Diabetes/Endocrine (Module 3) Flashcards
Type 1 Diabetes
AUTOIMMUNE
pancreas doesn’t secrete insulin by beta cells
w/o insulin, DKA and severe metabolic disturbances can develop
Type 2 Diabetes
insulin resistance/secretory deficit with insulin deficiency
Polydipsia Symptoms
loss of skin turgor, skin warm and dry
dry mucous membranes
weakness/malaise
rapid weak pulse and hypotension
Polyphagia
excessive hunger and eating caused by inability of cells to receive glucose because of lack of insulin or cellular resistance to insulin and body use of protein and fat for energy (causes ketosis)
weight loss
ketones in blood due to breakdown of fatty acids when insulin isn’t available, metabolic acidosis
kussmauls respirations
Kussmauls Respirations
increased RR and depth in an attempt to excrete CO2 and acid due to metabolic acidosis (r/t ketones; see also protein in urine)
Diabetes Risk Factors
insulin resistance
metabolic syndrome (Syndrome X, Insulin-resistance syndrome) obesity, sedentary lifestyle, HTN, elevated cholesterol and triglycerides, cardiovascular disease
Fasting Blood Glucose Test
levels >100 mg/dL but less than <126 indicate impaired fasting glucose (IFG)
levels >126 mg/dL obtained in at least 2 occasions
Glucose Tolerance Test (2hr postload result)
levels >140 mg/dL (7.8 mmol/L) and <200 mg/dL indicate impaired glucose tolerance
levels >200 mg/dL (11.1 mmol/L) indicate diagnosis
Glycosylated Hemoglobin (A1C) Test
levels of 5.7-6.4% indicate prediabetes
levels >6.5% indicate diabetes
levels >8% indicate poor diabetes control and need for changes in therapy
Labs and Diagnostics
blood glucose
gylcosated hemoglobin A1C (HgbA1C)
urine ketones
duloxetine for peripheral neuropathy
Lispro, Aspart and Glulisine
RAPID INSULIN; SQ WITHIN 15 MIN OF MEALTIME
15 min onset
1-2 hr peak
half life 80 min.; duration 3-5 hrs
can give with NPH, draw lispro up first, give inmed
Isophane (NPH)
INTERMEDIATE; SQ MIX CLOUDY
1-2 hr onset
4-8 hr peak
10-18 hr duration (monitor for issues 9hr after admin)
can mix with aspart, lispro, reg.; DONT MIX WITH GLARGINE
Regular (Humulin R, Novolin R)
SHORT ACTING; SQ 30-60 MIN BEFORE MEAL; IV
30-60 min onset
2.5 hr peak
6-10 hr duration
CAN MIX WITH NPH, sterile water, NS; DO NOT MIX WITH GLARGINE
Detemir (Levemir)
LONG ACTING INSULIN; SQ (1/day or 2/day, same time each day)
gradual onset
6-8 hr pear
up to 24 hr duration
DONT MIX WITH ANY OTHER INSULIN
Glargine (Lantus)
LONG ACTING INSULIN; SQ, 1/day or 2/day, same time each day
1-2 hr onset
no peak
24 hr duration
DONT MIX WITH OTHER INSULIN
Lipoatrophy
loss of subQ fat around the site of repeated insulin injections, a rare complication of insulin therapy causing erratic insulin absorption
Insulin Patient Education
refrigerate insulin not in use; may be kept at room temp for up to 28 days to reduce injection site irritation from cold insulin; DONT FREEZE
store prefilled syringes in upright position, needle pointing upward
roll prefilled syringes between hands before using
Oral Hypoglycemics (Biguanides/Glucophage (metformin))
reduces insulin resistance, decreases sugar production in liver and should be taken with meals for best absorption and effect; decreasing intestinal absorption of glucose
DONT DRINK ALCOHOL TO REDUCE RISK FOR LACTIC ACIDOSIS
MUST BE DISCONTINUED 48 HRS BEFORE AND AFTER CONTRAST TESTING DUE TO INCREASED RISK OF KIDNEY DAMAGE AND LACTIC ACIDOSIS
DM Nursing Care
diet (AVOID ALCOHOL; CAN POTENTIATE HYPOGLYCEMIA)
WATER exercise
foot care
sick days
DM Complications
cardiovascular and cerebrovascular disease (HTN)
diabetic retinopathy (impaired vision and blindness)
diabetic neuropathy and nephropathy
sexual dysfunction
hyper/hypoglycemia
dawn phenomenon
somogyi phenomenon
Dawn Phenomenon
hyperglycemia in the AM (2-3 am)
caused by nighttime release of adrenal hormones because pt doesn’t have nighttime insulin prescribed or not enough
treated by adding intermediate insulin at 10pm or raise dose
Somogyi Phenomenon
nocturnal hypoglycemia followed by a marked increase in glucose and increase in ketones
hyperglycemia in the AM caused by rebound effect of nighttime hypoglycemia
treated by lower 10 pm dose or ensure adequate snack with 10 pm dose or evaluate exercise program
Hypopituitarism
deficiency of 1+ more anterior pituitary hormones resulting in metabolic problems, sexual dysfunction
selective hypopituitarism is most common where only one hormone is deficient, opposite of panhypopituitarism
deficiency of gonadotropins (sexual characteristics); GH stimulates liver to produce somatomedins that enhance growth activity
Life-Threatening Deficiencies
adrenicorticotropic hormone (ACTH) and TSH
because both deficiencies effect hormones vital for balanced metabolism
Gonadotropin (LH and FSH)
loss of sexual characteristics (facial hair, decreased libido, impotence, amenorrhea, infertility, breast atrophy, painful intercourse, decrease of axillary/pubic hair)
neurologic changes (loss of visual acuity esp. peripheral vision, temporal headaches, diplopia, ocular muscle paralysis, limiting eye movement)
Hypopituitarism Diagnostics Testing
blood levels of pituitary hormones
hormone stimulation testing
CT scan of head
MRI of head
angiography of brain
lab assessment measures effects of hormones rather than actual hormone levels (ex. T3 and T4 for thyroid function)
Hypopituitarism Management
lifelong replacement of deficient hormones; human growth hormone injections SQ
Gonadotropin: androgen therapy for virilization (gynecomastia, acne, baldness, prostate enlargement SE)..contraindicated w/prostrate cancer; HRT (DVT and HTN SE)
TSH AND ACTH are replaced with thyroid hormone and cortisol
Hyperpituitarism
pituitary tumors or tissue hyperplasia; GH, prolactin, ACTH
pituitary adenoma (prolactin secreting benign tumors) most common (decreases in normal lvl of sex hormones, loss of libido, infertility and spontaneous milk flow, HA, visual changes, increased ICP)
Gigantism
GH; BEFORE PUBERTY
continues in adulthood resulting in abnormal height
Acromegaly
GH; AFTER PUBERTY
changes are seen in face, hands, feet and ears
Hyperpituitarism Patient Assessment
age
sex
family history of endocrine issues
change in appearance (lip/nose size, clothing size changes)
fatigue and lethargy
backache
arthralgias
HA and vision changes
menstrual changes
changes in sexual functioning
Hyperpituitarism Diagnostic Testing
hormone lvls in blood and urine
CT or MRI
suppression testing (high glucose lvls should normally suppress release of GH; give 100g of oral glucose or 0.5 g/kg followed by serial GH measurements..GH LVLS DONT FALL BELOW 5 ng/mL
Hyperpituitarism Non Surgical Management
encourage pt to express concerns and fears about altered appearance or sexual function
help identify personal strengths and positive characteristics
drug therapy may be used alone or in combo with surgery and radiation (take long time to complete and many years may pass before an effect is seen, not recommended for acromegaly; SE: hypopituitarism, optic nerve damage, other vision problems)
gamma knife procedure
Hyperpituitarism Drug Management
dopamine agonists to stimulate dopamine receptors in brain and inhibit release of certain pituitary hormones (prolactin and GH) (Bromocriptine (Parlodel) and Cabergoline (Dostinex))
somatostatin analogs (Ocreotide (Sandostatin) and lanreotide)
GH receptor blockers (Pegvisomant)
Hypophysectomy
most common treatment (removal of pituitary gland along with tumor; minimally invasive trans-nasal or trans-sphenoidal vs craniotomy)
decrease abnormal hormone lvls, relieve HAs, possible reversal of sexual dysfunction
Hyperpituitarism Pre-Op Care
explain the procedure, that body changes, organ enlargement and visual changes are usually not reversible
explain post-op wound management: nasal packing for 2-3 days after surgery, and mustache dressing placed under nose (breath through mouth)
instruct not to brush teeth, blow nose, cough sneeze or bend forward after surgery (increased ICP and delays healing)
decreases sense of smell may persist 3-4 mths after
Hyperpituitarism Post Op Care
monitor neurological symptoms hourly for 24 hrs then every 4 hrs and document any changes in vision, mental status, LOC, decreased strength in extremities
observe for complications such as DI, CSF leakage, infection and increased ICP
keep HOB elevated
avoid coughing, perform deep breathing exercises hourly
avoid bending forward
perform oral rinses and apply moisturizer over lips
assess for manifestations of meningitis
teach pt self administration of prescribed hormones
CSF Leak (Hyperpituitarism Post Op Complication)
assess nasal drainage for presence of glucose
halo signs
report persistent, severe HAs
most CSF leaks may heal themselves, repair surgery may be needed
provider must be notified
Diabetes Insipidus
water metabolism problem caused by ADH deficiency or inability of kidneys to respond to ADH; excretion of large amount of dilute urine
Nephrogenic DI
renal tubules don’t respond to ADH (severe kidney injury)
Primary Neurogenic DI
problem in hypothalamus or pituitary gland; lack of ADH production/release
Secondary Neurogenic DI
tumors, head trauma, infections, surgeries
Drug-Related DI
lithium and demeclocycline interfere with kidney response to ADH
DI Assessment
large amount of very dilute urine (causes dehydration and hypovolemia)
increased thirst but often not enough to compensate for volume less, can lead to hypovolemic shock
causes may include brain tumors and head trauma
24 hr fluid I/O: consider if urine output is more than 4L
dilute with low specific gravity and low osmolarity or osmolality
DI Cardiac Symptoms
hypotension
tachycardia
weak pulses
hemoconcentration
DI Skin Symptoms
poor skin turgor
dry mucous membranes
DI Neurologic Symptoms
decreased cognition
ataxia
increased thirst
irritability
DI Drug Therapy
desmopressin (DDAVP; FIRST LINE AGENT), a synthetic form of vasopressin given intranasally in a metered spray or oral tab
aqueous vasopressin (IV, IM, SQ) for short term therapy or when dosage must be changed often (may be required in acute care for dosage titration)
chlorpropamide (oral)
hydration with hypotonic IV fluids in acute care (lifelong vasopressin therapy with permanent condition, teach pt to weight themselves daily)
DI Nursing Interventions
replace fluids by encouraging pt to drink fluids equal to urinary output
monitor I/O, daily weights, report weight changes in a timely manner (1kg=1L of fluid)
monitor for s/s of dehydration
monitor serum and urine lab results
Fluid Deprivation Test
best test to diagnose central DI; urine production, blood electrolyte lvls and weight are measured regularly for a period of 24 hrs during which the person isn’t allowed to drink
DI Patient Education
teaching pt that polyuria and thirst are signals for need for another dose
use daily weights to estimate dehydration/overhydration
SE of nasal sprays, including ulceration of mucous membranes, allergy sensation of chest tightness, inhalation of spray into lungs which precipitates pulmonary issues
how to self inject drug
always wear a self-ID bracelet
SIADH
failure of negative feedback system; ADH (Vasopressin) secretes even when plasma osmolarity is low/normal
caused by shock, trauma, stress, malignancies
water retention>fluid overload
SIADH Assessment
dilutional hyponatremia
neurological symptoms r/t hyponatremia
GI disturbances, n/v, loss of appetite
weight gain
bounding pulse, hypothermia
decreased urine volume and increased urine osmolarity
SIADH Interventions
fluid restriction 500-1000 mL/24 hrs to monitor fluid overload
drug therapy with vasopressin receptor antagonists (vaptans), diuretics
treat/manage underlying cause
hypertonic saline (3% NaCl)
tube feedings and GI tube med admin (use saline instead of water)
SIADH Nursing Considerations
frequent neurologic checks
patient safety needs (fall risks, seizure precautions)
measure I and O
treat hyponatremia
assess for signs of volume overload (esp. cardiac and respiratory complications)
Adrenal Gland Hypofunction
adrenal cortex production of steroid hormone may decrease due to inadequate secretion of ACTH, dysfunction of hypothalamic-pituitary control mechanism or direct problems of adrenal gland tissue
acute adrenocorticol insufficiency (adrenal crisis) is life threatening
loss of aldosterone and cortisol action (hypoglycemia, potassium excretion decreased BUT Na and H2O excretion increased)
Primary Adrenal Gland Hypofunction
Addisons Disease (autoimmune, dx, metabolic dx, AIDS, adrenalectomy)
Secondary Adrenal Gland Hypofunction
pituitary tumors
hypophysectomy
sudden cessation of long term high dose glucocorticoid therapy
Adrenal Gland Hypofunction Assessment
ask about factors that may cause (radiation activity, drug use?)
changes in activity level (lethargy, fatigue, muscle weakness)
GI problems (anorexia, n/v, diarrhea, abdominal pain)
assess for hypoglycemia (decreased cortisol) and fluid depletion (sweating, HA, tachycardia, changes in neuro status, dehydration)
hyperkalemia (risk for dysrhythmias)
hyponatremia (decreased cognition)
Adrenal Gland Hypofunction Interventions
promote fluid balance
monitor for fluid deficit (weight pt daily, strict I/Os, monitor lab values for hemp concentration and electrolyte disturbances)
prevent hypoglycemia (steroids, -sone for fluid and electrolyte balance; glucose monitoring)
assess cardiac function (monitoring and vitals every 1-4 hrs)
Addisonian Crisis
life threatening event, need for cortisol and aldosterone is greater than available supply
usually occurs in response to stressful event like surgery, trauma, severe infections
loss of aldosterone leads to severe hypotension r/t blood volume depletion
Hypercorticolism (Cushing’s Syndrome/Disease)
syndrome (surplus of cortisol) disease (ACTH tumor)
can be caused by drug therapy (steroids)
most common non drug cause is ACTH-producing pituitary adenoma
Cushing’s Syndrome History Assessment
other health problems and glucocorticoid therapy
weight gain, increased appetite
sleep disturbances common
emotional instability
Cushing’s Syndrome S/S
changes in fat distribution (trunkal obesity, moon face, buffalo hump)
skin, cardiac, MSK, immune changes
glucose metabolism (fasting glucose high)
increased androgen production (acne, body hair, oligomenorrhea)
Hypercorticolism Lab Assessment
blood, salivary, urine cortisol lvls
dexamethasone testing (either 24 hr or 3 day period of time; set doses are given with a 24-hr urine collection after administering, urine corticosteroid excretion and cortisol lvls are suppressed in healthy pts with med)
CT
MRI
arteriography
Priority Problems for Hypercorticolism
fluid overload due to hormone induced water and sodium retention
potential for injury due to skin thinning, poor wound healing, bone density loss
potential for infection due to hormone-induced reduced immunity
potential for acute adrenal insufficiency
Hypercorticolism Nursing Considerations
HTN due to increased aldosterone
increased hepatic gluconeogenesis and insulin resistance
can lead to cardiovascular disease and frequent/poor wound healing
Pheochromocytoma
nonmalignant catecholamine-producing tumors of adrenal medulla
tumors produce, store and release epinephrine and norepinephrine (overproduction, hypertensive crisis!!)
Pheochromocytoma S/S
high BP
HA
sweating
flushing
anxiety/panic
palpitations
abdominal pain
dizziness
blurry vision
diabetes symptoms
tachycardia
heart failure
Pheochromocytoma Nursing Management
assess for and manage symptoms of HTN or HTN crisis
prevent additional injury and complications
perioperative care includes pt education, informed consent, post op management
alpha-adrenergic blockers (doxazosin, tolazoline) or removal of tumor
Hypoparathyroidism
decreased function of parathyroid gland; serum Ca lvls cannot be maintained
occurs post surgically after thyroid/parathyroid removal or after surgery for head and neck cancer
Hyperparathyroidism
increase in parathyroid hormone; hypercalcemia and hypophosphatemia
kidney stones, Ca deposits, bone lesions
Parathyroidism Diagnostics
Ca lvl
parathyroid US
scintigraphy (radioisotope use with imaging)
CT/MRI
Hypoparathyroidism Treatment
correct hypocalcemia
prevent kidney stones
calcium gluconate IV, oral calcitrol, oral Ca carbonate
oral vitamin D supplements
Hyperparathyroidism Treatment
drug therapy via cinacalcet, bisphosphonates
parathyroidectomy
DM Foot Care
NO SOAKING FEET or heat pads
moisturize (not between toes)
wear socks
don’t cross legs
cut nails straight across
DM Sick Days
monitor BG Q4H
drink 8-12 oz of water
call doctor if n/v, large ketones, fever for more than 24 hrs or high BG after 2 doses of insulin
