Endocrine Exam 3 Flashcards
diabetic ketoacidosis (DKA)
- uncontrolled hyperglycemia
- increased ketone production
- metabolic acidosis
DKA patho
NO INSULIN, so no glucose is being absorbed
-often initial presentation of type 1 DM
-missed doses of insulin
DKA causes
- infection!!! - pneumonia, UTI, abscess, sepsis
- trauma / surgery
- stress
- pregnancy
- growth spurts in children
DKA s/s
- flushed , dry skin
- dry mucous membranes
- decreased skin turgor
- tachycardia
- hypotension
- abd pain
- altered LOC
- kussmal RR
- acetone breath!!! - fruity breath
- n/v
- increased thirst - polydipsia!!!
- increased UO - polyuria
DKA labs
- CBC = WBC mildly elevated
- CMP =
-blood glucose = high
-serum bicarb = decreased
-potassium = elevated –CAREFUL (decreased)
-creatinine = elevated
-ANION GAP = elevated - ABGs = Metabolic acidosis
- UA = ketones and glucose
in DKA anion gap will be….
elevated r/t metabolic acidosis
DKA criteria
- blood glucose level > 250
- ketonuria
- pH < or = 7.3
- serum bicarb < 18
- positive anion gap
DKA actual complications
-hyperglycemia
-metabolic acidosis
-electrolyte imbalance
-dehydration
DKA potential complications
-respiratory compromise
-electrolyte imbalance
-fluid overload
-kidney injury
**cerebral edema
what is the most dangerous potential complication of DKA
cerebral edema!!
DKA respiratory support
may need ventilator support
prevent aspiration – NG tube for those vomiting and impaired mental status
DKA fluid replacement
initial fluid = NS
-1L bolus –> infusion of 10-15 mL during first hr
-shock s/s 20 mL
**sodium elevated or normal use hypotonic saline (0.45%) at slower rate!!!!
when is 5% dextrose added to fluids…
when serum glucose approaches 200 mg/dL
goal of fluid replacement
normovolemia , prevent fluid overload
fluid overload s/s
- tachypnea
- neck vein distention
- crackles
- increased pulmonary artery occlusion
- decreasing LOC –> CEREBRAL EDEMA
DKA insulin therapy
check POTASSIUM FIRST , should be > 3.3 prior to insulin given
-initial bolus is 0.1 unit regular insulin
transition of sub-q insulin….
when blood glucose is <200 …
1. venous pH > 7.3
2. serum bicarb is > 15
3. anion gap < or = 12
DKA electrolyte management
potassium!! - drops quickly after insulin therapy
-usually added to maintenance fluids after insulin is started
potassium management
maintain b/t 4-5 mEq / L
**UO must be 30 mL before administering IV potassium!!!
DKA nursing interventions
hemodynamic monitor
HOURLY i/o
HOURLY glucose check
neuro exams
fluid overload monitor
DKA education
maintain glucose level : diet, exercise, meds
monitor hemoglobin A1c
maintain regular schedule
insulin pump instructions
AVOID exercise / excessive activity when glucose > 240
hyperglycemic hyperosmolar state (HHS)
- hyperglycemia
- hyperosmolality
- dehydration
ALL WITHOUT KETOACIDOSIS
HHS patho
occurs when there is enough insulin to prevent rapid dat breakdown and ketone release but not enough to prevent hyperglycemia
HHS risks
-type 2 DM
-older adults
-major illness and infection = stress response !!
-high cal tube feeds
-meds
HHS s/s
- flushed dry skin
- dry mucous membranes
- decreased skin turgor
- shallow RR
- altered LOC -worse than in DKA
- hypotension
- tachycardia
HHS labs
- CBC
- CMP
-glucose increased
-sodium increased - increased serum osmolality
- ABGs:
-pH > 7.3
-bicarb > 15 - UA - no ketones
HHS dx criteria
- blood glucose > or = 600 mg
- serum osmolality of 320 mOsm or >
- serum pH Greater than 7.3 = not acidic
- profound dehydration
- serum bicarb > 15
- absent ketonuria
- altered LOC
HHS management
same protocol as DKA
-initial fluid NS
-insulin therapy : check K+ first
Primary adrenal crisis
destruction of adrenal gland
-autoimmune
-cancer
-infection
-hemorrhage
-adrenalectomy
-genetics
secondary adrenal crisis
mechanisms decrease ACTH secretion
-abrupt withdrawal of corticosteroids!!!
-pituitary patho
-systemic inflammation - sepsis, sickle cell
-trauma
adrenal crisis risk
- medication :
-steroids
-phenytoin
-barbituates
-rifampin - illness
-infection
-cancer
-autoimmune disorder
-disease tx w/ steroids - family hx :
-addison’s disease
adrenal crisis patho
life threatening absence of cortisol and aldosterone
deficiency of cortisol
-decrease glucose production
-decrease metabolism of fat and protein
-decrease appetite
-decrease intestinal motility
-decrease vascular tone
-decrease effect of catecholamines
deficiency of aldosterone
-decrease retention of sodium and water
-decrease circulating volume
-increase potassium and hydrogen ion reabsorption
adrenal crisis s/s
- hypotension
- weak rapid pulse
- cold, pale skin
- dysrhythmias
- HA
- fatigue
- weakness
- confusion , lethargy
- abdominal pain
- anorexia
- decreased UO
adrenal crisis labs
- CBC - increase eosinophils
- CMP -
-decrease glucose
-increase potassium
-decrease sodium
-increase BUN - ABGs : metabolic acidosis
- Cortisol = DECREASED in crisis
- cosyntropin stimulation test
cosyntropin stimulation test
- obtain baseline cortisol level 30 min before test
- administer cosyntropin over 2 min
- check cortisol levels 60 min after administration
adrenal crisis actual complications
- hypovolemia
- decreased tissue perfusion
- electrolyte imbalance
adrenal crisis potential complications
- shock
- dysrhythmias
adrenal crisis fluids
D5NS : tx hypoglycemia , may get up to 5L
adrenal crisis glucocorticoid….
most important initially!!!!
-if no previous dx give dexamethasone
-if hx give Solu-Cortef
SE of adrenal crisis meds
-hyperglycemia
-cushing’s syndrome
-electrolyte disorder
-euphoria
-fluid retention
-masking infection
-HTN
-peptic ulcers!!!!
-n/v
adrenal crisis meds considerations
- GI bleed prophylaxis med!!!
- drug interactions
- no abrupt discontinuation
- monitor glucose / electrolytes
- monitor for fluid overload
- monitor for infection
- maintain nutrition
- mouth care
adrenal crisis nursing action
- VS and i/o
- s/s of GI bleed
- HOB 45 degrees
- education on pt s/s and prevention
corticosteroids can….
have big effects on GI tract, check for bleeding and tx prophylactically
myxedema coma
end stage of improperly tx, neglected, underdiagnosed HYPOthyroidism
myxedema coma patho
pt experiences increased hormone use but had DECREASED hormone production… does not have enough
myxedema coma risks
- infection
- trauma
- meds
- older women
- winter time
- hypothermia
myxedema coma s/s
- decrease HR and BP
- pericardial effusion - distant heart sounds
- hypoventilation
- CO2 retention
- pleural effusion
- delirium
- seizures
8.coma - hypothermia
- sluggish movements
- edema
myxedema coma labs
- CBC - decrease RBC and platelets
- CMP -
-decrease sodium
-decrease glucose
-decrease potassium - thyroid hormone
-TSH increase if primary hypothyroidism
-TSH levels will be normal or low if secondary
-T3 and T4 decreased
myxedema coma imaging
- CXR - pleural effusion
- EKG - U waves w/ decreased potassium
myxedema coma thyroid meds
levothyroxine = PUSH OVER 5 min
liothyronine - avoid in older adults
myxedema coma and sedatives
need more observation b/c the absorption of medication is slower and resp compromise could occur
**narcotics and hypnotics
myxedema coma education
take meds!!!
-may be titrated depending on levels
myxedema coma potential complications
- respiratory arrest
- cardiac arrest
when intubating what is the order for medication….
sedative THEN paralytic
**keep in mind for myxedema coma oversedation is possible d/t slow metabolism
thyroid storm
occurs in untreated hyperthyroidism
-precipitated by stress r/t
-underlying illness
-general anesthesia
-surgery
-infection
-stroke
-DKA
-trauma
thyroid storm s/s
abrupt onset :
-severe fever : up to 106
-warm, moist skin
-tachycardia
-tremors
-HF
-systolic murmur!!!
-respiratory failure
-abd pain
-diarrhea
-weight loss
-shallow respirations
thyroid storm labs
- CBC : WBC increase , RBC decrease
- CMP :
-increase sodium
-increase glucose
-increase BUN
-increase calcium
Thyroid hormone :
-decrease TSH
-increase T3 and T4 - ABG : normal
thyroid storm meds
- Beta blocker - propranolol
- Tapazole - lack immediate effect!
- SSKI - given 1-2 hours after antithyroid (tapazole) medications
thyroid storm supportive care
- fever control : acetaminophen
- O2 administration
- vitals and i/o
- eye lubricant for exophthalmos
- high calorie , high protein diet
thyroid storm supportive care
- fever control : acetaminophen
- O2 administration
- vitals and i/o
- eye lubricant for exophthalmos
- high calorie , high protein dietthy
thyroid storm education
- consume adequate calories
- long term treatment : medications or surgery
definitive treatment thyroid storm
thyroidectomy :
-given potassium iodine before surgery
post op:
-VOICE CHANGE = laryngeal nerve damage
-bleeding
-hypocalcemia
what is needed at bedside after thyroidectomy….
airway / O2 supplies
suction
trach tray
diabetes insipidus
primary cause is traumatic injury to posterior pituitary or hypothalamus
neurogenic DI
ADH deficiency
-idiopathic
-intracranial surgery!!
-tumor
-infection : meningitis / encephalitis
-TB
-severe head trauma
nephrogenic DI
ADH insensitivity
-hereditary
-renal disease
-multisystem disorder affecting kidney
-medications
secondary DI
-idiopathic
-psychogenic polydipsia
-sarcoidosis
-excessive IV fluids
-medications
diabetes insipidus patho
impaired renal conservation of water = polyuria , > 3L / 24 hours
neurogenic DI s/s
occurs suddenly with abrupt onset of polyuria
nephrogenic DI s/s
will have gradual onset
DI s/s
-pale dilute urine
-polydipsia
-hypovolemia
-hypernatremia
hypovolemia s/s
- hypotension
- decreased skin turgor
- tachycardia
- dry mucous membranes
- weight loss
- low R atrial and pulmonary occlusion pressure
hypernatremia s/s
- altered mental status
- weakness
- focal neurological deficit
- ataxia
DI labs
-low urine osmolality!!!
-decreased urine specific gravity!!
-high serum osmolality
CBC : increase H and H
CMP :
-increase sodium
-increase calcium
-decrease potassium
-increase BUN
DI dx criteria
- urine specific gravity : < 1.005
- urine osmolality : < 200 mOsm
- water deprivation test
-serum osmolality increases w/ no increase in urine osmolality
water deprivation test
all water is withheld and urine osmolality and pts weight’s are measured hourly
**not appropriate for pts that are critical
DI complications
dehydration
hypovolemia
hypernatremia
DI potential complications
circulatory collapse
neuro complications : r/t hypernatremia
DI volume replacement
- hypovolemia = D5W corrects hypernatremia and replaces lost water
- PO when able
DI neurogenic hormone replacement
DESMOPRESSIN- ADH replacement
**inject over 1 min
desmopressin SE
HA
nausea
mild abd cramps
desmopressin monitor
dyspnea
HTN
weight gain
hyponatremia
HA
drowsiness
DI nursing interventions
-I/O monitor
-IV access
-meds
-oral fluids
DI education
-medications
-when to call dr
-daily weights
-drinking according to thirst and not over drinking
DI 7 D’s
- diuresis (high UO)
- diluted urine (pale, low specific gravity)
- dry inside (hyperosmolality, hypernatremia)
- drinking a lot
- dehydrated mucous membranes
- decrease BP
- desmopressin
SIADH
excess secretion of ADH
SIADH causes
-head injury
-hemorrhage
-stroke
-surgery
-tumor
-small cell cancer of ling
-pancreatic cancer
-pneumonia
-NSAIDs
-ACE inhibitors
SIADH s/s
-edema
-crackles!!!
-pink frothy sputum
-increase respirations
-confusion
-seizure
-HA
-n/v
-increased BP
SIADH labs
-CBC : h and h low
-CMP : decrease sodium
-Serum osmolality : decrease
-Urine osmolality : increase
-UA : urine specific gravity increase
SIADH dx
based on decrease UO
increase urine specific gravity
decrease sodium
decrease serum osmolality
SIADH complication
fluid volume overload
-edema and crackles
SIADH potential complication
s/s of hyponatremia
cerebral edema
SIADH tx goal
-tx underlying cause
-eliminate water excess
-increase serum osmolality
SIADH fluids
on fluid restriction
-less than 1,000mL / day
SIADH meds
- 3% saline via central line
-use a PUMP!!!
-do NOT go over 50 mL/hr
-monitor sodium every 4 hrs
-wean solution
-mental status change
-lung sounds
-i/o hourly - diuretics
- demeclocycline
when should 3% saline be held…
when sodium is > 155 mEq
SIADH nuring action
- vitals
- i/o
- seizure precuation
- fluid restriction
- s/s of fluid overload
SIADH education
AVOID NSAIDs
fluid restriction
cerebral edema s/s
daily weight
SIADH 7 S’s
- stop urination (low UO)
- sticky / thick urine (high specific gravity)
- soaked inside (hypoosmolality, hyponatreamia)
- sodium low
- seizures
- severe high BP
- stop all fluids , give salt (3% IV) , diuretics
phenochromocytoma
excessive catecholamines may lead to life threatening HTN or cardiac dysrhythmias
phenochromocytoma s/s
- severe HA
- severe HTN : >250 / 140
- tachycardia
- palpitations
- excessive sweating
- hypermetabolism
- hyperglycemia
what do you NOT do when assessing a pt with phenochromocytoma…
do NOT palpate the abdomen!!!
phenochromocytoma labs
-increase blood glucose
-increase metanephrines
-increase normetanephrines
plasma free metanephrines / normetanephrines test…
pts must lay down 30 min prior to blood collection!!!
urine matanephrines / normetanephrines test…
pts should avoid
-bananas
-chocolate
-vanilla
-tea
-coffee
phenochromocytoma dx
based on presentation, urine and plasma levels, imaging
phenochromocytoma imaging
abd CT
head CT
phenochromocytoma medication
- BP mamagement
-nipride : IV admin
-alpha adrenergic blocker : Cardura - HR control
-beta blockers
phenochromocytoma surgery
Adrenalectomy is definitive tx
- preop: alpha adrenergic blocker 7-10 days before surgery , GLUCOCORTICOID morning of surgery
- postop- monitor BP, HR , glucose
**bilateral adrenalectomy = cortisol daily!!!
phenochromocytoma nursing action
- elevate HOB
- quiet non stimulating environment
- cardiac monitor
phenochromocytoma education
s/s of adrenal insufficiency
post op care
