Nursing care of client with endocrine system disorder

Endocrine - Made up of gland in many tissues & organs in diff. body areas Main feature of all endocrine gland is the secretion of hormones -Maintenance and regulation of vital functions -Response to stress injury -Growth and development -Energy metabolism -Reproduction -Fl & elec., acid base balance

Hormones
- Are natural chemical substances that initiate or regulate activity and exert their effect on specific tissues known as Target tissues.

Target Tissue
- Are usually located some distance

from the endocrine gland with no direct physical connection bet. the endocrine gland & its target tissue. Then endocrine gland are called ductless gland and must be used the blood to transport secreted hormones to the target tissue.

Negative Feedback
- The level of hormone in the blood is regulated by the homeostasis called Negative feedback Ex: control of insulin secretion - Inc level of bld glucose, the hormone insulin is secreted thus inc glucose uptake by the cells ->causing a dec in bld glucose.

The FF: Endocrine Gland

1. Islets of langerhans:Pancreas 2. Pituitary Glands 3. Adrenal Gland 4. Thyroid gland 5. Parathyroid gland 6. Gonads

Pancreas
- Located posterior to the liver; it influence Carbohydrate metabolism; indirectly influence fat and protein metabolism; produces insulin and glucagon 1. Glucagon-

raises blood glucose 2. Insulin lower blood glucose 3. Somatostatin inhibits secretion of insulin, glucagon, and growth hormone from the Anterior pituitary and gastrin from the stomach

Anterior Pituitary
1. TSH- thyroid stimulating hormone
stimulates thyroid growth and secretion of the thyroid hormone

2. ACTH- Andrenocorthropic hormone

stimulates adrenal cortex growth and secretion of glucocorticoids

3. GH-growth hormone stimulate growth 4. Prolactin or lactogen Stimulate breast

development during pregnancy and milk secretion after delivery

AnteriorPituitary Glands
5. FSH-Follicle stimulating hormone stimulates ovarian follicles to mature and produce estrogens; in the male stimulates sperm production 6. LH-luteinizing hormone Acts with FSH to stimulate estrogen production; causes ovulation; stimulates progesteron production by corpus luteum; in male stimulate testes to produce testosterone 7. Melanocytes stimulating hormone synthesis and spread of melanin in the skin

Posterior pituitary
1. ADH Antidiuretic hormone stimulate water retention by kidneys to decrease urine secretion 2. Oxytocin stimulate uterine contraction, causes breast to release milk into ducts

Thyroid gland
1. Thyroid hormone(thyroxine T4 and TriidothyronineT3) increases metabolic rate 2. Calcitonin decreases blood calcium concentration

Parathyroid gland
1. Parathyroid hormone - increases blood calcium concentration ADRENAL CORTEX 1. Glucocorticoids(Cortisol,hydrocortisone) stimulate gluconeogenesis and increase blood glucose, antiinflammatory, antiimmunity;antiallergy 2. Mineralocorticoids regulates electrolyte and fluid homeostasis 3. Sex hormones(androgen) stimulates sexual drive in females; in male negligible effect

Adrenal Medulla
1. Epinephrine( adrenalin) prolongs and intensifies sympathetic nervous response to stress 2. Norepinephrine prolongs and intensifies sympathetic nervous response to stress

Diagnostic evaluation with endocrine disorder

Laboratory studies: 1. Test of thyroid to differentiate primary and secondary hypothyroidism 2. Serum thyroid-stimulating hormone to measure the basal serum thyroid-stimulating hormone concentration 3. Serum thyroxine and triiodothyronine to measure concentration of thyroxineT4 (T3) in the blood 4. Test of parathyroid function to measure the concentration of calcium, phosphorus, alkaline, phosphatase, parathyroid hormone and osteocalcin in the blood

Diagnostic evaluation with endocrine disorder 5. Test of adrenal function to measure concentration of adrenocortical hormones and adrenal medullary hormones through urine and blood specimen 6. Aldosterone levels aids in the diagnosis of hyperaldosteronism 7. Urine catecholamines to assess function of the adrenal medulla

Diagnostic imaging and other studies

Test for thyroid structure & function to assess the size, shape, position, and function of the thyroid through ultrasound, MRI, CT scan, & radionuclide imaging Radioactive iodine Uptake to measure the amount of radioactive iodine in the thyroid 24h after administration of a radioiodine isotope through scintillation scanner Achilles Tendon Reflexes to diagnose thyroid disorders by measuring the amplitude and duration of ankle jerk using an instrument that will help to elicit the reflex

Care of patient with Pituitary Disorders

HYPERPITUITARISM - Oversecretion of hormone due to tumor or hyperplasia -> compresses brain tissue -> neurologic S&S: ICP, Visual changes, headache - Hormone affected: Growth hormone & ADH - Resulting to Gigantism if the secretion occurs in childhood; in Adult Acromegaly

a. Acromegaly
Pathology: - GH hypersecretion during adulthood Risk: Pituitary adenoma Cardinal Signs: large hands and feet; protrusion of lower jaw(Prognathism). Coarse facial feature Nurse Concern: Psychosocial adjustment to Altered body image; monitor Diabetes Insipidus

b. Dwarfism
- due

to hyposecretion of growth hormone Nursing Intervention: Assess patient using DDST Monitor height and weight Assess other neurologic functions Focus on the family clients feeling Medical Mgt: Biosynthetic growth hormone Somatrem

b. Gigantism
- Results from excessive secretion of growth hormone Clinical manifestation:  Height more than 8 feet  Acromegaly Medical Mgt:  Radiation therapy  Parlodel  Transphenoidal hypophysectomy

Panhypopituitarism (Simmonds Disease)

-complete absence of pituitary secretion resulting to: Dwarfism Hypoglycemia Extreme weight loss Hair loss Emaciation Impotence hypometabolism absence of gonadal & adrenal function Atrophy of all endocrine gland and organs

Medical/surgical Mgt

1. 2. 3. 4.

Transphenoidal hypophysectomy Stereotactic radiation therapy Bromocriptine octreotide

Nursing Mgt. who Undergone Transphenoidal Hypophysectomy removal of the Pituitary gland Assess inc. ICP & CSF leaks Monitor seizure and stress ulcer Elevate head 20 degrees Apply cool, moist packs over the eyes foe ecchymosis and periorbital edema Adm. artificial tears or ointment as ordered Use sterile technique for all dressing to prevent meningitis Do not suction through the nose

Type of hypophysectomy & Ng Consideration

1. 2. Supratentorial surgery elevate head of the bed to 30 degrees Infratentorial surgery keep client flat on bed to prevent pressure on the brainstem. Turn q 2 h but never on the back Posterior Fossa surgery position on either side but never on the back. A pillow may be placed under the head for support, Monitor VS changes since the site close to vital brain stem function, monitor cardiac arrhythmias and air embolism Bony Flap place the client only on the unoperated side or back

3.

4.

3. Hyperpituitarism - Results from excessive secretion of hormones produced by the pituitary gland caused by tumor S&S: Gigantism, acromegaly galactorrhea,Visual field abnormalities, headache Surgical Mgt: - Removal of the tumor

Hyperprolactinemia
- Results from oversecretion of prolactin associated with pituitary tumors - Mgt and Ng Mgt same as hyperpituitarism

Nursing Intervention after surgery

Monitor VS Monitor LOC Orient to time, place and person Check response to stimuli Assess visual acuity Monitor hormonal insufficiencies Monitor ICP

4.

Hypopituitarism

- Result from destruction of the anterior pituitary gland, hypothalamic dysfunction, trauma, tumor, vascular lesion, and complication of radiation therapy to the head and neck area S&S: - Extreme weight loss Emaciation - Hypoglycemia Impotence - Amenorrhea Hypometabolism

5. Pituitary

tumor

Types: 1. Eosinophilic result to gigantism if developed early in life and acromegaly if developed during adult life 2. Basophilic results to cushings syndrome; clinical manifestation: amenorrhea & masculinization in females, truncal obesity, HTN, osteoporosis & polycytemia 3. Chromophobic produces no hormone but destroys the whole pituitary glands resulting to hypopituitarism. S&S: obesity, somnolence, scanty hair, dry, soft skin, loss of libido, headache, blindness, polyphagia, polyuria, and lowered BMR

6. Gonadal Disorder
- Result from hypothalamic-pituitary dysfunction resulting to hyposecretion of gonadotropins may lead to infertility and hypoandrogenism - Collaborative Mgt: - Removal of the underlying cause of pituitary dysfunction

Posterior Pituitary Disorders

SIADH Syndrome of Inappropriate Antideuritic Hormone resulting from abnormal increase of ADH secretion & excessive water retention leads to inc urinary sodium Etiology: Bronchogenic carcinoma, head injury, tumor, infection, and brain surgery Cardinal signs: water intoxication, neurologic signs Medical Mgt: Diuretics & Demecclocycline (declomycin) Eliminate underlying cause 1.

Nurse Concern
Check daily weight Oral fluid restriction, IV with hypertonic solutions Monitor I&O & weight Assess clients neurologic status Monitor urine and blood chemistries

2. Diabetes Insipidus
- A condition characterized by a defficiency in antideuritic hormone resulting to excessive fld excretion: neurogenic and nephrogenic Risk: head trauma, irradiation, removal of pituitary gland, renal disease Manifestation: diluted urine, polydipsia, excessive urination Dx: vasopressin and H20 deprivation test; serum Na inc &UA Cardinal signs: Polyuria, Polydipsia

2. Diabetes Insipidus
Medical Mgt: - Vasopressin/petressin replacement (desmopressin) - Thiazide diuretics - Chlorpropamide (diabinese) - Clofibrate (Hypolipidemic agent) - Advice the client to wear a medical alert bracelet - IV hypotonic; MIO, weight, low Na & no caffeine

Care of patient with Abnormal thyroid Function

1. Hypothyroidism/myxedema due to decreased thyroid hormone concentration in the blood result in hypometabolism: cretinism, myxedema, iodine dficiency, Hashimotos thyroiditis Risk: congenital, elderly, infection, iodine deficiency, antithyroid medication, undiagnosed Dx: Inc TSH, dec T3T4; dec RAIU with thyroid suppression test

Cardinal Signs
Cold intolerance Non-pitting edema Anorexia All symptoms are dec Fatigue mask-like face Medication: Levothyroxine; Synthroid, Liotrix, IV glucose for hypoglycemia Nurse Concern: Monitor both hypo &hyper symptoms Monitor VS, weight and toxicity Avoid cabbage, carrots, spinach, turnips and peaches

Hyperthyroidism/GRAVES DISEASE
Pathology: due to excessive secretion of TH -> oxygen consumption & heat production: Graves, Parrys Baseows, Exophthalmic goiter, toxic diffuse goiter Risk: stress, injury, infection, surgery, female, immunologic, excessive prothyroid meds DX: dec TSH inc T4T3, Inc RAIU with thyroid suppression test

Cardinal signs:
Heat intolerance inc appetite All symptom elevated except weight, sex drive, fluid volume S&S: thyroidism T- tremor I-intolerance to heat H-heart rate up D- diarrhea Y-yawing/fatigability I irritability R- restlessness S- sweating O-oligomenorrhea &amenorrhea muscle wasting &wt. loss DOC: i met a pro: Methimazole(tapazole) & Propylthiouracil (PTU) Nursing Intervention:

Nursing interventions
Monitor VS Advice to wear eye patch during night if exompthalmus is present Advice to wear sunscreen

Keep environmental cool Caloric requirement is 4000 5000/day Post op care: thyroidectomy; monitor complications: hemorrhage, respi distress, laryngeal nerve damage & tetany

Thyroiditis
- Inflammation of the thyroid gland S &S:  Pain & swelling of the anterior neck  Pharyngitis or pharyngeal pain  Dysphagia Dysphonia DOC: ORAL CORTICOSTEROIDS; NSAIDs; antimicrobial Collaborative Mgt:  Surgical incision & drainage  Fluid replacement  Avoid ASA coz it displaces thyroid hormone from its binding sites and inc the amount of circulating hormone

Thyroid tumors
Classified as benign or malignant, on the basis of the presence or absence of associated thyrotoxicosis Types: 1. Endemic goiter iodine-deficit goiter mostcommon type as caused by iodine deficiency 2. Nodular nodules inc in size, with some descending into the thorax

Medical/surgical Mgt Thyroidectomy Anticoagulants are stopped several weeks before surgery Nursing Intervention: Preop: Prepare quite and relaxing forms of recreation/occupational therapy Teach the importance of a diet in CHO &CHON Demonstrate how to support the neck with the hands to prevent stress on the incision

Postop care Position the patient in the most comfortable position (semi-Fowlers) Manage pain Assess the surgical dressing periodically & reinforce when necessary Monitor VS For indication of bleeding, and sensation of fullness at the incision site Assist patient to eat foods that are easily eaten Prescribe a well-balanced diet, high calorie to promote wt gain

Care of client with abnormal parathyroid Function 1.Hypoparathyroidism hyposecretion of parathyroid hormone by the parathyroid gland S&S: latent tetany: numbness, tingling, cramps, stiffness of hands and feet Overt tetany: bronchospasm, lyngospasm, photophobia, dysrhythmias, hyperphosphatemia Anxiety, irritability, depression, delirium Positive Chvosteks signs & trousseaus signs Thin, patchy hair, brittle nails, dry scaly skin Cataract formation

Medical & Surgical Mgt: Elevate the serum calcium level to 9 10mg/dl Calcium gluconate IV in Hypoparathyroidism & Hypocalcemia Parenteral parathormone, bronchodilators, Phenobarbital Tracheostomy or mechanical ventilation High calcium, low phosphorous diet Oral calcium salts, aluminum hydroxide gel or aluminum carbonate Vit D

Nursing Intervention: Closely monitor for allergy to parathormone Instruct to avoid milk, amd milk products, eggyolk, spinach For acute Hypoparathyroidism:
 Administer IV calcium gluconate  Monitor hypocalcemiaa, tetany, seizure, & respi distress  Monitor for convulsion & protect from injury  Monitor for cardiac Arrhythmias  Administer calcium supplement & Vit D as prescribed

2. Hyperparathyroidism Pathology: inc PTH -> Hypercalcemia & hypophosphatemia -> bone decalcification, renal calculi, metabolic acidosis (from inc CHO3 excretion) Risk: elderly, female, thyroid adenoma DX: Serumcalcium, & Phosphorous inc Cardinal Signs: bone pain S&S: Backache, joint pain,Polyuria, Polydypsia Kidney stone,Nausea, anorexia, constipation Abdominal pain, restlessness, depression, irritability, neurosis, psychosis

Medical & surgical Mgt:

Hydration therapy Loop diuretics, furosemide promote renal calcium secretion Avoid thiazide diuretic can inc calcium level DOC: calci, youre such as Pig( calcitonin, plicamycin, IV saline, Gallium nitrate inhibit bone resorption

Nursing intervention Encouraged fluid intake up to 3000ml/day Encouraged low calcium, low Vit D Monitor VS, cardiac dysrhythmias Assess skeletal pain Monitor I&O/ ECG Monitor calcium & phosphorous level Strain urine

Care of Client with Abnormal Adrenal functions: 1. Addisons disease

Pathology: chronic adrenocortical insufficiency -> hypovolemia -> shock(Addisons crisis) Risk: immunologic, removal of adrenals,infection and tumor of adrenals,m head rauma affecting pituitary withdrawal of corticoids DX: dec serum cortisol, dec sodium, Inc potassium and dec aldoterone; ECG (peaked T wave), ABG (acidosis)

Signs and Symptoms:

Cardinal signs: Hyperkalemia, bronze skin. Fatigue, diarrhea Muscle weakness, fatigue bronzed skin: knuckles, knees, elbows, mucous membrane Anorexia, wt loss, emaciation Postural hypotension, stress DOC: cortisone or florinef; IV glucocorticoid; fluid with Na

Nursing Interventions
Instruct patient to report inc thirst Provide Na and high in CHO & CHON Educate lifelong adrenal cortex hormone replacement Avoid beverages or foods with caffeine Instruct patient to avoid strenuous exercise in hot & humid environment Avoid OTC medication Avoid individual with infection Monitor VS Monitor blood glucose, & Potassium levels Maintain bed rest and provide a non stimulating environment Monitor I&O Monitor neurologic status

2. Adrenocortical Hyperfunction a. Cushing syndrome Pathology: Hypercortisolism/ hypersecretion of glucocorticoids and androgens due to overactivity of the adrenal gland Etiology: Pituitary tumors excessive corticosteroids DX: serum cortisol, Na, K+ and glucose; ACTH/ dexamethasone suppression test

Signs & Symptoms Cardinal signs: psychosis, Buffalo hump, truncal obesity with slender limbs, hirsutism, hypernatremia. moon face S&S: Muscle wasting, osteoporosis, kyphosis, backache, fractures Hypokalemia, metabolic alkalosis Hypertension. CHF Skin oiliness, acne Inc susceptibility to infection, dec resistance to stress Poor wound healing Menstrual irrigularities, loss of libido

Medical/Surgical Mgt:
Radiation therapy for pituitary tumors Cytoxic antihormonal agents Hydrocortisone therapy lifetime replacement of adrenal cortex hormones Adrenal enzyme inhibitors Transphenoidal hypophysectomy adrenalectomy

Nursing intervention

Provide High protein, calcium and Vit D and low NA, CHO and calories Promote rest and activity Nsg. Intervention after transphenoidal hypophysectomy Assess for signs of cerebral edema and rising of ICP Assess for signs of meningitis Observe client for rhinorrhea after nasal packing removed

b. Hyperaldosteronism or Conns syndrome)

Pathology: excessive secretion of aldosterone by the adrenal cortex of the adrenal gland,caused by adenoma S&S: Headache, fatigue, muscle weakness Polydepsia, polyuria, paresthesis, visual changes, hypernatremia low urine specific gravity Increased urinary aldosterone

Nursing Intervention
Monitor VS particularly BP Monitor hypokalemia Monitor I&O & urine specific gravity Administer potassium-sparing diuretics Administer antihypertensive as ordered Prepare client for adrenalectomy

3. Adenomedullary disorders 1. Pheochromocytoma Pathology: catecholamine-secreting tumor of the adrenal medulla; excessive secretion of epinephrine and norepinephrine Risk: genetics, middle age S&S: Cardinal signs: 5Hs:HTN, Headache, Hyperglycemia, Hyperhidrosis(excessive sweating, Hypermetabolism

S&S
Acute attack: profuse diaphoresis,dilated pupil, and cold extremities, extreme anxiety and weak, headache, vertigo, blurring of vission, tinnitus, air hunger, dyspnea, feeling of impending doom, palpitations, tachycardia -Clonidine suppression test reveals no change in cathecholamine levels

Medical /Surgical MGT Alpha-adrenergic blockers phentolamine Smoothes muscle relaxants-Na Nitroprusside for HNT Beta-adrenergic blocker Nursing Intervention: Standard pre/post op care Monitor BP,UO,glucose & ketones & neurologic signs Seizure precaution. Provide high CHO, Vit and minerals

Pancreas
Lies horizontally behind the stomach at the level of the 1st and 2nd lumbar vertebrae The head attached to the duodenum, tail reaching to the spleen With exocrine and endocrine function Produced two Impt. hormones: 1. Insulin: beta cells of islets of Lagerhans Decrease glucose levels: transcellular membrane transport of glucose; inhibits breakdown of fats and protein; requires Na for transport pf CHO; requires K for production

Glucagon
Alpha cells of Islets of Lagerhans Stimulates release of glucose by the liver Increases glucose levels (gluconeogenesis)

Diabetes mellitus
A chronic systemic disease characterized by disorder of CHO, CHON and fats Classifications: 1. Type 1: IDDM; Juvenile onset; Brittle; labile; 2. Type 2: NIDDM; Adult onset 3. Other Specific Types: beta cell genetic defect; endocrinopathies, drug/chemical induced 4. Gestational Diabetes mellitus

Diagnostic test
1. 2. 3. FBS: 80 120mg/dl- DM: Incr. 140 for 2 readings 2 h PPBS: initial bld is withdrawn , 100g of CHO diet, 2h after meal bld specimen is withdrawn bld sugar returns to normal level OGTT/GTT: initial urine & bld specimen are collected, 150-300g of CHO/po, series of bld. specimen is collected: 30min, 1h, 2h-S.CHO return to normal, 3, 4, 5 h as required; done when result of FBS/ 2h PPBS are borderline Glycosylated Hgb: most accurate; reflects s. CHO level for the past 3 -4 mos: excess glucose in the bld>attaches to Hgb-> hgb lifespan 90 120 days

4.

Predisposing Factors
Stress stimulates secretion of epinephrine, noeepiniphrine, glococorticoids increases CHO Heredity type 11 DM Obesity adipose tissues are resistant to insulin ->glucose uptake by the cell is poor Viral Infection increase risk to autoimmune disorders Autoimmune disorder type 1 DM Women - multigravida

Pathophysiology
-

Insulin Deficiency -> Hyperglycemia: a. -> Inc.bld osmolarity = ICF dhn b. Glycosuria -> glucose level exceeds renal threshold (180mg/dl) c. Polyuria - > glucose exerts high osmotic pressure within the renal tubules ->osmotic diuresis occurs - > hypovolemia ->ECF dhn. d. Polydipsia -> result from ECF/ICF dhn. e. Inc bld viscosity - > sluggish circulation -. Proliferation of microorganism - > infections. f. Polyphagia the cell are starved. - > inc lipolysis: -> a. Hyperlipidemia -> Atherosclerosis: Macroangiopathy: in brain CVA, Heart MI, Peripheral arteries PVDs( Peripheral vascular Disease); Microangiopathy: Kidneys RF, Eyes Retinopathy/cataract; Neuropathy: spinal cord/Autonomic Nervous system, paralysis, Gastroparesis, neurogenic bladder, dec libido, impotence, peripheral neuropathy, numbness /tingling b. Ketonemia: Acetone, acetoacitic acid, beta-hydroxy-butyric acid -> dec bld pHKETOACIDOSIS -> Ketonuria -> inc, CHON breakdown -> a. (-) Nitrogen balance b. Inc BUN, s creatinine c. Tissue wasting d. Weight loss e. Debilitation

Comparison of clinical manifestation of type 1 and type 2 Type 1 Type 2

Etiology-----------Autoimmune--------------genetic, obesity Age of onset -----rare before age 1--------incr with age % of diabetics-----5 -10% -----------85 90% Onset ---------------Abrupt, rapid ------------gradual, over yrs BW at Onset ------normal or thin ----------80% overweight Insulin Production ---None ------------------less, normal, greater Insulin Injection ------always ----------------30% are required Ketosis -------occurs mainly in children ---unlikely & adolescence Mgt. ----------insulin, diet, exercise -------diet, weight loss, exercise, oral or insulin

Signs & Symptoms Cardinal Signs: Polyuria, Polydipsia, polyphagia, Hyperglycemia (for type1: weight loss; type 2: weight gain) Vision changes Tingling, numbness in the hands/ feet, slow healing sores Fasting Plasma Glucose > 126mg/dl Random plasma glucose levels>200mg/dl

Medica/Surgical Mgt

Five components in Diabetes Mgt: 1. Nutrition/diet therapy 2. Exercise 3. Monitoring 4. Pharmacologic therapy 5. Education Insulin therapy Pancreas transplant

Nursing intervention
Encourage weight loss Instruct patient not to skip meals Monitor CHO intake Reduce saturated fats & cholesterol intake Increase dietary fiber intake Provide exchange list for meal planning Limit alcohol intake Educate about urine ketones testing, normal blood glucose range and medication Educate on the method of self-monitoring of blood glucose

Acute Complication of Diabetes

a. Hyperglycemia & Diabetic ketoacidosis absent/ markedly inadequate insulin production Three main Clinical features: 1. Hyperglycemia 2. Dehydration and electrolytes loss 3. Acidosis

Causes of DKA & Hyperglycemia

Taking too little insulin Omitting doses of insulin Developing insulin resistance due to insulin antibodies Failing to meet increased need for insulin due to infection, surgery, trauma, pregnancy or puberty

DKA VERSUS HHNS

Charac: DKA HHNS Patient affected type1 or 2 type1 0r 2 more in type1 more in type Precipitating omission of insulin, physiologic stress event stress physiologic infection, surgery CVA, MI,surgery MI, CVA Onset rapid< 24hr slower- days Bld glucose level >250mg/dL >600mg/dL >13.9mmol/L >33.3mmol/L Arterial pH <7.3 normal Serum&urine ketones present absent Serum osmolality 300-350mOsm/L >350mOsm/L Plasma bicarbonate <15 mEq/L normal BUN & creatinine Elevated elevated Mortality rate <5% 10 to 40%

Sign& Symptoms
Warm dry skin, nausea & vomiting Flushed appearance, dry mucous membrane, soft eyeballs Kussmauls respiration, fruity or acetone odor of the breath Alteration in LOC, Hypotension Polyuria early sign Oliguria late sign

Medical Mgt:
Fluids & electrolytes replacement K+ Continuous insulin infusion Nursing Intervention: Monitor blood glucose q 1 2 h Monitor LOC & neuro status and notify Monitor sign of hypo & hyperkalemia Monitor I&O Watch out for signs of fld overload Monitor for signs of ICP

b. HHNS Hyperglycemic Hyperosmolar NonKetotic Syndrome

Pathology: a variant of diabetic ketoacidosis characterized by extreme hyperglycemia, mild or undetectable ketonuria and absence of acidosis. Often see in aging clients with NIDDM Precipitating factor: Stress, infection, medication: thiazide, diuretics, steroids, phynetoin

Signs & symptoms

3Ps, glucosuria,dehydration, hyperpyrexia Abdominal discomfort, hypotension, shock, hyperventilation, neurologic signs Seizures, tachycardia MEDICAL Mgt: Fluid & Electrolytes replacement Insulin therapy

C. HYPOGLYCEMIA

Pathology: blood glucose levels <60mg/100ml SIGNS & SYMPTOMS: Tachycardia, headache, weakness, irritability Lack of muscular coordination Night hypoglycemia, Bizarre nightmares, restlessness, diaphoresis Sleeplessness, confusion

Nursing Intervention Mild hypoglycemia Administer fast acting sugar Perform blood glucose test at the onset of symptoms Retest the blood glucose in 15 30 min.& treat again if the blood glucose is not over 100mg/100ml Instruct to carry simple sugar at all time Instruct to refrain from eating high-calorie, high fat dessert foods in treating hypoglycemia

Hypoglycemia in Unconscious or Semiconscious

Glucagon may be given im or subcu 20 50 ml of 50% glucose bolus A longer acting CHO and CHON snack should follow either of the above tx once pt. is awake 1.Hypoglycemic Unawareness - A syndrome wherein the diabetic patient is unaware that he/she is hypoglycemic - Absence of clinical manifestation when glucose level is less than 55mg/dl

2. Hypoglycemia with rebound hyperglycemia

Known as SOMOGYI Phenomenon result from excessive evening dose of insulin Hypoglycemia occurs at around 2 4 AM which causes an increase in the production of counterregulatory hormones and increase production of glucose in the liver tx include the bedtime snack and dec the evening dose of intermediate-acting insulin

3. Dawn Phenomenon

Refers to an early-morning(48am) increase in the blood glucose level May cause by wearing off of insulin and nocturnal release of growth hormone

Chronic complication of DM
A. coronary artery disease - Due to diposition of lipids to the inner layer of the vessel walls - Most common cause of death in DM pt B. Cerebrovascular disease - Most common and severe in DM pt - Manifested by TIA and stroke - Most common form: atherothromboembolic infarction

C. HTN - HYPERTENSION - A major risk factor for the development of stoke and nephropathy D.PERIPHERAL VASCULAR DISEASE - Total or partial occlusion of the blood vessels resulting to deprivation of O2 and other nutrients to the extremities - May lead to the development of intermittent claudication, absent pedal pulses, ischemic gangrene, sensory and autonomic neuropathy and inc risk of infection

e. INFECTION

-Slow progression of wound healing due to damage blood vessel - 3 factors to the development of infection in DM Pt; 1. Polymorphonuclear leukocyte function 2. Neuropathies 3. Vascular insufficiency

Microvascular complication a. Diabetic retinopathy chronic and progressive impairments of the retinal circulation characterized by blurring of vission sec. to macular edema S&S: microaneurysm, intraretinal hemorrhage, hard exudates including sp, macular edema, blurry vision, floaters, cobwebs in the visual field, sudden visual changes , hazy vision, complete vision Mgt: Argon laser photocoagulation. Vitrectomy, maintain safety, control HTN and glucose level

B. Nephropathy
- Renal disease due to diabetic microvascular changes in the kidney S&S: albuminuria, anemia, thirst, frequent UTI, fatigue, malnutrition, weight loss Mgt: - Maintain bld glucose level - Control HTN, low Na & low CHON - Treat infection; I&O - Monitor BUN and Creatinine albumin level

NEUROPATHY - Deterioration of the nervous system throughout the body S&S: paresthesias, dec or absent reflexes, dec. sensation, burning sensation in the LE, poor peripheral pulses, dizziness, and postural hypotension, incontinence NG. Intervention: - Monitor VS, bld. glucose level, foot care, bladder training, administer analgesic as prescribed

Categories of Insulin Lispro (Humalog) rapid acting - onset-10 -15 min - duration 3h indication used for rapid reduction of glucose level, to treat postprandial hyperglycemia & to prevent nocturnal hypoglycemia Aspart (Novolog) -rapid acting onset 10 to15 min peak 40 to 50 min. duration 4 to 6 hr indication same as Lispro Regular (Humalog R, Novolin R, Iletin 11 regular I short acting onset -I hr peak 2-3 hr duration 4 to 6hr usually administered 20 30 min. AC; may be taken alone or in combination with longer acting Insulin

Categories of insulin

NPH(NEUTRAL PROTAMINE Hagedorn onset immediate acting onset 2-4hr peak 6- 12h duration 16 20hr usially taken PC Humulin N, Iletin11 lente,iletin11 NPH NOvolin L (Lente), Novolin N (NPH) immediate acting onset -3- 4 hr, peak 6 -12hr, duration 16 20 hr usually take with food

Insulin categories
Ultralente(UL) long acting,onset-6 to8 hr ,peak- 12 -16 hr, duration 20-30hr, used primarily to control fasting glucose level Glargine (Lantus) very long acting, onset iht, peak contionus no peak, duration 24 hr, used for basal dose

Complication of insulin therapy Local allergic reaction redness, swelling tenderness Systemic allergic reaction- local skin reaction Insulin lipodystrophy localized reaction in the form of either lipoatrophy( loss of subcutaneous fats and appears as slight dimpling or more serious pitting of subcutaneous fat) or lipohypertrophy( development of fibrofatty masses at the injection site

Insulin complication Insulin resistance common for obesse patient, and immune antibodies develop and bind the insulin Morning hyperglycemia insufficient level of insulin due to: dawn phenomenon (bld glucose begin to rise), Somogyi effect( nocturnal hypoglycemia followed by rebound hyperglycemia), insulin frequently seen in the evening waning