Hyperglycemic Hyperosmolar State (HHS)

Question 1

Hyperglycemic Hyperosmolar State (HHS)

Answer 1

• Similar to DKA
• Both caused by hyperglycemia and dehydration
• Difference:
  — Slow/gradual onset
  — Increased blood osmolarity >350mOsm/L
  — Ketones absent
  — Blood glucose levels higher than DKA
  —- Serum glucose >600mg/dL

Question 2

Hyperglycemic Hyperosmolar State (HHS) Indications:

Answer 2

• Ketosis and Acidosis DO NOT OCCUR
• Hypotension
• Dry mucous membranes
• Poor skin turgor
• Tachycardia
• Altered awareness
• Seizures

Question 3

• Mostly seen in older adult population with type 2 DM
• Can also occur in type 1 that is not controlled properly
• Other hyperglycemic conditions
  — corticosteroid therapy or diuretics
• Usually precipitated by illness or infection

Answer 3

• In HHS, pt secretes just enough insulin to prevent ketosis but not enough to prevent hyperglycemia
• Hyperglycemia is more severe than that of DKA
  — This leads to Extreme diuresis with severe dehydration & electrolyte loss
  — Greatly increasing blood osmolarity (measure of hydration status) blood osmolarity increases with dehydration

Question 4

(HSS) Nursing Care basics

Answer 4

• Administer NS and Regular insulin
• Assess:
  — vitals
  — blood glucose
  — Level of consciousness
  — Urine output
  — temperature
  -
• First priority: fluid replacement (NS, ½ NS)
  — ½ of fluid deficit is replaced in first 12 hrs, then the rest is replaced over next 36 hrs.
• Assess for:
  — for severe hypotension & shock
  — - From diuresis and dehydration
  — Signs of cerebral edema –as fluids are replaced

Question 5

HHS Nursing Care continued

Answer 5

• IV insulin administered after adequate fluids have been replaced
  — Initial bolus, followed by IV infusion given until BG decreases to 250mg/dL
  — A reduction of blood glucose of 50-70mg/dL per hour is expected
• Monitor closely for hypokalemia
  — Total body potassium depletion is often unrecognized because blood potassium level may be nl or high due to dehydration
  — The potassium level may drop quickly once insulin IV is started
• Potassium replacement is initiated once urine output is adequate
  — Serum electrolytes checked every 1-2hrs until stable
  — Monitor cardiac rhythm
• Provide teaching on ways to minimize/prevent dehydration

Question 6

HHS and the older adult

Answer 6

• Older pts at greater risk for dehydration & HHS due to age-related changes
  — Poor urine-concentrating abilities
  — Thirst perception
  — Use of diuretics
• *Stress importance of maintaining hydration!
  — Especially in those who have diabetes
  — HHS does not occur in adequately hydrated pts

Question 7

(Compare DKA vs HHS):
—DKA—

Answer 7

• Patients most commonly affected
  — can occurs in type 1 or type 2 diabetes; more common in type 1 diabetes
• Precipitating factor
  — omission of insulin; physiologic stress (infection, surgery, stroke, MI)
• Onset
  — Rapid (<24hrs)
• Blood glucose levels
  — usually >250 mg/dL
• Arterial pH levels
  — <7.3
• Serum & urine ketones
  — present

Question 8

(Compare DKA vs HHS):
—HSS—

Answer 8

• Patients most commonly affected
  — Can occur in type 1 or type 2 diabetes; more common in type 2 diabetes, especially older patients with type 2 diabetes
• Precipitating factor
  — Physiologic stress (infection, surgery, stroke, MI)
• Onset
  — Slower (over several days)
• Blood glucose levels
  — Usually >600 mg/dL
• Arterial pH levels
  — Normal
• Serum & urine ketones
  — Absent

Question 9

Hormones

Answer 9

• ADH/Vasopressin/arginine vasopressin (AVP)
• Renin
• Erythropoietin
• Aldosterone
• Cortisol
• Angiotensin
• Sex hormones

Question 10

ADH

Answer 10

• Hormone made by hypothalamus & stored in posterior pituitary
• Promotes water conservation by kidneys
  — Therefore decreased urine production
• ADH is always regulating & balancing amount of water in the blood.
• An increase in blood osmolality stimulates ADH

Question 11

When ADH is stimulated, ADH will:

Answer 11

• Increase body water reabsorption in kidneys
  — Make blood more dilute
• Urine becomes more concentrated