Endocrine | Exam 3 Flashcards
Diabetic Ketoacidosis
Pathology
Very LOW INSULIN
TYPE I DIABETES
Body burns fat as fuel, creates ketones
Ketones = metabolic acidosis, excreted in urine
Diabetic Ketoacidosis
Symptoms
Dehydration
Lethargy, weakness
Abd pain, N/V
Kussmal resps
Acetone breath
BG > 250
pH < 7.3
Ketones in serum/urine
Diabetic Ketoacidosis
Emergency Management
Patent airway, give O2
NS Bolus 1L/hour x 1-2 hrs
Regular INSULIN IV 1:1
If serum K+ <5, keep between 4 - 5
Diabetic Ketoacidosis
Insulin Administration
Serum Glucose should not drop more than 65 to 125 mg/dL per HOUR
Serum draws q 2 hrs
Fingerstick q 1 hr
Admin REGULAR INSULIN IV 1:1
When serum glucose reaches 250 or below, switch to dextrose-containing IVF
Diabetic Ketoacidosis
Lab Results
HYPOnatremia
HYPOchloremia
HYPERkalemia initially… then progresses to HYPOkalemia due to treatment (IVF and IV Insulin)
LOW Bicarbonate < 16 mEq/L [22 - 26] (Metabolic Acidosis)
BG > 250 mg/dL
MOD - HIGH Ketones in serum + urine
Diabetic Ketoacidosis
Complications
Dehydration –>
Hypovolemia –>
Shock –>
Renal Failure –>
Death
Diabetic Ketoacidosis
IVF Administration
Priority nursing action: REPLACE FLUIDS
Bolus NS 1L/hour x 1 - 2 hrs
Followed by 0.45% NS 200 - 1000 mL/hr
When serum glucose is 250 or under, switch to dextrose-containing IVF
Goal: Restore urine output to 30 - 60 mL/hr
HHS
Pathology
HYPERosmolar
HYPERglycemic
LOW Insulin
More common in Type II Diabetes
HHS
Symptoms
DEHYDRATION
HYPERglycemia
LOW/No Ketones
Serum glucose >1000 mg/dL
Profound LOC changes!
NO ACIDOSIS: pH > 7.3
Shallow Resps
HHS
Emergency Management
Similar to DKA…
Patent airway, give O2
NS Bolus 1L/hour x 1-2 hrs
Regular INSULIN IV 1:1
If serum K+ <5, keep between 4 - 5
HHS
Lab Results
HYPERnatremia
HYPERosmolarity
HIGH BUN/Creatinine
Serum Glucose 600+ mg/dL
No Acidosis –> pH > 7.3
HHS
Nursing Management
Monitor
Blood Glucose
Urine Output + Ketones
IVF
Insulin therapy
Electrolytes (esp K+)
Assess
Renal status
Cardiopulmonary status
LOC!!!
Hypoglycemia
Pathology
HIGH Insulin resulting in a Blood Glucose level < 70 mg/dL
Causes:
Too much insulin
Too little food
Too much exercise
Delaying time of eating
Hypoglycemia
Symptoms
Shakiness
Palpitations
Nervousness
Diaphoresis
Anxiety
Hunger
Pallor
Altered LOC
“Mimics alcohol intoxication”
Hypoglycemia
Complications
Priority over pt with high blood sugar!
Untreated can progress to:
Loss of conciousness –>
Seizure –>
Come –>
Death!
Hypoglycemia
Treatment of Concious Patient
Priority over pt with high blood sugar!
- Consume 15 g of a simple carb (4 - 6 oz juice/soda)
- Recheck glucose level in 15 minutes
- Repeat if still < 70 g/dL
- If stable, give CARB + Protein
Hypoglycemia
Treatment of
Unconcious Patient
Priority over pt with high blood sugar!
With IV Access:
* 50% dextrose 20 - 50 mL IV push
Without IV Access:
* Glucagon 1 mg IM or SC
* Watch for N/V –> Aspiration precautions
Diabetes
Rapid-Acting Insulin
Rapid
Lispro/Humalog/Aspart
Onset: 15 mins
Peak: 1 hour
Diabetes
Short-Acting (Regular) Insulin
Short
Regular/Humulin R
Onset: 30 - 60 mins
Peak: 2 - 3 hours
CLEAR (1st)
Diabetes
Intermediate-Acting Insulin
Intermediate
NPH/Humulin N
Onset: 2 - 4 hours
Peak: 4 - 12 hours
CLOUDY (2nd)
Diabetes
Long-Acting Insulin
Long
Glargine/Lantus
Onset: 1 hour
Peak: No peak
Addison’s Disease
Pathology
Adrenal Gland HYPOfunction
Aldosterone insufficiency
Causes:
* Autoimmune or Idiopathic
* Long-term steroid use
* Infection (TB, Histoplasmosis)
* Removal of adrenal glands
Addison’s Disease
Symptoms I
Muscle weakness + fatigue
Anorexia + emaciation
N/V, weight loss, ABD pain, constipation or diarrhea
HYPERpigmentation (bronzing)
Decreased body hair
Menstrual changes + Impotence
Increased urine output
Addison’s Disease
Symptoms II
HYPOtension
HYPOglycemia
HYPOnatremia
HYPOvolemia
Anemia, Low H/H
Headache, Lethargy, Depression, Confusion, Emotional Lability
Addison’s Disease
Symptoms III
HYPERkalemia
HYPERcalcemia
Increased HR
Tachy dysrhythmias
Addison’s Disease
Complications
Addisonian Crisis
May be caused by stress r/t surgery, dehydration, acute infection, overexertion, exposure to cold
Can lead to circulatory shock and death
S/S: Severe N/V, Diarrhea, Dehydration, Sudden pain in lower back/ABD/legs, Hypotension, Tachycardia, Confusion, Restlessness, Fatigue, Headache
Addison’s Disease
Diagnosis + Labs
ACTH Stimulation Test (Most definitive)
ACTH is given and plasma cortisol levels are checked
Absent/Low: PAI
Increased: SAI
HYPOglycemia
HYPOnatremia
HYPERkalemia
WBCs: Elevated
Addison’s Disease
Nursing Management
Interventions
Treat HYPOvolemia
Increase Na+ levels (IVFs + foods)
Monitor K+ levels (HYPERkalemia) –> Dysrhythmias, Acidosis
Monitor weight and I/Os
Manage HYPOglycemia
Addison’s Disease
Nursing Management II
Education
Medical alert/ID card
Avoid strenuous activity in hot/humid weather
Strategies to deal with stress
Notify Drs about disease BEFORE Tx
Increase fluid + salt intake when sweating
High carb, high protein diet w/ adequate sodium
Addison’s Disease
Medical Management
Hydrocortisone (Solu-Cortef):
Corrects glucocorticoid deficiency
Oral is Prednisone –> Divided Doses
2/3 in AM + 1/3 in PM
Mineralocorticoid Hormone (Fludrocortisone)
Maintains or restores F/E balance
Dosage adjustment in hot weather
Addison’s Disease
Emergency Kit
- Corticosteroid prefilled syringes: 100 mg vials of hydrocortisone or 4 mg of dexamethasone + NS to reconstitute
- Verbal/written instruction on how and when to use injection for pt, family, or caregivers
- ENTIRE dose of 100 mg of hydrocortisone or 4 mg of dexamethasone should be given and medical attention
- Should be seen IMMEDIATELY after administration
Cushing’s Disease
Pathology
A cluster of clinical abnormalities caused by excessive levels of adrenocortical hormones (particularly cortisol)
CUSHING’S = CORTISOL
More common in women than in men
Primarily between ages 25 - 40
Cushing’s Disease
Causes
- Hyperplasia of the adrenal cortex
- TUMOR: Cortisol-secreting + usually benign
- Long-term steroid therapy r/t asthma or RA
- Small cell lung cancer
Cushing’s Disease
Symptoms
Classic Presentation:
* Buffalo hump: Fat pads over the upper back
* Moon face: Excess fat on the face
* Truncal obesity: Fat pads throughout the trunk with thin limbs
Cushing’s Disease
Symptoms II
Atrophy of lumphoid tissue = Compromised immune system
Skin: Thin, fragile, easily bruised
Peptic ulcer r/t inadequate prostaglandins
Muscle weakness, wasting, lack of energy
Osteoporosis = Pathological FRACTURES
Distrubed sleep, irritability
Hypertension + Heart failure
Weight gain
Cushing’s Disease
Symptoms III
HYPERtension
Tachycardia
Bounding Pulse
Dependent Edema
Risk for thrombus
Cushing’s Disease
Lab Results
HYPERnatremia
HYPOkalemia
Glucose HIGH
Cushing’s Disease
Diagnosis
Serum Cortisol:
* Usually higher in the morning and lower in the evening
* Loss of variation = positive
Urinary Cortisol:
* Requires 24-hour urine collection
* 3x upper limit of normal = positive
Low-dose Dexamethasone Suppression Test
* Dexamethasone given orally late in evening/bedtime + plasma cortisol obtained next morning
* Suppression of cortisol to < 5 mg/dL = negative
* Lack of suppression = positive result
* Stress, obesity, depression, anticonvulsants can falsely elevate cortisol
Cushing’s Disease
Nursing Assessment
- Health history: Level of activity and ability to perform ADLs
- Physical exam: Skin assessed for trauma, infection, breakdown, bruising, and edema
- Mental function: Mood, responses to questions, awareness of environment, and level of depression
Cushing’s Disease
Nursing Interventions
- Fluid + electrolyte balance, daily weights IOs
- Diet: Increase protein, calcium, and vitamin D to minimize muscle wasting and osteoporosis
- Low carb, Low sodium
- Fall risk: Susceptible to bruising, skin trauma, fractures
- Reduce risk of infection: Compromised immune system
- Promote periods of rest
- Promote skin integrity
- Psychosocial: Body image + weight gain
Cushing’s Disease
Nursing Education
F/U appointments
Medication compliance
Cushing’s Disease
Treatment: Drugs
Adrenal enzyme inhibitors may be used to reduce hyperadrenalism if the syndrome is caused by ectopic ACTH secretion by a tumor that cannot be eradicated
* Metyrapone
* Aminoglutethimide
* Mitotane
* Ketoconazole
Cortisol therapy: Essential during and after surgery, to help the patient tolerate the physiologic stress imposed by the removal of the pituitary or adrenals
Diabetes Insipidus
Pathology
ADH LOW
Urine Output - (up to 12 L/day)
UNKOWN
HEAD TRAUMA
CNS INFECTION
KIDNEY ISSUES (2nd)
MEDS - LITHIUM
Diabetes Insipidus
Symptoms
- Primary Symptom = Excretion of large quantities of urine (250 mL/hour)
- Extreme thirst, craving cold water (2 - 20 L)
- Severe dehydration can occur if fluid intake cannot keep up
- The patient will experience hypotension, tachycardia, hypovolemic shock
Diabetes Insipidus
Labs
LOW specific gravity < 1.005 [1.005 - 1.030]
LOW URINE osmolality < 100mOsm/kg [500 - 800]
HIGH SERUM osmolality
Hypernatremia caused by pure water loss of the kidneys
Diabetes Insipidus
Labs
LOW specific gravity < 1.005 [1.005 - 1.030]
LOW URINE osmolality < 100mOsm/kg [500 - 800]
HIGH SERUM osmolality
Hypernatremia caused by pure water loss of the kidneys
