CARE 2
EXAM 2
HTD
ENDOCRINE DISORDERS
the endocrine system HPA axis
hypothalamus = releases GnRH = stimulates pituitary gland to release all types of hormones
posterior pituitary = ADH (vasopressin), oxytocin
anterior pituitary = everything else = GH, ACTH, TSH, FSH, LH, prolactin
the thyroid during surgery, located posteriorly
PITUITARY GLAND
sits in sphenoid sinus cavity, below optic chiasma = connected to hypothalamus with stalk = therefore,
pituitary enlarges it puts pressure on optic chiasma = resulting in visual disturbances
s/s of adenoma = headaches, hemianopia (lose upper/outer/lower vision = tunnel vision), loss of visual
acuity = can go blind if not treated
anterior pituitary
posterior pituitary
most common = adenoma tumor (benign, but do
problem with ADH
get bigger) = results in over or under secretion
hormones = vasopressin (ADH) and oxytocin
of 1 or more hormones = sign and symptoms of
diabetes insipidus = lots of urinating due to no
whatever the hormone does + adenoma
ADH (10L of urine a day)
most common overproduced hormones =
SIAHD = not urinating due to too much ADH
prolactin and growth hormone
produced (diluted sodium, water retention,
when anything grows in the head = it will
weight gain)
increase the ICP
under secretion of hormones
causes = tumor, no blood flow, infection, sheehan syndrome, surgical removal,
irradiation, head injuries, sarcoidosis or amyloidosis, damage to hypothalamus
o change in blood flow causes infract to pituitary gland
hypopituitarism
o sheehan syndrome = changes in blood flow during pregnancy = causes infarct
(rare)
sign and symptoms
o hyposecretion of target organ
o headaches, visual changes, anosmia, seizures (s/s of tumor)
o anosmia = changes in smell
teaching = have a smoke/carbon monoxide detector
oversecreting of hormones = typically prolactin or growth hormone
age 30-50 = end plates of bone closed therefore bones grow wider not taller
o therefore, bones become deformed rather than elongated (for acromegaly +
GH)
prolactin hypersecretion
most common
prolactin = used for lactation, breastfeeding
sign and symptoms (target organ)
hyperpituitarism
o galactorrhea = enlarged breast tissue, mainly men
(more common)
o amenorrhea = no period
o decreased libido
o erectile dysfunction
o + headache, visual changes, changes in smell, seizure (from adenoma)
treatment = surgery = based on tumor size and prolactin levels secreted then decision
is made to surgically remove or to medically treat
medical treatment = bromocriptine or cabergoline = a dopamine agonist to inhibit
prolactin secretion by the tumor
acromegaly
due to over secretion of GH and occurs after the epiphyseal plates are closed
known as gigantism in children = grow taller
first notice in hands + feet = bigger shoe size needed *
happens very slowly (insidious), takes time for people to realize (7 years)
sign and symptoms
o
fit
o unique facial feature = protruding jaw, frontal bossing, thick nose/lips/
o macroglossia (big tongue) is associated w/ sleep apnea & cardiac arrhythmia
o voice changes (lower voice)
o high risk for sleep apnea = decrease airway to sleep apnea, snoring *
o joint pain = arthritis
o heart enlargement = leads to heart failure
diagnosis = blood work for IGF1, IGF3, OGTT = GH is an antagonize to insulin *
treatment = surgery removal (hypophysectomy) or radiation
o drug therapy = octreotide (sandostatin) = reduces GH levels = SQ 3x weekly
o therefore, have to give them hormone replacement
diet = diabetic (ADA) or carbohydrate intolerance = due to GH suppressing insulin =
can develop diabetes
o salt restriction = if they start developing heart failure due to increase heart
size
THYROID
secretes = T3, T4, calcitonin (T3 & T4 essential for life)
airway problem, displaces the trachea
hyperthyroidism
everything increases tbh
high T3 and T4 and low TSH *
most common cause, autoimmune disorder
ophthalmopathy/exophthalmos * = bulging eyes
thyroiditis
inflammation of the thyroid gland = leads to
overproduction
know you have it when you see the white above
the eyes/cornea
sign & symptoms
thyrotoxicosis (thyroid storm)
atrial fibrillation (very rapid) & febrile (fever)
increase metabolic rate = increase appetite (but
still weight loss)
diagnosis = decrease TSH levels because
heat production = warm & moist skin = heat
levels
intolerance
eye care for ophthalmopathy *
tachycardia, palpitations, dyspnea = heart
stop smoking = not just limit like stop it now
failure
raise the head of the bed = due to tissue/fluid
dyspnea = due to pushing the trachea because
build up
of goiter
all
elevated blood sugar, decrease cholesterol = on
the way, protect from irritants
ADA or diabetic diet
moisten eyes with artificial eyedrops because
increase CNS = nervousness, irritable,
dry eyes
restlessness, insomnia
special prism glasses = to correct double vision
increase excretion of calcium & phosphorus =
osteoporosis
older adults = more likely to see confusion,
depressed, and heart failure
treatment *
methimazole (tapazole) = 1st choice, if they have time and not severe
neutropenia
o take weeks to be in affect
radioactive iodine (most common) * = one treatment, then another if needed, fast = permanent treatment
o diet low in iodine
o stop meds high in iodine = 1 month prior
o stop meds for hyperthyroidism meds (methimazole or PTU) = 5-7 days prior
o take pregnancy test = because radioactive will destroy fetus :-/
o drink lots of liquids to flush out the iodine
o do not eat for 2 hours post procedure
o use bathroom every hour for first 8-12 hours, flush twice after use
o limit contact with others, wash hands often, do not share bed, food, drinks, no kissing, sexual
contact
o resume normal thyroid medication 48 hours after treatment
once treated for hyperthyroidism will have lifelong hypothyroidism so need levothyroxine * (please know
this, please)
hypOthyroidism
(second most common endocrine problem)
everything decreases
decrease secretion of thyroid hormone = high TSH, low T3 and T4 *
hashimO
autoimmune = enlarged thyroid because it thinks the gland is broken, cannot convert iodine into TH
diagnosis = draw for thyroid antibodies because autoimmune disorder
thyroid left untreated = leads to depression (for HESI)
diagnosis = increase TSH levels (+ cholesterol, LDL, triglycerides) decrease T4 levels
sign & symptoms
treatment *
decrease metabolic rate = decrease appetite, but
weight gain due to edema, fluid build-up
decrease heat production, body temperature =
cold intolerance
thin, dry hair = pale, dry, cool skin
life-threatening event = myxedema * = going
breathe
decrease erythropoietin = anemia = yellow skin
decrease blood glucose, increase triglycerides
& cholesterol
bradycardia, fatigue
constipation = fiber and water diet
levothyroxine (synthroid) = DOC = review this
older adults = start at low dose to see if heart
can behave = 25 mcg
takes 6-8 weeks to work
side effect = tachycardia
take before breakfast, on an empty stomach in
the morning
space out medications = 4-5 hours
disorders
PARATHYROID
located = posterior surface of thyroid gland (4)
important to regulate calcium = when calcium is low, it releases parathyroid hormone (PTH) to increase
osteoclastic activity in the bone to release calcium into the bloodstream
hyperparathyroidism *
too much PTH = too much calcium released from bone = leads to osteoporosis, osteomalacia, and extra
calcium in bloodstream can lead to kidney stones
sign & symptoms
treatment
muscle weakness, loss of appetite, fatigue
constipation
osteoporosis, pathological fractures, kidney
stones
avoid lithium & thiazide = can increase calcium
levels
stay hydrated, 2-3 L of fluid daily = because of
risk for kidney stones
avoid inactivity = moving/exercise, weight
bearing will move the calcium back into the
bone
avoid high calcium diet = cheese, dairy
products
increase fluid intake!!! *
hypoparathyroidism
too little PTH = too little calcium = hypocalcemia (which means phosphorus is high)
o remember = inverse relationship between calcium and phosphorus
s/s = tingling around the lips = neuromuscular excitability
o acute = can cause tetany = tonic spasms in upper/lower extremities with pain
o neuromuscular excitability, irritability, muscle cramping
= tap on cranial nerve 7, facial nerve = twitching = low calcium or magnesium
sign = palmar flexion with BP cuff on or grasping
wrist = positive for low calcium
o see these in hypoparathyroidism and thyroidectomy (might be removing parathyroid)
treatment = replacement for calcium & vitamin D
o calcium supplement = 1.5-3 g/day
diet = high in calcium = tofu, dark green vegetables, soybeans
acute tetany = tonic spams in the upper/lower extremities caused by decreased calcium followed by pain
o give IVP calcium gluconate (at the bedside, ready to go) *
SURGICAL PROCEDURES
hypophysectomy
thyroidectomy
parathyroidectomy
removal of pituitary gland
transsphenoidal approach = cut in upper gum line to avoid disturbing the cranium
o incision performed in upper gum line
high risk of infections = clean sinus with antibiotic spray
cortisol given = to reduce stress since we are removing the pituitary gland, so no
more cortisol is being produced
muscle graft from anterior thigh used to = pack dura to prevent CSF from leaking
o if CSF can leak out, anything can leak in = portal of entry
strict I&O and daily weights = to look for diabetes insipidus
o lifelong replacement of cortisol and ADH
no coughing, sneezing, blowing nose = CSF can leak = risk for meningitis
oral hygiene = no toothbrush for 2 weeks = use oral rinse and dental floss *
monitor nasal drip for glucose >30 = if glucose is above 30 then CSF fluid is
leaking which is bad
prevent constipation = because head pressure
elevate HOB to 30 degrees
patient may have anosmia for 3-4 months
note = CSF has glucose so if tested positive on dip stick for glucose = it is CSF
removal of thyroid (partial/subtotal or total)
pre-op = start
= to reduce vascularity
and shrink the thyroid gland = for less risk of hemorrhaging
o can stain teeth = drink through straw
o give with meals in a full glass (240 mL) of water or fruit juice and at
bedtime with food or juice to disguise salty taste and minimize gastric
distress
ineffective breathing pattern = assess respiratory status
post-op = hematoma formation, assess respiratory depression = elevate HOB
o assess wound/dressing = in neck and shoulders (posterior) because of
gravity moving blood back there *
o place in semisupport head & neck with pillows *
o hemorrhage = tachycardia with hypotension
o tracheostomy set = available immediately for emergency use so they can
breathe
assess for low calcium because procedure can accidentally remove parathyroid
glands
o
signs
o tingling around the lips, etc. *** why?
o keep calcium gluconate 10% at the bedside IVP!! *
total or partial removal of parathyroid
similar to thyroidectomy
monitor for = hemorrhage, airway obstruction, hypocalcemia
tracheostomy set = available immediately for emergency use
monitor calcium levels = assess for tetany
mild hypocalcemia = give oral calcium
severe hypocalcemia = give calcium chloride or calcium gluconate IV
ADRENAL GLAND
composed of adrenal cortex and adrenal medulla
adrenal cortex = glucocorticoids (cortisol), mineralocorticoids (aldosterone), sex steroid hormone
(androgens)
any disorders = all 3 are affected (under/over secreted)
adrenal medulla = norepinephrine, epinephrine (adrenaline)
aldosterone = increases sodium reabsorption and water follow, therefore low potassium = can lead to
overhydration or = vice versa and dehydration
cortisol = regulates glucose = directly related!!!
o increase cortisol = increase glucose
HPA axis = hypothalamus = releases corticotropin-releasing hormone (CRH) = stimulates pituitary gland
to release adrenocorticotropic hormone (ACTH) = to stimulate adrenal to produce cortisol/aldosterone
o on a negative feedback loop
addisO
hypOfunction of adrenal cortex
decrease in mineralocorticoids, glucocorticoids, androgen secretion (all 3 are affected)
autoimmune disorder = results in atrophy of gland = 90% destroyed before s/s shows
diagnosis
o ACTH-simulation test = gives ACTH to see if adrenal gland will start working
if adrenal gland starts working = then pituitary gland is the problem
problem
o basal metabolic panel = look at electrolytes
decrease sodium (decrease water)
increase potassium
low blood sugar (due to low cortisol)
elevated BUN (due to dehydration due to low water due to low sodium)
o urine = low in cortisol and aldosterone
hyperkalemia = K+ levels above 7 meq/L = leads to arrhythmias and cardiac arrest
due to Na+ & water excretion = dehydration = results in hypotension, decrease cardiac output =
tachycardia = decrease heart size (microcardia) = heart failure
o why is it decrease heart size??? idk hahahhahahha
due to low cortisol = low glucose = hypoglycemia = results in glycogen deficiency after using up all the
glycogen
decreased resistance to stress due to low cortisol
there will be an increase ACTH to try to increase aldosterone = which also increases melanocyte
stimulating hormone (MSH) = resulting in increased skin pigmentation = tanned/bronzed skin *
mood changes = delusional thinking, lethargic, apathetic, depressed, forgetful
high risk for infection due to alters in immune system (nursing diagnosis) = due to low cortisol
hypoaldosteronism
vital signs = monitor for = hypotension, tachycardia, tachypnea
fluid volume deficit = report if urine under 30 cc/hr = on fluid replacement
observe for addisonian crisis = major emergency & life-threatening
o severe hypotension, hyperkalemia, hypoglycemia
o occur within 24-48 hours
lifelong replacement cortisol replacement *
sign & symptoms
fludrocortisone (florinef) = mineralocorticoid =
reabsorbs Na+ and water (know what this drug
is for *)
take 2/3 dose in morning and 1/3 in late
afternoon = mimic body regulation
increase dose for increased physical stress
take medication with snack or meal
never skip a dose, or stop = will go back to
disease
wear medical alert bracelet
learn how to give emergency IM injection of
hydrocortisone
note = amount taken varies depending on stress
levels = so higher dose during stressful
situations
bronze skin pigmentation
weight loss
postural hypotension
hypoglycemia
hyperfunction of adrenal cortex (too much glucocorticoids but all 3)
altered protein = muscle wasting, osteoporosis, slow wound healing, thin skin
o
body
o think about how diabetic patients have ulcers and thin skin, etc.
altered fat metabolism = obesity, moon face, buffalo hump
altered carbohydrate = hyperglycemia = due to increase cortisol
altered inflammatory & immune = can easily get infection = so prevent infection
altered water = Na+ and water retention = weight gain and edema
altered androgen = acne, bronzed skin, purple striae, ecchymosis, hirsutism
increase RBCs = facial plethora = redness to face, red cheeks
diagnostic testing
o draw blood for plasma cortisol and ACTH = at 8 am and 4 pm (normal body function)
high levels of cortisol and low levels of ACTH
o 24-hour urine collection = for the byproduct of cortisol
has to be kept cold = in ice or refrigerator
discharge the first void and then start
fluid retention = I&O, daily weight
treatment = hypophysectomy = remove pituitary adenoma
low sodium diet, give potassium supplement
hyperaldosteronism
hyperaldosteronism = give K+ sparing agent = spironolactone * (but loop and thiazide better = to get rid of
fluid)
primary
secondary
due to too much mineralocorticoid
(aldosterone)
results in = sodium retention, therefore,
excretion of potassium and H+ ion
due to too much aldosterone results in increase
angiotensin II
results in = renal stenosis, increase BP
metabolic alkalosis = due to losing H+ ions
pheochromocytoma
benign tumor from chromaffin cells (located in adrenal medulla) producing catecholamine = epinephrine
and norepinephrine
hypertensive & hyperglycemia
hypertension = silent disease but presents with severe headaches *
diagnosis = 24 hours urine collection for metanephrines = byproduct of catecholamine
treatment = surgery
o give short-acting alpha-adrenergic blocking drug = to control hypertension
o give long-acting alphasurgery
SURGICAL PROCEDURES
adrenal surgery
need cortisol replacement = IV first then oral when can take food
mineralocorticosteroid replacement = fludrocortisone (florinef)
DIABETES MELLITUS: AN EPIDEMIC
micro- and macro- vascular disease = affect heart and small blood vessels
chronic disease = causing hyperglycemia due to no insulin production, insulin resistance or both
leads to = adult blindness, end-stage kidney disease, lower-limb amputations
o affects heart disease, stroke, hypertension
beta cells in islet of langerhans in pancreas makes insulin
normal blood sugar = 70 to 120
insulin
moves K, PO4, and Mg into the cells = insulin is treatment for hyperkalemia
alcohol = inhibits insulin release
pre-diabetes
impaired glucose intolerance
o two-hour oral glucose tolerance test (OCTT) = 140 to 199 for pre-diabetic
o over 200 = diabetic
impaired fasting glucose (IFG)
o fasting glucose level = 100 to 125 for pre-diabetic so over 126 = type 2 diabetes
asymptomatic but long-term damage already occurring = like back/foot problems
patient teaching
o screening, manage risk factors, monitor symptoms, maintain weight, diet, exercise
metabolic syndrome
(known as pre-diabetes)
at high risk for type 2 diabetes
elevated glucose, blood pressure and triglycerides, obesity, decrease HDLs (the good one)
o 3/5 components = positive for metabolic syndrome
diabetes mellitus syndrome
lack of insulin leads to increased blood and urine glucose
gestation DM = glucose intolerance discovered during pregnancy = risk for type I or II
type 1 diabetes
type 2 diabetes
autoimmune disorder
metabolic disorder
rapid onset
gradual onset
dependent on insulin to live
elevated glucose levels due to insulin resistance
due to insulin resistance OR impaired insulin
insulin-producing cells of pancreas, beta cells
secretion
HHNS = no ketones
to regulate glucose levels
DKA = ketones
honeymoon period * = time where blood
glucose is okay but then marked increase and
insulin
diabetes = hyperglycemia symptoms
diagnosing diabetes (4)
polydipsia = extreme thirst
polyuria = frequent urination = s ugar in urine
polyphagia = increase appetite but unexplained
getting the sugar and loses weight because
used
hemoglobin A1C level = 6.5% or higher *
fasting plasma glucose = higher than 126
two-hour plasma glucose = higher than 200
symptoms of hyperglycemia with random
glucose level over 200+
fruity breath odor
lethargic, tired
treatment
management = exercise 30 minutes 5 out of 7 days (start baby steps)
type 1 = insulin replacement
o clear to cloudy
o draw rapid/short acting first then intermediate acting
o ace inhibitors = prevent diabetic nephropathy & diabetic hypertension
ARB better to prevent hacking cough from ACE
o statins = reduce high levels of LDL
type 2 = ORAL antidiabetic medicine = metformin = drug or choice + lifestyle changes with
weight/exercise
types of insulin *
rapid acting/short duration (lispor) (-log) = give 15 minutes before meals = clear
slow acting/short duration (regular) (R) = give 30-45 minutes before meals = clear
intermediate duration (NPH) (N) = cloudy solution, mix with short acting
long duration = glargine (lantus) = lasts 24 hours, no peak
insulin = causes hypoglycemia, edema, and weight gain
rapid-acting (bolus)
short-acting (bolus)
intermediate-acting
insulin (NPH)
long-acting (basal)
mealtime insulin (bolus)
lispro, aspart, glulisine (-log)
onset = 15 minutes
injected within 15 minutes of mealtime
regular
onset = 30-60 minutes
injected 30 to 45 minutes before mealtime
duration 12 to 18 hours
peak 4 to 12 hours
can be mixed with short or rapid acting insulin (this is the cloudy one)
insulin glargine (lantus) or determir (levemir)
released steadily = no peak = no hypoglycemic events
administer once or twice a day
DO NOT mix with any other insulin (but you also can lmao)
remember = rotate injection sites to avoid lipodystrophy *
insulin storage
DO NOT heat or freeze
leave at room temperature for 4 weeks max = extra ones refrigerated
avoid exposure to direct sunlight, extreme heat or cold
store prefilled syringes upright for 1 week if 2 insulin types; 30 days for 1 type
insulin
given subcutaneous (SQ) injection = NO oral insulin
regular insulin may be given IV
fastest absorption = abdomen, followed by arm, thigh, and buttock
abdomen = preferred site
two concentration = U100 and U500
o 1 mL contains 100 U of insulin
do not need to use alcohol swab anymore, can use soap and water
inject at 45 to 90-degree angle = because SQ
problems with insulin therapy = hypoglycemia, allergic reaction, lipodystrophy, somogyi effect
o somogyi effect = wakes up with high blood sugar, due to high insulin at night = get hypoglycemia
at night which causes increase glucose
hypoglycemia s/s = sympathetic system activated basically
o shaking, sweating, anxious
o dizziness
o weakness, fatigue
o headache
o irritable
o fast heartbeat
o impaired vision
o hunger
acanthosis nigricans = occur in obese people with diabetes = dark, velvety patch on skin in armpit, groin,
neck (big sign of diabetes)
type 2 diabetes
oral anti-diabetic drug (metformin) used for type 2 ONLY = never type 1
adverse effects = nausea, diarrhea, decreased appetite, weight loss = does not cause hypoglycemia
goal = decrease insulin resistance and increase insulin sensitization
metformin
o give with meals = causes nausea + vomiting
o contraindication = elevated creatinine (nephrotoxic) = normal = 0.6 1.2
diabetic teaching diet/meal planning
low carb, low fat
use sugar substitutes, if possible
alcohol affects blood sugar so try to avoid
o drinking alcohol with food = to reduce risk of nocturnal hypoglycemia
DASH diet = fruits, vegetables = 8-10 servings per day
eat food rich in fiber = 25 to 30 g/day
stay away from fruit juice = fresh fruit better
know how to monitor glucose with machine
self-monitoring of blood glucose
people who need to monitor blood glucose
o people taking insulin = 4 times day = before each meal and bedtime (type 1)
o people who are pregnant
o people who have low blood glucose levels
individualize per patient
dawn phenomenon vs somogyi effect
dawn
phenomenon
natural process = waking up in the morning with high blood sugar = hyperglycemia
due to release of counterregulatory hormones at predawn hours
increase hormone (growth hormone and cortisol) in the morning = causes increase glucose
OKAY SO = due to counterregulatory hormones in predawn hours, they release hormones
during dawn hours causing blood glucose to rise resulting in morning hyperglycemia
o no hypoglycemia here = unlike in somogyi effect
treatment = increase insulin or adjust the time insulin is taken
somogyi
effect
manmade = rebound effect in which an overdose of insulin causes hypoglycemia
release of counterregulatory hormones causes rebound hyperglycemia
overdose of insulin causes low glucose = hypoglycemia = results in body freaking out and
increasing morning to increase glucose
OKAY SO = due to giving too much insulin at night, the person becomes hypoglycemia
resulting in the bodying compensating with counterregulatory hormones to increase blood
glucose causing morning hyperglycemia
treatment = give bedtime snack or reduce insulin
exercise
if patient is over 35 = need to take a stress test
test blood sugar (glucose) before and after exercise
carry extra snack (carbohydrate) in case of hypoglycemia *
DO NOT exercise if blood glucose is <100 or >240 AND if ketones present
o type 1 = no exercise glucose >300 with no ketones
o type 2 = no exercise glucose >400 with no ketones
exercise 1 to 1½ after eating = within NOT like wait 1 to 1½ hours
always carry carbohydrate snack = 15 grams
wear shoes that fit well
if blood glucose <100 = eat 15 g of carbohydrate before exercising
for every 30 minutes of exercise, need 15-20 g of carbohydrates
S
sick day care
vomiting + diarrhea = causes elevated blood glucose
sick causes increase cortisol = hyperglycemia
type 1 diabetes & glucose level >240 = check for ketones in urine
o if ketonuria, call provider
if unable to keep solid down = drink 1 cup of liquid every hour to prevent dehydration
if unable to keep liquid down = go to emergency room
contact provider if
o blood sugar = higher than 180 or lower than 70
o
down
o temperature over 101 F
o diarrhea and/or vomiting
sugar check blood glucose every 2-3 hours
I
insulin
continue to take insulin to avoid DKA
C
carbs
eat adequate carbs to prevent high/low glucose
K
ketones check blood/urine for ketones every 4 hours
foot care *
daily foot care = emergency treatment
neuro exam for sensory changes = check temperature, color, ulcers
wash feet everyday using warm water and soap
dry between toes very well
rub cream on feet BUT NOT between toes (tinea cream)
do not cut nails too short, cut straight across
use nail filer to smooth sharp edges = or see a podiatrist if problem arises
DO NOT soak feet
DO NOT walk barefoot = outside and inside
wear thick socks and change when needed = cotton socks
buying shoes rules
o wear slippers around the house *
o made soft, stretchable leather
o laced shoes over loafers = better for fitting and provide support
o cushioned soles over thin leather soles
o
largest
o SO soft, stretchable leather, laced shoes with cushioned soles
annual tests
A1C = less than 6.5 but 8 is acceptable for elderly
normal blood sugar = 70 to 120
but for elderly = 90 to 130 = a little higher than normal
flu and pneumonia vaccine yearly!!!
preoperative/morning of surgery + postoperative
NPO status
stop metformin = 48-72 hours before surgery
after surgery, check blood glucose and urine ketones every 4-6 hours
if hyperglycemic = give insulin
chronic complications of DM
macrovascular = heart disease, hypertension, stroke from atherosclerosis
microvascular = eye disease, damage to small blood vessels = retinopathy, nephropathy, neuropathy, etc.
diabetic foot = due to neuropathy, ischemia, sepsis
changes occur in the blood vessel of the retina
bleeding in retina, leakage of serum, protein deposits (exudates)
diabetic retinopathy
need to get eyes examined annually
yearly
anyways
lab = microalbuminuria or proteinuria
o place on low protein diet
causes renal failure
diabetic nephropathy
hypertension causes DM nephropathy
can lead to end stage renal disease (ESRD) = go on low protein diet
affects the feet first and then moves up higher
presents in a
peripheral neuropathy
treatment = orthotics
medication = gabapentin = drug of choice
capsaicin = ointment = wear gloves will cause burning
gastroparesis
bezoar = food sits in stomach
diabetic emergencies
hypoglycemia defined according to the following blood glucose
<50 = in men
<45 = in women
<40 in infants and children
onset = epinephrine released = sympathetic nervous system
sign and symptoms
o hunger, shakiness, pounding heart, nervousness
o headache, confused, blurred vision
the rule of 15 *
unconscious hypoglycemic patient
blood sugar less than 70 = treat with 15 grams
of simple carbohydrate
o 4 oz fruit juice
o 4 oz of soda
o 8 oz skim milk
o 6-8 lifesavers (chew)
o 1 serving of chewy candy (gummy
bears)
o 1 box of raisins
o 1 tube of cake decorating gel
o 1 tube of glucose gel
o 3-4 glucose tabs
wait 15 minutes and retest blood glucose = if
not above 70 then give another 15 grams
once above 100 = give a substantial snack/meal
= sandwich, cheese, crackers, meal with protein
= protein + carb meal
if after 2 treatments and still low = call
911!!!!!! oh they dying.
at home = unavailable venous access
o give glucagon 0.5-2 mg IM
turn to left side, head in recovery position (they
can aspirate)
repeat in 15 minutes if no response
when aroused = give carbohydrate + protein
snack
glucagon lasts 1½ hours = check blood sugar
hourly for 3-4 hours
site
o give 1 ampule of 50% glucose IV
o give continuous 50% glucose drip until
glucose >200
diabetic ketoacidosis (DKA)
type 1 = too much ketones in the body because no insulin so body goes into anaerobic metabolism
hyperglycemia with ketones produced = fatty acids converted
common cause = acute infection or not following medication
blood glucose elevated >300 = leads to dehydration *
acidosis = due to ketoacidosis, will have kussmaul breathing to decrease CO2 and acid
peripheral vasodilation = skin warm, dry, flushed = can lead to shock
goal = restore fluid balance
rapid onset <1 day
hyperglycemic hyperosmolar syndrome (HHS)
type 2 diabetes due to insulin deficiency
hyperglycemia = glucose >800
no ketones and no kussmaul breathing!!!
fluid replacement = 9-12 liters of fluid loss so = start isotonic NS and then dextrose
FLUID is the answer = or else we are fighting
priority question = fluids first
CHECK POTASSIUM BEFORE GIVING INSULIN *
takes a while for people to realize they have this