Med/Surg Nursing

Endocrine System-2009
Endocrinologist-
specialist (MD) trained in the
specialty of endocrine glands and
hormones

Endocrine disorders are caused
by overproduction or
underproduction of specific
hormones

Dx TEST

Blood, urine tests
CT's, xrays
Indirect/direct observation (d/t
growth or appearance
abnormalities)

Pituitary Function Test
Xrays, CT's, blood test, urine
test

Thyroid Function Test
Lab test
Several different blood test may be
done
Thryoid Scan (Radioscan or
Scintiscan)-client ingests radioactive
iodine or IV. A scanogram is then done
to determine the amount of radioactive
activity in the body. If the thyroid
absorbs most of the iodine, the thyroid
is then said to be hyperactive. If the
thyroid does not absorb the iodine it is
then hypoactive

RAIU Test
Measures thyroid gland activity
A scan is done of the thyroid to
determine how much radioactive
material it removes from the
bloodstream and absorbs
Check for allergies to shellfish, or
iodine
Test can be altered by the use of
BCP's, anticoagulants, salicylates and
propylthiouracil derivatives


Thyroid Ultrasound
Determines the size of the thyroid
gland, its shape and position
May be done to monitor the
effectiveness of therapy or evaluate
thyroid function during pregnancy
Uses a gel to transmit sound waves
that are then interpreted by radiologist
or physician


Parathyroid Function Test
Lab: serum PH, PTH, phosphate and
calcium levels
Urinary calcium and serum alkaline
phosphatase
Other test: US, MRI, biopsy; this can
localize cysts, tumors and hyperplasia
(abnormal increase in size)
PTH: increased calcium levels in blood
aids in regulating calcium function

Adrenal Function Test
Blood Tests: ACTH stimulation test, serum
ACTH test, plasma cortisol test
Measured during the diurnal period (0800 and
1600) to determine if the ACTH and plasma
cortisol levels are normal
Urine Tests: 24 hour urine specimen to test for
vanillylmandelic acid a metabolite of
catecholamines
~clonidine suppression test to determine
pheochromocytoma (catecholamine-
secreting adrenal tumor)
phentolamine (Regitine) can be given to
cause a hypotensive situation , the drop in
BP is indicative of pheochromocytoma


Radiographic Evaluations
Adrenal angiogram or venogram-
insertion of a catheter and injection of a
contrast (dye) so that x-rays can be
taken for studies
Complication-allergy to dye
Premedicate with Benadryl or Inderal
Contraindicated in unstable, pregnant
clients, hemophiliacs, bleeding
disorders
General Pancreatic Function
Tests
Pancreatic enzymes: lipase (fat
digestion), amylase (CHO
metabolism)
Elevations suggest pancreatitis

DM Tests

Blood test: Fasting plasma glucose or
fasting blood sugar is used for diabetic
screening
~Fasting elevation usually indicates
DM
~Normal range is 65-115mg/dl
(depends on source)
OGTT
Timed test to confirm the Dx of
DM, can also diagnose functional
hypoglycemia
Plasma glucose levels peak at
169-180 ml within 30 minutes to 1
hour after administration of oral
glucose solutions and levels
should return to normal in 2-3
hours
Glycosated Hemoglobin (Hb
A1c)
Blood sugar reflection over the
previous 6-10 weeks
Measurements detect the amount of
glucose attached to a portion of the hgb
in RBC's
Range should be between 5-8% out of
a scale of 13%
Urine Tests

Glucose can spill over into the urine
from the blood, acetone is a by-product
of faulty metabolism
Most common test is for ketones if
blood glucose level is consistently high
Monitor for readings in excess of 240
mg/dl
Keto-Diastix
Measures for acetones (ketone
bodies) in urine
Buildup of acetone ketones
acidosis
Vomiting or excessive perspiration
can alter electrolytes
Pituitary Gland The Master
Gland
Anterior lobe produces
GH
ACTH (stress situations)
TSH
Prolactin
FSH
LH
All of the above are involved in growth,
maturation, and reproduction
Disorders of the Anterior Pituitary
Gigantism children
Acromegaly adults
Cause Overproduction of growth
hormone STH
Gigantism/Acromegaly
S/S:
Thick lips
Massive lower jaws
Bulbous nose
Enormous hands and feet
Bulging forehead
H/A
Visual loss
Impotence
Amenorrhea
Facial hair in females (hirsuitism)
Gigantism/Acromegaly
Tx: Pituitary irritation
Drugs parlodel, lowers STH levels
Tx can stop progression of disease but can
not alter abnormal growth that has occurred

Posterior Pituitary Secretes:
ADH regulate the passage of H2O
through kidneys
Vasopressin
Oxytocin
Diabetes Insipidus
Lack of production of ADH which regulates passage of
water through the kidneys
S/S:
Huge urinary output
(15-20 liters in 24 hrs.)
Thirsty
Urine SG lowers 1.006 (very dilute
Normal = 1.030)
Increased appetite
Weakness
Tx:
Vasopressin Subq, IM or nasally to control urine
output
Weigh every day
Disorders of the Posterior Pituitary
SIADH
Increase secretion of ADH, unable to excrete dilute
urine
Fluid retention and intoxication can occur
Cause CNS disorders, chemo, vasopressin overuse
Tx Monitor I & O
Fluid restriction
Hypertonic IV solutions
Meds: Declomyein or lithium carbonate
interfere antidiuretic action of ADH
SIADH
S/S:
Concentrated urine
Edema
Decreased urine output
HA
Wt. gain
Decreased LOC (lethargy)
Confusion
Hyponatremia diarrhea
Disorders of the Posterior Pituitary
Pituitary Neoplasms
Gigantism overgrowth of eosinophilic cells
Cushing syndrome hyperadrenalism from
basophilic tumor
Hypopituitarism (pituitary can be destroyed
by chromophobic tumor)
Change body temperature
Scant, fine body hair
Obese
Slow movers
Hypophysectomy
Surgical removal of the pituitary
To control pain in breast or prostate Ca
If malignant tumor is present
Decrease diabetic retinopathy
Postop ICU admit
Pituitary and Adrenocortical
Hormones
GH (somatotrophic hormone)
Secrete by anterior pituitary and regulates growth
Available as somatrem (Protropin) and somatropin
(Humatrope)
Recombinant DNA origin and are identical to human GH
and produce skeletal growth in children
GH is ineffective in clients with closed epiphysis (allow
for growth) because when the epiphyses close, growth
cannot occur
Few adverse reactions hypothyroidism or insulin
resistance, swelling, joint pain and muscle pain may occur.
Contraindications
Use caution with sensitivity to benzyl alcohol, clients
with thyroid disease or diabetes and during pregnancy.
Nursing Process
Assessment
Thorough physical exam
Children may increase their growth rate from 3.5-
4 cm/year before treatment to 8-10 cm/year
during the first year of treatment
GH is given IM or subq., swirl, dont shake bottle
Periodic testing of GH, thyroid levels may be
done
Patient with Diabetes
If blood glucose levels increase or urine is
positive for glucose or ketones, the nurse
notifies the primary health care provider.
Some patients may have latent diabetes and
corticosteroids may precipitate
hyperglycemia.
Adrenal Gland Disorders
Cushings syndrome (hyperadrenalism)
Cause: overproduction of hormones secreted form the
adrenal cortex, excessive steroidal use, tumors of the
adrenal glands
Steroids may cause hyperglycemia
S/S: rounded moon face, heavy abdomen that hangs
down, thin arms and legs, backache as the disease worsens,
edema, decreased urinary output, hypokalemia,
hypernatremia, hyperglycemia, HTN, poor wound healing,
ecchymosis, Buffalo hump, easy bruising
Lab elevated cortisol level
If develop during childhood, puberty begins early for boys
and the girls develop masculine traits.
Adrenal Gland Disorders (cont.)
Tx: depend on cause, removal, of adrenal
gland, adrenocortical hormones are given.
Nursing Considerations
Prevent injury and infection
Monitor weight, v/s, labs: electrolytes,
glucose levels


Primary Aldosteronism
Cause excessive aldosterone secretion
S/S-HTN, muscle weakness secondary to
low potassium levels.
Addisons Disease
Rare
Cause-TB, CA, infection or the gland atrophies for
unknown reasons
S/S-Decreased production of adrenal hormones
which results in fluid and electrolyte imbalances,
hypoglycemia
Darkening of the skin and mucosa
Dehydration, anemia and wt. Loss
BP decreases
Thin hair
Stress may cause adrenal shock (low BP, n/v/d, h/a,
restless
Addisons Disease

Addisonian Crisis- function falls to a critically
low point
Tx: IV hydrocortisone, IV Florinef to supply
electolytes, vasopressors (raise BP), diet high in
protein and low in potassium
Addisons Disease
Nursing Considerations
Replace fluid
5-6 small meals/day with snacks
Monitor for decreased blood pressure of dizziness
Protect from falls
Accurate I & Os including food
Specific gravity of urine
Daily wts
Teach importance of follow up visits
Protect from stressful situations

Adrenal Neoplasms
Pheochromocytoma benign tumor (usually)
originating from the adrenal medulla
This tumor will increase epinephrine and
norepinephrine secretion that results in HTN, h/a,
n/v, tremor, dizziness, increased urination.
Tx: surgical removal of tumor (dangerous d/t BP
variations), IVP, CT scan may be used to locate
the tumor, if a bilateral adrenalectomy of
performed, the clients must be treated for
Addisons disease postop
Thyroid Gland Disorders
Thyroid secretes T3 and T4
Hyperthyroidism
Overproduction of T4
Graves disease
Exopthalmic or toxic diffuse goiter is most
common
Cause is unknown but it is thought to be
manifested by infection, physical or
emotional strain, changes r/t puberty or
pregnancy
Hyperthyroidism
S/S: tremors, tachycardia, SBP elevated,
feel hot, lose weight despite eating,
sensitivity to heat
Exopthalmos noted in women with Graves
disease, may lead to blindness, the neck is
swollen
use artificial tears (need MD order)
If left untreated, may cause nervousness,
delirium and death
Hyperthyroidism
Tx: medical or surgical
Antithyroid drugs: PTU or methimozole
(inhibits synthesis of thyroid hormones) may
be given daily over a long time and may have
toxic effects.
RAI may be given to destroy the thyroid
gland
Thyroidectomy may be done if all else fails
Nursing Considerations:
Minimize overactivity, provide calm
environment
Provide increased calories-proteins,
vitamin D and B complex, minerals, fluids

Hypothyroidism
Deficiency of T4 which slows down the
metabolic process
D/T removal of the thyroid gland or a
decrease in its activity
Affects women more than men
Congenital form of the deficiency is
cretinism; advanced from is myxedema
Hypothyroidism
S/S: untreated results in dystrophy of bones and
soft tissues the person is dwarfed with a large
head, short arms and legs, puffy eyes, the skin is
dry and movement is uncoordinated
If discovered early, can be treated with T4
replacement and continued for life
Myxedema in adults
S/S: slowing physical and mental activity, mask
like expression, dry skin, hoarse and low voice,
hair coarse and falls out, weight gain
RAIU uptake is normal and menorrhagia can
occur
Hypothyroidism
Tx:
Oral thyroid-Armour Thyroid or proloaid
may be ordered
Synthetic thyroid hormones may be ordered;
Levothroid or Cytomel to supply the
deficiency and must be done gradually
Effective treatment will show an increased
alertness and appearance will be normal
Hypothyroidism
Nursing Considerations:
Focus on improvements in activity tolerance
and independence, thyroid deficiency clients
are a risk for respiratory depression
F/u visits to PCP
If left untreated, may result in myxedema
coma, a medical emergency requiring
immediate care
Avoid sedatives, narcotics as these drugs
decrease HR and RR, with hypothyroidism,
the HR and RR is already low.
Hashimoto's Thyroiditis
Autoimmune hypothroidism disorder
Simple Goiter-thyroid gland enlarges and fills
with colloid
Affects women more than men and usually occurs
during pregnancy, infection or adolescence
No harmful affects on health unless it enlarges and
obstructs breathing
Diet is deficient in iodine which is needed to produce
thyroid hormones
Toxic goiter occurs when there is too much T4
(hyperthyroidism)
Tx: Iodine for 2-3 weeks, repeating tx 3-4x/year
Thyroid Neoplasms
Liquid or semisolid cyst forming in the
thyroid
Aspiration can be performed on a simple
cyst
semisolid cyst is usually malignant and
must be removed
if thyroid tumor is cancerous, it must be
treated with radioactive isotopes
most often thyroid cancers grow slowly
Thyroidectomy
Surgical removal of thyroid gland, client will
need thyroid supplements for life
About 5/6 of the gland (subtotal thyroidectomy)
Thyroid hormone levels must be normal prior to
surgery to reduce the risk of a thyroid storm
(Thyroid crisis)
Caused by sudden increase in T4; s/s:
tachycardia, anxiety, elevation in v/s, heart
failure
Tx: Maintain 02 and glucose levels, reduce fever
place in semi- fowlers
Lugols solution preop to decrease size and
vascularity of the gland
Postop Complications
Hemorrhage
Hematoma
Laryngeal nerve damage
Edema of glottis
Tetany; caused by accidental removal of the
parathyroid glands during surgery
Chvosteks sign-abnormal spasm of the facial muscles in
response to light taps on the facial nerve
Trousseaus sign-carpopedal spasm occuring after inflating
a sphygmomanometer cuff on the upper arm for 3 minutes
Serum calcium levels may be low resulting in seizures
and cardiac arrhythmias
Nursing Considerations
Avoid excessive physical activity
Increase nutritional intake to ensure
adequate calories, vit. D and calcium
Semi-fowlers
Keep emergency trach set a bedside
Parathyroid Gland Disorders
Parathyroid secretes PTH
Vitamin D helps PTH regulate calcium and
phosphorous in the blood.
Hyperparathyroidism
Excess PTH resulting in a rise of blood calcium
levels
Bones are then soft and weak
More susceptible to pathologic fractures
Muscles become weaker and the client then feels
fatigue, nausea and constipation
Kidney stones, UTIs and uremia develops
Dx: high blood level of PTH and by x-rays
Diuretics (Lasix; furosemide), may be given to
prevent renal disorders which develop as a result
of high blood calcium levels
Hyperparathyroidism
Phosphates may be given to reduce the serum
calcium levels
Thyroid lobectomy to remove part of the thyroid
gland containing the parathyroid may be done
Encourage exercise to help the bones from releasing
some calcium (blood levels are high enough)
Limit calcium
Postop, tetany may occur and calcium gluconate can
be given
Keep trach tray and IV calcium at bedside postop
Avoid activities that may result in an injury so that
the bones do not break, they need time to be
recalcified
Ca level >10.5
Hypoparathyroidism
Deficiency of PTH resulting in lack of available
calcium in the body with phosphorous
accumulating in the blood
Cause may be accidental removal of the
parathyroid during a thyroidectomy.
Calcium deficiency causes tremors and tetany
Cardiac output decreases
+ Trousseaus sign or Chvosteks sign
S/S: hair loss, coarse skin, brittle nails,
arrhythmias, possible heart failure
Tx: increase serum calcium level using calcium
gluconate (IV), large doses of Vitamin D,
administer sedatives or anticonvulsants to prevent
seizures.
THYROID AND ANTITHYROID DRUGS
T4 & T3-Iodine is an essential element for the
manufacture of both of these hormones
Treat:
Hypothroidism & Hyperthyroidism
THYROID AND ANTITHYROID DRUGS
USES
Thyroid hormones are used as replacement
therapy when the client is hypothyroid
By supplementing the decreased endogenous
thyroid production and secretion with
exogenous thyroid hormones, and attempt is
made to create a euthyroid (normal thyroid)
THYROID AND ANTITHYROID DRUGS
Adverse Reactions
During initial therapy, the most common
adverse reactions are signs of overdose and
hyperthyroidism
THYROID AND ANTITHYROID DRUGS
Contraindications
Clients with a known hypersensitivity to the
drug
After a recent MI
Clients with thyrotoxicosis
Precautions
Used carefully in clients with Addisons
disease and during lactation
Antithyroid Drugs
Used to treat hyperthyroidism
Strong iodine solutions, radioactive iodine
or surgical removal of some or all of the
thyroid gland may be done as well
Strong iodine solutions
Adverse reactions-iodism; metallic taste in
the mouth, swelling and soreness of the
parotid glands, burning of the mouth and
throat, sore teeth and gums, symptoms of a
head cold and GI upset
Antithyroid Drugs
Nursing process:
The nurse observes the client for a thyroid storm-high
fever, extreme tachycardia, AMS which can occur in
clients whose hyperthyroidism is inadequately treated
Strong iodine solutions are measured in drops which are
added to water or fruit juice (the drug has a strong, salty
taste)
Iodine solutions should be drunk through a straw because
they can cause tooth discoloration
Radioactive iodine is given by the PCP, orally as a single
dose
If the client is hospitalized, radiation safety precautions
identified by the hospitals dept. of nuclear med are
followed
When using radioactive iodine, thyroid hormone
replacement therapy may be needed if hypothyroidism
develops
Nursing Process
S/S of hypothyroidism may be confused with
normal aging signs in the geriatric client
depression, cold intolerance, weight gain,
confusion or unsteady gait.
Full effects of thyroid hormone replacement
therapy may not be apparent for several weeks of
more, but can be seen in as little as 48 hours
Signs of a therapeutic response weight loss,
mild diuresis, sense of well-being, increased
appetite, increased pulse rate, increased mental
activity, and decreased puffiness of the face,
hands, and feet.

Nursing Process
The nurse will report signs of
hyperthyroidism-nervousness, anxiety,
increase appetite, elevated body temp,
tachycardia, etc.
The nurse monitors the client with diabetes
during thyroids hormone replacement
therapy for signs of hyperglycemia.
Replacement therapy for life - usually
Pancreatic Endocrine Disorders
Hyperinsulinism
Hypoinsulinism
Diabetes Mellitus Type I and II
Gestational diabetes
Impaired glucose tolerance
Diabetes Mellitus
Islets of Langerhans in the pancreas secrete
insulin
If insulin is not available, glucose cant
enter the body cells and this results in an
increase in circulating blood glucose
Classification
Type I (IDDM, or juvenile diabetes)
Onset age: under 30
Beta cells are not producing insulin
Tx: diet, exercise, oral meds or insulin


Diabetes Mellitus
Type II (NIDDM, adult onset diabetes)
Onset age: over 30
Tx: diet, exercise, oral meds or insulin
Gestational Diabetes
Occurs during pregnancy only
Impaired fasting glucose (IFG and IGT)
Risk factors for diabetes
S/S: most common is the 3 Ps
Polyuria
Polydipsia
Polyphagia
Classic sx: fatigue, blurred vision, mood changes, dry
skin, wt. loss, infections, numbness and tingling in
extremities.
Diabetes Mellitus
TYPE I DM
2 forms
Immune mediated results from an
autoimmune destruction of the pancreatic
beta cells.
Idiopathic diabetes Develops
spontaneously, no cause
Type I DM = 5-10% of US cases
Diabetes Mellitus (cont)
Will be on INSULIN!!!
Goal of tx is to achieve metabolic stabilization,
relieve hyperglycemic symptoms, and restore body
weight

Type II DM
Usually occurs after age 30, overweight
Pancreas usually produces some insulin at time of
diagnosis
May present with decreased tissue sensitivity to
insulin known as insulin resistance
May require insulin injections
Diabetes Mellitus
More prevalent in African Americans, Native Americans,
and Hispanics
Seen more in Women
Type II DM may be inherited, cause is unknown,
autoimmune destruction of pancreatic beta cells does not
occur
The muscle cells of diabetics cant take up glucose which
leads to increased glucose concentration in the
bloodstream (hyperglycemia)
Hyperglycemia gradually develops and symptoms are
unnoticed
Increased risk for macrovascular and macrovascular
complications

Diabetes Mellitus
Goals for Tx: prevent vascular
complications, achieve metabolic control,
meal planning, exercise program, wt. loss
and medications.
Gestational Diabetes Mellitus
Occurs during the 2
nd
or 3
rd
trimester of
pregnancy
Screened between 24-28 wks gestation
Disappears after birth; however,
Have a greater chance of having type II DM
later in life
Impaired Glucose Homeostasis
Glucose levels above normal but are not high
enough to have diabetes
IFG occurs when the FPG is above 110 but less
than 126 mg/dl
IGT means that the results of an OGTT are
greater than 140 but less than 200 mg/dl in the 2
hour sample
Clients with IGH are at risk for diabetes
development MIs, strokes
Requires close glucose monitoring
Treatment
Diabetics must maintain carefully planned and
balanced diet, exercise, and medications
Goals of Tx:
Relieve sx
Maintain normal wt. and activity
Maintain glucose levels between 70-140 mg/dl
Hgb A1C levels less than 7%
Prevent LT and ST complications
Prevent hypo/hyperglycemic reactions
Nutrition Therapy
Individualized
Establish baseline-degree of diabetic
management, any complications??
Teach and encourage diet maintenance
Obtain glucose levels before meals
CHO counting-blood glucose levels are affected
by the CHOs in foods, total amount of CHO is
more important than the source
Nutrition Therapy
The starch/breads, milk and fruits have been labeled as
CHOs; these food groups can be interchanged in a
single meal
CHO counting diets consult with dietician, 3 levels
involved
Diabetes Food Guide Pyramid
Diabetic Exchange List developed by the American
diabetic association and in conjunction with the American
dietetic association
Food in this group contains approximately equal contain
approximately equal amounts of kcal, CHO, protein,
and fats
This means that any one food on a list can be substituted
for any other food on a particular list
Nutrition Therapy
Fiber can reduce the amount of insulin
needed because it lowers blood glucose
levels by lowering the cholesterol and
triglyceride levels
Sucralose is the approved sweetener of the
FDA
Nutrition Therapy
Exercise
Important for the diabetic
Increases circulation
Controls weight
Decreases blood pressure
Reduced stress
Assists in blood glucose regulations by
increasing insulin receptor sites and
stimulation glucagons production

Nutrition Therapy
Diabetics who use medications to control
their glucose levels, need to know when
and how often to exercise as exercise can
cause HYPOGLYCEMIA
Also need to maintain proper hydration as
dehydration can affect glucose levels

Insulin
Available as purified extracts from beef
and pork pancreas (used infrequently)
Synthetic insulins, such a human insulin and
insulin analogs
Activates a process that helps glucose
molecules enter the cells
Stimulates the liver glycogen synthesis
Insulin
Onset when insulin first begins to act in
the body
Peak - when insulin exerts maximum
action
Duration the length of time the insulin
remains in the body.
Insulin
When insulin is combined with protamine
(protein), the absorption of insulin from the
injection site is slowed and the duration of
action is prolonged.
The addition of zinc also modifies the onset
and duration action of insulin.
Insulin is needed to control Type I DM.
Insulin
Adverse Rxns
Allergy to the animal from which the
incluin is obtained or to the protein or
zinc added to the insulin
Human insulin or purified insulin is
used to decrease the possibility of
adverse reactions
Hypo/Hyperglycemia
Insulin
Nursing Process:
Insulin doses are individualized
Care must be taken to give the correct insulin
and dosage
Insulin can be administered SubQ, or IV
(Humulin R only)
Insulin lispro is given 15 minutes before a
meal or immediately after a meal.
Insulin
When mixing insulin's, the short acting insulin is drawn
up first
FYI when mixing insulin, the insulin must be given
within 5 minutes of with drawing the two insulin from
the vials
Liposdystrophy-atrophy of SubQ fat, appearance of
pitting or dimpling of SubQ fat, interferes with the
absorption of insulin from the injection site; insulin
injection sites must be rotated.
Glycosylated hemoglobin (HbA1c) is used to monitor
the average blood sugar over a 3-4 month period
Normal levels vary but generally you want the level to be
between 2.5% and 6%, this level indicates a good control
over diabetes

Insulin
Storage of Insulin
Keep at room temp, away from heat and light
if used in 1 month, keep in refrigerator for 3
months, vials not in use are stored in the
refrigerator
Insulin Therapy
Given subq-insulin is destroyed by
digestive enzymes
What does insulin do?
Enables glucose to cross the cell membrane
for use be the cell
Helps liver convert glucose to glycogen
use of 02 by the cells
No 02?
Increase confusion
Lower ability to think
Insulin Therapy
Types of Insulin
Rapid-acting
Regular
Clear
Onset = - 1
Peak action - 2 - 4
Duration = 5 - 7
Hypoglycemia reaction = before lunch
Mixes with all other insulins
Can be given IV
Insulin Therapy
Intermediate acting
NPH
Cloudy
Onset= 1 - 2
Peak action = 6 - 12
Duration= 24
Hypoglycemia reaction = night and early
a.m.



Insulin Therapy
Long Acting
Humulin U
Cloudy
Onset = 6
Peak action = 16-18
Duration = 36 +
Hypoglycemia reaction = night and early
a.m.
Insulin Therapy
Care of insulin
Refrigerate
Avoid excessive hear or light
DO NOT FREEZE
May mix Regular with all types of Insulin
Roll vial DO NOT SHAKE
Check expiration date
Check with another nurse
Draw up regular THEN NPH
clear to partly cloudy
If insulin clumpy discard
Insulin Therapy
Nursing Guidelines
Always get an order to give if pt. is NPO
Do FSBS before giving insulin
DO NOT USE a 3-cc syringe-use only
insulin syringes
Give subq at 90 angle and withdraw
needle at 90 angle
Document BS and insulin
Assess for signs/symptoms of hypo-
hyperglycemia
Insulin Therapy
Coverage
D.M. may be out of control during illness
Sliding scale of regular insulin based on
B.S.
Insulin requirements during illness and
stress
Usually checked for coverage
AC lunch
AC dinner
HS
Insulin Therapy
Insulin Pump
Mechanical
Injects insulin automatically
Tries to maintain a constant blood
level
May bolus prior to eating
Buffered insulin in used
Insulin Therapy
Complications
Hypoglycemia
(insulin shock)
Too much
insulin in
relation to the
amount of
available
glucose
S/S
Weak
Cold
Tired
Hungry
Nervous/tin
gling/tremb
ling
Perspiring
HA
N/V
Blurred
vision
Seizures
LOC
decreased
Death
<70 mg/dl
blood
glucose


Hypoglycemia
Treatment and Nsg. Considerations
Develops rapidly
CHO needed to counteract insulin reaction
Client Conscious give sugar OJ, soft drink, honey,
candy
Unconscious give glucagons IV IM or 50% Dextrose IV
Somogyi phenomenon hypoglycemia followed by a
rebound hyperglycemia as the body attempts to correct
the problem
Develops lat at night or early am
Tx reduce insulin dosage until glucose level achieved
DKA
Hyperglycemia (Diabetic Ketoacidosis)
To little insulin available for use
Glucose cannot enter muscle cells
Fats and proteins are broken down into ketones as an
alternative energy source
These ketones are sent to the cells for use
If too many ketones accumulate (ketones), an
electrolyte imbalance will occur
Ketoacidosis where acetone is also produced
DKA
Ketone bodies are formatted in any
condition which interferes with the
Storage of glycogen in the liver or
Increase the bodys need to burn fat for
energy
DKA
S/S
Slow onset
Weakness, drowsiness
Vomiting
Thirst
Dehydration
Flushed cheeks
Dry skin and mouth
Sweet odor to breath
Increase respirations
Without tx-
Dizziness
Confusion loss of
speech
Blurred vision
Seizures
Loss of consciousness
^ BP
^ pulse
Brain damage
Death

DKA
Tx:
IVF
Insulin
Warm blankets
IV-regular insulin
Lower production of ketones> makes more
CHOs available to tissues.
NKHOS Nonketonic Hyperosmolar State
Glucose 1,000/dl and above
Occures in older adults most often
Mortality rate high
Causes include age, stress undiagnosed
hyperosmolarity, coma
Tx continuous low dose insulin infusion,
aggressive IVF
Nsg. Care administer IVFs monitor I & O,
daily wt., monitor glucose levels frequently
NKHOS
Infections
R/T vessel wall damage due to increased
blood sugar
DM client susceptible to yeast and fungal
infections, colds, flu, carbuncles and
furuncles
Nsg. roleinjury prevention
NKHOS
Laboratory Evaluation of
DKA vs NKH
DKA NKH
Plasma Glucose Elevated Very High
pH Below 7.3 Above 7.3
Bicarbonate <15 meq/1 >20mEq/L
Serum ketones Present Negative
Ketonuria Present Negative
Osmolarity Varies Very High
Insulin Levels Very Low Can be normal
NKHOS
Post op surgical risk
Difficulty regulating B.S.
Circulatory Problems
Decreased healing ability
Increased infections
Diabetes
Macrovascular complications
Increased glucose levels may increase
arteriosclerosis in LEs, vessels of heart and
kidneys
HTN, CAD, PVD, MI, stroke can result from
arteriosclerosis
DM clients are 2-6 times more likely to have a
stroke and 2 times as likely to have an MI
Assess for skin breakdown and teach clients to
assess for breakdown esp. on FEET!!
Diabetes
Microvascular Complications
Diabetes causes changes in the capillary
walls, resulting in decreased blood flow
and poor 02 to highly vascular tissues
Retina and kidneys are primarily
affected
Diabetes
Nephropathy-kidney disease that may
result in death caused by kidney failure
Kidney infections or albumin or blood
in the urine are the first indications of
nephropathy
Tx: slow approach, control BP, control
blood sugar levels and diet
Diabetes
Retinopathy a leading cause of blindness
in this country caused by diabetes
Loss of the functional retinal tissue d/t
microvascular damage
Yearly eye exams
Damage cannot be reversed
Diabetes
Neuropathy nerve damage
Long term complication of poorly controlled
diabetes
Peripheral neuropathy
Begins as tingling and numbness in the toes and
progresses gradually to the ankle and then leg.
Can be painful or numb
Tx-Elavil, Tegretol, Dilantin
Autonomic neuropathy-can result in impotence
intestinal involvement, urinary retention,
stomach involvement, orthostasis
These are treated based on the symptoms
Client Teaching
Education is very important !
There is NO cure for diabetes!!
Diabetes is only controlled or managed:
Person feels well
Maintain balanced diet and normal wt.
Blood glucose level 70-140 mg/dl
Carry rapid acting sugar with you at all
times
Client Teaching
Long-term complications can be reduced
by controlling the blood glucose level
Need regular care involving their feet,
hands, teeth, and eyes.
Clients will be responsible for managing
foods, blood testing, exercise, and
medication administration
Client Teaching
Physician will plan a medication schedule,
exercise program and diet management
Type 1 DM clients will test their urine for
ketones
Clients will notify MD if glucose level is above
240 mg/dl for 3 days
Meal plans are individualized with assistance
from a dietician
Foods containing sugar are not prohibited but
must be included in their CHO intake
Client Teaching
Lifestyle factors exercise lowers glucose
levels, be careful to make sure glucose
level does not drop too much.
Smoking should be avoided d/t
vasoconstrictor effect of nicotine
Insulin needs to be taught to the client;
dosages, onset, peak and duration times,
storage of the battle, etc.
Rotate injection sites to keep skin healthy and
prevent lipodystophy
Diabetics
Know the s/s of each!!
Know how to manage them!!
Encourage the client to carry CHO snacks with
them-hard candy, glucose tablets, cheese and
peanut butter.
Glucagon/glucose emergency kit should be
carried for those who receive insulin
Encourage client to wear a medic alert bracelet.
Diabetics
Sexuality
Diabetic men may have erectile
dysfunction
Cause is neurogenic
May need to use penile implants or
prostheses, or oral meds - Viagra
Diabetics
Exposure to Cold
Cold slows blood circulation
Diabetics are at risk for hypothermia or
frostbite
Diabetics
Vision Impairment
Annual eye exams
Strategically place furniture to
avoid falls
Diabetics
Dental Exam
Regular dental exams
Dental caries can lead to infection
and alter glucose levels
Diabetics
Foot Care
At risk d/t poor circulation and decreased
sensation
Traveling
Consult MD before traveling long distances
Consider diet and exercise
Identification
MedicAlert tags
Nursing Process:
Observe client every 2-4 hours for symptoms of
hypoglycemia once therapy has been initiated
Exposed to stress, infection, fever, surgery, or
trauma may increase the blood sugar levels
requiring the use of insulin vs. oral drugs
Take the drug exactly as prescribed, at the same
time/times each day, dont skip meals, avoid
alcohol
Clients must monitor glucose before and after
exercise, ingest extra CHOs if glucose levels are
under 100 mg/dl