type 2 DM Classic symptoms: Non-specific symptoms Polyuria: frequent May have classic urination symptoms of Type 1 Polydipsia: Excessive Fatigue thirst Recurrent infections Polyphagia: Excessive Recurrent vaginal yeast or hunger monilia infection Weight loss Prolonged wound healing Weakness Visual changes Fatigue R. Stent Winter 2025 NRSG 311 56 R. Stent Winter 2025 NRSG 311 57 Diagnostic Studies related to DM Hemoglobin A1C: recommended diagnostic test Determines glycemic levels over time Amount of glucose attached to hemoglobin molecules over RBC lifespan (approx. 120 days) > 6.5% Fasting plasma glucose > 7mmol/L Random/casual plasma glucose > 11.1mmol/L Two-hour plasma glucose level in 75g oral glucose tolerance test > 11.1mmol/L R. Stent Winter 2025 NRSG 311 58 Diabetes Mellitus: Interprofessional Team Members who may be Involved Optometrist/ Dentist: regular Podiatrist: foot Dietitian: nutrition Ophthalmologist: dental examinations, counseling and regular eye examinations proper footwear support examinations Primary care Nursing: wound Laboratory techs: provider: monitor Pharmacist: fill care, education, regular blood for risk factors, prescriptions, support in tests medications, provide education community and order tests, etc. acute settings Diabetes nurse And others as educator needed R. Stent Winter 2025 NRSG 311 59  Goals: Decrease symptoms Diabetes Mellitus: Promote well-being Prevent acute complications Interprofessional Delay onset and progression of long- Collaboration and term complications Nursing Requires a collaborative Interventions approach: Medication management Diagnostics, screening, and monitoring Dietitian/nutritional therapy Blood glucose monitoring Exercise program R. Stent Winter 2025 NRSG 311 60 R. Stent Winter 2025 NRSG 311 61  Encourage active participation in care and treatment plan Diabetes Self-monitoring of blood glucose Medication therapy Mellitus: Exercise, regular physical activity, and nutrition Maintaining healthy bod weight Patient Stress importance of proper foot care, regular eye exams, and regular dental care, consistent glucose monitoring, diligent skin and hygiene care Family Educate about signs, symptoms, and management of Education hypo- and hyperglycemia When to seek emergency treatment R. Stent Winter 2025 NRSG 311 62  Patient with New Diagnosis of Diabetes Mellitus: Nursing Management Can they understand key concepts to self- Cognitive: administer? Remember their regimen? Psychomotor: Are they physically able to perform the steps? Do they accept their diagnosis? Ready to learn? Affective: Emotions and attitudes towards treatment plan? Attend to profound Significant lifestyle changes, demands on time impacts of diagnosis: and energy, fear of complications Supportive and non-judgmental attitude, collaborative teaching and care planning, Nursing Approach: consideration of patient context and support system R. Stent Winter 2025 NRSG 311 63  Chronic complications of diabetes Eyes: damage to small blood vessels, impact vision Kidney: damage to small blood vessels, decreased kidney function Stroke: blood clots prevent blood supply to part of brain Heart: blood vessels blocked with fat, poor blood supply to heart, can cause MI Nerves: damage to tiny blood vessels of nerves, affect how nerves work (diabetic neuropathy) Feet: damage to blood vessels, loss of sensitivity, more vulnerable to injury Integumentary: delayed healing Infection: more susceptible, impaired inflammatory response, loss of sensation delaying detection R. Stent Winter NRSG 311 64 2025  Diabetes Mellitus Management: Nutritional Therapy Key aspect of care for patients with diabetes Can be very challenging Glycemic Index: rise in blood glucose levels after carbohydrate-containing food is consumed Needs to be considered when meal plan is formulated Important to connect with interdisciplinary team for support Diabetes nurse educator Registered dietitian with diabetes experience Patient and family teaching: Often initially provided by dietitian Alcohol: high calorie, no nutritive value, promotes hypertriglyceridemia, detrimental to liver, can cause severe hypoglycemia Carbohydrate counting, plate method to help visualize ideal portions R. Stent Winter 2025 NRSG 311 65  Nutritional Therapy: Type 1 and Type 2 Diabetes Mellitus Type 1 Diabetes: Meal plan around individual’s usual food intake Balance with insulin and exercise pattern Insulin regimen managed day to day Type 2 Diabetes: Emphasis is on achieving glucose, lipid, and blood pressure goals Calorie reduction is likely necessary R. Stent Winter NRSG 311 66 2025  Diabetes Mellitus Management: Exercise Essential to diabetes management Increases insulin receptor sites Lowers blood glucose levels Contributes to weight loss R. Stent Winter 2025 NRSG 311 67  Diabetes Mellitus Management: Blood Glucose Monitoring Patient and Family Teaching: Self-Monitoring Encourage participation Emotional/physical stress can increase blood glucose ( illness, Detects episodic hyper- and injury, surgery) hypoglycemia Immediate information about Testing instructions: blood glucose levels Wash hands with soap and warm water Patients must be educated Cleaning site with alcohol may artificially lower test results If difficulty obtaining adequate blood drop: warm hands, let Continuous Glucose Monitoring arm hang, use higher setting on lancing device New lancet for every puncture Displays glucose values, Use side of finger pad rather than centre (fewer nerve endings) updating every 1-5 minutes Helps identify trends, track Puncture only deep enough to obtain sufficient drop patterns Dispose of lancets in designated sharps containers R. Stent Winter 2025 NRSG 311 68  Medication Management for Diabetes Mellitus Oral Medications for Type 2 Insulin Therapy Diabetes Ranging from one to four injections per Work on: day Insulin resistance Basal-bolus regimen most closely Decreased insulin production mimicking endogenous insulin Increased hepatic glucose production production: Examples: Bolus: Rapid- or short-acting insulin before Sulphonylureas, Meglitinides, Biguanides, meals α-Glucosidase Inhibitors, Basal: Intermediate- or long-acting Thiazolidinediones background insulin once or twice a day Patient and family teaching: Goal: achieve near-normal glucose level Avoid oral antihyperglycemics when dehydrated of 4-7mmol/L before meals Continue insulin when ill or dehydrated, R. Stent Winter 2025 NRSG supplement 311 food intake with 69 Insulin Administration Administered via subcutaneous injection Abdomen preferred site (fastest absorption) Next choices: arm, thigh, then buttock Rotate injections within one particular site Avoid sites that will be exercised Usually available as U100 (1mL = 100 units of insulin) 45-90 degree angle (depends on fat thickness) Can be administered via IV when indicated R. Stent Winter 2025 NRSG 311 70 Table 52.3 R. Stent Winter 2025 Presentation Title 71 FIG. 52.5 Mixing insulins This stepwise process avoids the risk of contaminating regular insulin with intermediate-acting insulin. R. Stent Winter 2025 NRSG 311 72 Insulins: Onset, Peak, and Duration of Action R. Stent Winter 2025 NRSG 311 73 Safety Check Point: Insulin Administration in Hospital Settings Insulin is one of the top 5 medications implicated in medication incidents associated with death in Canada When given in hospital, requires a standard two- nurse check (independent double check) before administration R. Stent Winter 2025 NRSG 311 74  Patient and Family Teaching for Insulin Therapy Administration instructions: Insulin storage: Wash hands thoroughly Do not heat/freeze Check insulin type, expiration, inspect for clumping, Can be stored at room precipitation, clarity, colour Gently roll container if cloudy temperature up to 4 weeks Remove needle cover, pull plunger to line for units required, put Refrigerate extra insulin needle into vial and push air in. Turn vial upside down, slowly Avoid exposure to direct push plunger up and down to remove bubbles, pull plunger to sunlight line for dose Check dose is correct, no large air bubbles, remove syringe Select injection site, do not need to cleanse with alcohol in Insulin regimens may be community, may be done in hospital to avoid hospital-acquired overwhelming for infections patients. Include patient With/without skin lift (pinch skin) insert 45-90 degrees; do not in planning, ensure aspirate regimen is manageable After injecting, leave in place for 5 sec, ensure all insulin for them. injected, remove needle, release skin. Do not recap needle, R. Stent Winter 2025 dispose NRSG 311 in sharps 75  Assessing Patients treated with Antihyperglycemic Agents Effectiveness of Adverse events Self-management therapy Hypoglycemic episode Manages hypoglycemic episodes, able Symptoms of hyper- or frequency, time of day, to analyze/determine cause hypoglycemia precipitating events Able to adjust dose appropriately and Blood glucose record Nightmares, night sweats, communicate circumstances showing good/poor early morning headaches control Aware of treatment regime Rashes, GI upset, ankle Aware/able to follow nutrition Is Hemoglobin A1C edema, weight gain consistent with recommendations correlating with glucose records? Atrophy or hypertrophy at insulin peak action, and perform blood injection sites glucose monitoring appropriately R. Stent Winter 2025 NRSG 311 76 How to support patients experiencing challenges with management plans Supportive, non-judgmental approach Assess readiness to learn, readiness for change, level of knowledge Identify patient and family priorities, what is important to them, assist with identifying realistic goals Individualize care plan: consider context, barriers, support system Involve patient and support people in care plan and treatment decisions Discuss importance of following the management plan, risk factors Identify barriers to following management plan Discuss adverse effects and safety issues, how to minimize risks R. Stent Winter 2025 NRSG 311 77 Connect patients with resources to help with adjustment,  Nursing Process related to diabetes mellitus: Nursing Diagnoses and Planning Nursing Diagnoses: Ineffective health management resulting from insufficient resources (deficient knowledge of diabetes management) Risk for unstable blood glucose levels related to insufficient diabetes management Planning – Overall goals: Active participation and self-care Few/no episodes of acute hyperglycemic emergencies or hypoglycemia Maintain normal blood glucose levels Prevent or delay chronic complications Adjust lifestyles with minimal stress R. Stent Winter 2025 NRSG 311 78  Nursing Process related to diabetes mellitus: Implementation of Acute Interventions Hypoglycemia Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic Nonketotic Syndrome Stress of illness and surgery Increased blood glucose level Continue regular meal plan and increase intake of noncaloric fluids Continue taking oral agents and insulin Frequent monitoring of blood glucose Ketone testing if glucose >14mmol/L Surgery or Radiological procedures requiring contrast medium: Hold metformin day of surgery and for 48 hours R. Stent Winter 2025 NRSG 311 79  Critical Thinking A nurse is educating a patient newly diagnosed with Type 1 diabetes on insulin administration. Which statement made by the patient indicates a need for further teaching? a) "I will rotate injection sites each time I administer my insulin.” b) "I can mix my glargine insulin with regular insulin in the same syringe to reduce injections.” c) "I will check my blood sugar before administering my insulin dose.” d) "If I experience symptoms of low blood sugar, I will eat a fast-acting carbohydrate.” R. Stent Winter 2025 NRSG 311 80  Critical Thinking A nurse is explaining how to treat hypoglycemia to a patient taking insulin. Which of the following options is the most appropriate treatment? a) 8 ounces of whole milk b) 4-6 ounces of orange juice c) 2 teaspoons of peanut butter d) 10 crackers with cheese R. Stent Winter 2025 NRSG 311 81  Critical Thinking A patient is prescribed a sliding scale insulin regimen. The nurse knows that this involves administering insulin based on: a) The time of day. b) The number of carbohydrates consumed during a meal. c) The patient’s current blood glucose level. d) The patient’s body weight. R. Stent Winter 2025 NRSG 311 82  Hypoglycemia: Cause and Clinical Manifestations Low blood glucose: 4mmol/L Provide regularly scheduled meal/snack to prevent rebound hypoglycemia Check blood sugar again 45 min after treatment If not alert enough to swallow: 1mg glucagon IM or SC After recovery, ingest complex carbohydrate Acute care settings: 20-50mL of 50% dextrose IV push R. Stent Winter 2025 NRSG 311 84 Diabetic Ketoacidosis (DKA): Cause and Clinical Manifestations Cause: profound deficiency of insulin Most likely to occur in Type 1 Glucose cannot be properly used for energy, body breaks down fat stores Ketones, by-products of fat metabolism, alter pH balance, cause metabolic acidosis Ketone bodies excreted in urine, electrolytes become depleted Precipitating factors: Illness, infection, inadequate insulin dosage, undiagnosed Type 1 DM, poor self-management Clinical Manifestations: Hyperglycemia, ketosis, acidosis, dehydration Polyuria, polydipsia, lethargy, weakness, dehydration (poor skin turgor, dry mucous membranes, tachycardia, orthostatic hypotension), abdominal pain, Kussmaul’s respirations (rapid deep breathing, attempt to reverse metabolic acidosis), sweet fruity odour to breath R. Stent Winter 2025 NRSG 311 85  Diabetic Ketoacidosis: Treatment and Nursing Actions Medical emergency, requires prompt diagnosis Fluid resuscitation and maintenance Insulin therapy Electrolyte replacement Close monitoring of glucose, vital signs, and electrolytes to prevent complications Supportive care R. Stent Winter 2025 NRSG 311 86  Hyperosmolar Hyperglycemic Syndrome (HHS): Cause and Clinical Manifestations Medical emergency with high mortality rate Life-threatening syndrome, often occurs with Type 2 DM Less common than DKA Caused by: Very high blood glucose for long period of time Enough circulating insulin that ketoacidosis does not occur; produces fewer symptoms in earlier stages Often underlying condition such as infection that contributes to high blood sugar Clinical manifestations: Severe dehydration and highly concentrated blood (high osmolality) Neurological manifestations due to increased serum osmolality; confusion, mental status changes, delirium, hallucination, loss of consciousness, weakness or paralysis, seizures, coma; polydipsia, polyuria Laboratory Values: Blood glucose >34mmol/L, increased serum osmolality, absent or minimal ketone bodies R. Stent Winter 2025 NRSG 311 87 Hyperosmolar Hyperglycemic Syndrome: Treatment and Nursing Management Treatment: Similar to DKA but requires greater fluid replacement Nursing management: Monitor closely for signs of potassium imbalance, cardiac status, and vital signs Administer IV fluids, insulin therapy, and electrolytes Assess renal status, cardiopulmonary status, and level of consciousness R. Stent Winter 2025 NRSG 311 88  Critical Thinking A nurse is caring for a patient admitted with diabetic ketoacidosis (DKA). Which of the following findings would the nurse expect during the initial assessment? a) Blood glucose of 8 mmol/L, shallow respirations, pH 7.45 b) Blood glucose of 30 mmol/L, fruity breath odor, pH 7.25 c) Blood glucose of 7 mmol/L, normal breath odor, pH 7.35 d) Blood glucose of 5 mmol/L, rapid respirations, pH 7.40 R. Stent Winter 2025 NRSG 311 89  Critical Thinking What is the nurse's priority intervention for a patient with DKA? a) Administer sodium bicarbonate to correct acidosis. b) Start an insulin infusion immediately to lower blood glucose. c) Begin IV fluid resuscitation to address dehydration. d) Administer potassium supplements regardless of serum potassium levels. R. Stent Winter 2025 NRSG 311 90  Critical Thinking Which of the following findings differentiates Hyperosmolar Hyperglycemic Syndrome (HHS) from Diabetic Ketoacidosis (DKA)? a) HHS is more common in Type 1 diabetes, while DKA is more common in Type 2 diabetes. b) HHS is associated with significant ketonemia, while DKA is not. c) HHS typically has a higher blood glucose level and lacks significant ketoacidosis. d) HHS has an arterial pH of 7.3. R. Stent Winter 2025 NRSG 311 91  Diabetes Insipidus: Etiology and Pathophysiology Group of conditions: Associated with deficiency of ADH production or secretion and decreased response to ADH Decreased ADH  fluid and electrolyte imbalance: Caused by increased urinary output, increased plasma osmolality ADH deficiency: Inability to conserve water; permeability to water is diminished  excretion of large volume hypotonic fluid May be: Fig. 51.4 Pathophysiology of diabetes insipidus Transient or chronic/lifelong R. Stent Winter 2025 NRSG 311 92 Diabetes Three patterns may develop: Insipidus: Transient diabetes insipidus: abrupt onset, first few Classifications and days after neurosurgery, then resolves Causes Permanent diabetes insipidus: abrupt, early onset, persists several weeks or life Triphasic diabetes insipidus: acute phase with abrupt onset of polyuria; interphase, urine volume seems to normalize; third phase, permanent central diabetes insipidus Table 51.3 R. Stent Winter 2025 NRSG 311 93  Diabetes Insipidus: Clinical Manifestations, Assessment, and Diagnostics Clinical Manifestations Assessment: Genitourinary: Polyuria (5-18L/day of clear urine), frequency, nocturia Initial identification of cause If oral intake cannot keep up with losses  severe fluid (central, nephrogenic, or volume deficit, low urine osmolality, severe dehydration, risk psychogenic) imperative Complete history, thorough of hypovolemic shock Gastrointestinal: physical examination Weight loss, constipation Polydipsia (if thirst mechanism is intact) Diagnostics: Integumentary: Water deprivation test: significant Dry skin and mucous membranes, poor tissue turgor increase in urine osmolality Neurological: indicates Central DI, no response Mentation changes due to electrolyte imbalance and indicates Nephrogenic DI Very low urine specific gravity hypotension: irritability, mental dullness, coma Cardiovascular: (