Endocrine Handout 3
I. Reading Assignment: Reading assignment: Brunner & Suddarth’s Textbook of Medical-
A. Chapter 41, pages 1398 – 1402
II. Student learning outcomes
A. The student will be able to discuss medical terms commonly used in the endocrine
B. The student will be able to review and identify anatomy and physiology of the
C. The student will be able to identify components of a complete endocrine physical
D. The student will be able to describe etiology, pathophysiology, clinical
manifestations, nursing management and patient education for the following
1. Diabetes mellitus
2. Diabetes ketoacidosis
3. Hyperosmolar nonketonic syndrome
E. The student will be able to discuss pharmacological interventions in the treatment
of a patient with an endocrine disorder
III. ORAL HYPOGLYCEMIC AGENTS:
A. Medication names
Metformin hydrocholide (Glucophage)
Glucovance (Sulfonylurea + Biguanides)
B. Oral Hypoglycemic Agents: General Information
1. Oral hypoglycemic meds are not ________________________
2. Oral hypoglycemic meds require some ______________of insulin
3. Oral hypoglycemic agents are used in the treatment of type ____ DM.
4. Oral hypoglycemic agents are meant to supplement
___________________& _________________ not replace them.
5. Oral hypoglycemic meds cannot be used during ______________
6. Oral hypoglycemic meds may need to be ____________ temporarily &
insulin prescribed if BS levels rise due to infection, trauma, stress, surgery, etc.
7. Action varies so effect may be enhanced by use of ____________ meds.
1. Sulfonylurea work primarily by ______ the secretion of __________ by
directly stimulating the _____________________
2. Sulfonylurea are to be taken: ________________________
3. ****Except for ___________________________is to be taken 30
minutes before meals
4. Sulfonylurea (especially Diabinese) when taken with
______________________ can cause severe DISULFIRAM reactions
a. Disulfiram (antibus): A compound when used with
___________________ produces ______________________
b. Symptoms of Disulfiram: ________________________________
5. Side-effects of Sulfonlurea: _______________-______________
1. Biguanides works primarily by aiding insulin’s action
2. Biguanides are not associated with episodes of ___________________
3. Biguanides ______ Sulfonylurea may ______ the glucose lowering
4. Major side effects of Metformin are: ____________________________
5. Metformin is contraindicated in patients with ______________________
E. Alpha Glucosidase Inhibitors
1. These act by ____________the absorptions of ______________ in the
2. Side effects _____________________ & _______________________
3. Take __________________ _______________________ meals
1. Used for patients with type 2 DM who take _______________________
2. Acts by increasing insulin action at the __________________site
3. Decreases insulin ___________________________
4. Affects __________________ function ________________________
5. Indications of altered _____________ function
G. Can Oral hypoglycemics help me?
1. Only type _________________DM
2. Results _______________
3. Effectiveness ________________________
4. _________________ may still need to take occasionally
5. Pregnant ____________________
6. ____________ “best” pill
IV. Drug interactions:
These medications directly interact with Sulfonamides
Sulfonylurea (Sulfonylurea + these medications) NSAID’s
and cause an increase risk of _______________
These medications cause _______________
(Without drug interaction) Monoamine oxidase inhibitors/ MAO
This medication can ___________ the signs and
symptoms of hypoglycemia
These medications __________ blood glucose Potassium-losing diuretics
V. Small Group Questions:
A. A type 1 diabetic asks you, “Why do I have to have insulin injections, why can’t I just
take the Insulin pills?” How would you answer him?
B. Mr. Jones is a type 2 diabetic who is unable to control his diabetes with diet and
exercise alone. The doctor prescribes Glucatrol 5 mg PO BID. When would you
advice Mr. Jones to take his medication?
C. What would you warn Mr. Jones about when taking Glucatrol?
D. Mrs. Murdock is a Type 2 DM. She was taking Glucatrol 20 mg BID. The doctor
changed her medication today to Micronase 5 mg PO BID and Glucophage 500 mg PO
BID. Mrs. Murdock asks you why she is taking two medications now, instead of just
increasing the dose of the Glucatrol?
E. What side-effects would you warn Mrs. Murdock about with these medications?
F. Mrs. Henderson, a 51 yr old type 1 DM is in the gynecologists office complaining of
hot flashes, mood swings and irritability. The doctor diagnosis these as menopausal
symptoms and prescribes estrogen replacement. What nursing teaching would you
provide Mrs. Henderson regarding this medication and her diabetes?
G. Mr. Bigfoot is a type-2 DM who takes Micronase/Glyburide BID. Which of the
following medication would interact and potentially cause a hypoglycemic event?
2. Potassium-losing diuretics
H. Mrs. Connor is a type-1 DM. Which of the following medication might cause her to
4. MAO inhibitor
I. Ms. Knowitall is a type-2DM who takes Gucagtrol/Glipizide BID. Which of the
following meds might cause an increase in her FSBS?
3. MAO inhibitor
Acute Complications of Diabetes Mellitus
Hyperglycemia Hyperosmolar Non-ketonic Syndrome
VI. HYPOGLYCEMIA (AKA: _______________________)
1. When blood glucose levels fall below _______________________mg/dl
2. < ____________________mg/dl = SEVERE
B. Etiology / causes
1. _________ time
a. Usually: _________ meal or at _______________________
2. ___________________ insulin or oral hypoglycemic medication
3. ___________________ food
4. Excessive ________________________
C. Signs and symptoms of hypoglycemia:
c. Palpitations ______________________
a. __________________ / disorientation
b. ___________________ changes
b. Loss of _____________________________
c. ______________________ respirations
D. Hypoglycemia Diagnosis/ Assessment:
a. Can occur _______________________
b. If a patient is a long-time diabetic their _______________________ may
be damaged No ________________ ________________
2. #1 diagnostic tool ___________________________
a. SMBG / FSBG/ FSBS
E. Medical Management:
1. Assess for _____________________
2. Check ________________________levels
3. Administer ____________________
F. Fast Glucose:
1. _______________ g fast acting carb.
a. _______________________ tabs
b. 4-6 oz of ________________ or ___________
c. ___________ life saviors or hard candies
G. Rules to Remember
1. Do not add _______________ to OJ
2. Recheck FSBS ______________ until within normal limits
3. Avoid high _____________ slows absorption of glucose
4. Instruct pt. to carry _________________________
5. _______________ if “unconscious” or confused
6. If next meal is > 1 hr away, follow sugar with a __________________&
H. Protein source
1. 1 Tablespoon of _______________ butter
2. 1 oz of ________________
3. 1 oz of meat
I. Hypoglycemic Treatment for Unconscious
1. Position: _______________________________________
2. IV 25 – 20 mL of 50% _________________________ in water
3. _______________________ 1 mg sub-q or IM
a. Action (hormone) __________________________________
b. Onset: ____________________________________
c. Peak: _____________________________________
d. Duration: __________________________________
e. S/E: ___________________________________________
J. Gerontology Considerations
1. Cognitive deficits may not recognize __________________
2. Decreased renal function oral hypoglycemic meds will ____________
3. More likely to ____________________ a meal
4. Vision problems inaccurate ________________________________
K. Nursing Measures/Education:
1. Follow ________________
a. Carry _______________________ at all times
b. _________________ of hypoglycemia
c. How to _________________ hypoglycemia
d. Check _________________ if you suspect
e. Enc to wear __________________________
f. Teach family that belligerence is ______________ of hypoglycemia
VII. Small Group Questions
A. What is the definition of hypoglycemia
B. What can lead to a diabetic developing hypoglycemia?
C. Name 3 S&S of mild, moderate and severe hypoglycemia.
D. What is the appropriate medical management for a patient suffering from
E. Give 3 examples of a quick carbohydrate.
F. What type of food should be avoided when treating hypoglycemia?
G. If a person is hypoglycemia and their next meal is more than one hour away what
should be done? (be specific, give examples)
H. How do you treat hypoglycemia in a patient who is unconscious?
I. What is Glucagon? How is it given? What should the nurse know about this med?
J. Why are the geriatric more at risk for hypoglycemia than a young adult?
K. You are teaching a new diabetic about the complication of hypoglycemia. What three
things would you prioritize in your teaching?
L. Mr. Grumpy is a 53 year old man who has been recently diagnosed with diabetes. He is
taking insulin injections 2 times a day. One evening he becomes very rude and mean.
His wife tells him to check his blood sugar levels and he yells at her and tells her, “I’m
not a baby! Don’t tell me what to do. I am just fine! Leave me alone.” Mrs. Grumpy
calls you for advice, what would you say?
M. Mrs Sweetcake is brought to the ER unconscious. Her family tells you she is a diabetic.
How would you assess for hyper/hypo glycemia? Her blood sugar level is 50mg/dL
what would you do?
N. Mr. Bottoms-up is a new diabetic who comes to the clinic not feeling well, but he does
not know why. How would you assess for hyper/hypo glycemia? You check his blood
sugar level and it is 60 mg/dL, what should you do?
VIII. DIABETIC KETOACIDOSIS (AKA: ______________)
A. General information
1. Serious complication of _________________d/t lack of ________
2. Usually occurs with type _______ DM (but can occur with others
especially if on insulin therapy)
1. #1 cause - _____________ (infection, stress)
2. Absence or inadequate _______________________
3. _________________ or undiagnosed DM
4. GET THIS: Illness (esp. infection) can cause blood glucose levels to
increase. The patient does NOT need to decrease the insulin dose to
compensate for decreased food intake when ill – in fact they may need to
increase the insulin dose
C. 4 main clinical features
D. Conditions caused by DKA / Signs & Symptoms:
Hyperglycemia Dehydration/Electrolyte loss Acidosis
_______ blood glucose Poly ____________ ____ respiration rate
________________ Poly_____________ Kussmaul’s
Poly ____________ ________________ skin ____________ breath
_____ attention Orthostatic ____ tension _____________ breath
confusion _________ cardia Serum pH _______
Abdominal _________ ______ Na+ levels
______________ vision ______ K+ levels Severe ________ upset
E. Pathophysiology DKA
F. Diagnosis / Lab Values
1. Blood sugar levels
2. Serum pH
3. BUN/Blood Urea
a. __________________ = _____________________________
a. __________________ = _____________________________
5. Serum Osmolatlity
7. Hemoglobin: __________________
a. Female ______________ g/dL
b. Male ________________ g/dL
a. Anemia, hemorrhaging, over-hydration
d. DKA _____________ hgb levels
8. Hematocrit: ______________________
a. Female : ______________ %
b. Male: ________________ %
a. Dehydration or _______________
a. Anemia, leukemia
d. DKA _____________ Hct levels
9. Serum Potassium levels
a. _________ - _________ mEq/L
b. Increased K+ levels = _____________________________
c. Decreased K+ levels = ____________________________
d. Purpose of K+
a. Skeletal & cardiac _________________ activity
e. *DKA _______ K+
f. S&S of Hypokalemia
a. ____________________ / N&V
b. Muscle ______________________
c. Leg ______________________
e. ________ sensitivity to ___________________
G. Treatment of DKA: Focus on the four main clinical features
a. Give _____________
d. _✓_____________ sounds
e. Monitor _____________________
3. Electrolyte loss
a. Polyuria _____________________
b. Treatment of DKA dehydration ____________________
c. Replace ________________
d. Monitor ___________ values closely
a. Reverses with ____________________
a. ___________________ glucose to enter _______________
________ fat metabolism ________ ketones acidosis
1. #1 cause of DKA? __________________________
2. Educate patient about “Sick Day Protocol/Rules”
a. Never omit ___________________________________
b. If you are unable to eat normally _____________stop taking insulin
c. Use a ___________________ scale
d. Test blood sugar every _________________ hours
e. Test urine for ______________________ every 3-4 hours
f. Take liquids every _____________
g. If you can not eat your usual meal, substitute _____________________
h. Have “sick day” food ________________________
i. If vomiting, diarrhea or fever persists, take liquids every _________ hour
j. If you miss or replace 4 meals with fluids call ____________
k. Go to ____________ and keep warm
l. Significant other with _____________________
IX. HYPERGLYSEMIA HYPEROSMOLAR NONKETOTIC SYNDROME
1. HHNK occurs when there is insufficient _______________ to prevent
_______________________, but there is enough _______________ to prevent
2. Occurs in ____________ types of diabetes: Especially
1. ____________ eating
4. Too ______________ insulin
C. Signs & Symptoms:
a. 3 ____________
a. Skin: ________________
b. _____________Skin turgor
3. Electrolyte loss
4. Mental status ____________
5. Lab values
a. FSBS ________- _________ mg/dL
b. Serum Osmolality _____________
c. Urine: ____ ketones
D. Medical management/treatment
1. Confirm with _________________________
2. If > 300 mg.dl check urine for _________________
3. Fluid and electrolyte ______________________ especially
5. Treat ___________________ factors
E. Nursing Responsibility/Same as with DKA
X. Small Group Questions
A. What is the pathophysiology that causes DKA?
B. What type of diabetes is DKA usually seen with?
C. What are the four main clinical features of DKA and what is the pathophysiology for
each of them?
D. Describe the serum pH of a patient with DKA.
E. Describe the changes in lab values associated with DKA. (K+; Urine; Hgb; Hct.; BUN;
Blood sugar etc.)
F. What would you teach a new diabetic about being sick?
G. What are the S&S of hypokalemia?
H. Even if a patient’s K+ levels are normal, treatment of DKA can lead to what problem?
I. What is the difference between DKA and HHNK?
J. Identify 3 priority nursing diagnosis for a patient with DKA or HHNK?
LONG-TERM COMPLICATION OF DIABETES
o Diabetic retinopathy
o Sensory-motor polyneuropathy
o Autonomic neuropathy
XI. Macro-vascular Complications
a. Characterized by ________________and loss of ___________________
of the arterial walls. (_______________________ of the arteries)
a. _________________ artery disease
b. _________________ vascular disease
c. _________________ vascular disease
RISK FACTORS FOR
ARTERIOSCLEROSIS / CAD / CVA
Blood glucose levels
XII. Microvascular Complications
1. Characterized by basement membrane ______________________
2. Effects ____________________ blood vessels
3. Due to _____________________________
a. Diabetic Retinopathy
XIII. DIABETIC RETINOPAHTY
A. Descriptions / pathophysiology
1. Damage to the tiny blood vessels that supply the _________
2. Episode of _______________________
3. Small _________________________ occurs
4. ***Damage is due to ________________________
1. #1 Control…
a. No _________________________
b. Use _________________________
c. Avoid lowering ________________________
d. Avoid lifting above _______________________
e. No __________________________________
C. Medical management
1. Control ______________________________
2. Control ______________________________
3. Photocoagulations ________________________ treatment
D. Nursing responsibilities
1. Diabetic retinopathy is ____________________________
2. Frequent ______________________ exams
3. _____________________________ but uneven
E. OTHER OPTHALMOLOGIC COMPLICATIONS
2. _____________ Changes
3. Extraocular muscle __________
XIV. NEPHROPATHY (CHRONIC RENAL FAILURE)
1. Damage to the tiny blood vessels within the _____________ due to
1. ________ glucose levels
2. Stresses __________________ ________________ mechanism
3. ______________& ________________ leaks into urine
4. Pressure in blood vessels of kidney _____________
1. Normal kidney function
a. Kidney __________________ blood
b. ___________ molecules & waste squeeze through kidneys _______
c. Big stuff ( ___________ & __________ ) stay in blood where they
2. Diabetes damages system
a. Filter start to ___________________
b. ______________ & __________________ are lost into the urine
c. Filter ________________________ lose of filtering ability
d. Kidney _________________ or ESRF
e. Waste products build up ____________________
g. Kidney ____________________________
D. Signs & Symptoms
1. _________ uria or ______________ uria
2. ________ urine output
4. BUN _________ Creatinine ________________
5. BP _____________
1. Control _____________ & Control _____________
2. Tx _________________
3. No _____________________substances
4. ________ Na+ diet
5. ______ protein diet
1. Tight _____________________
2. Anti- ________________________
a. Calcium channel blockers, Alpha blockers, ACE inhibitors
3. ________________ & ______________________
XV. Small Group Questions
A. The microvascular complications of diabetes are all associated with that condition?
B. Describe the pathophysiology of diabetic retinopathy?
C. How do you prevent diabetic retinopathy?
D. Describe the pathophysiology of nephropathy.
E. What are the clinical S&S of nephropathy?
F. What lab values are associated with early onset of nephropathy?
G. Describe the urine associated with early onset of nephropathy? How do the urine
characteristics change as the disease progresses?
H. What dietary recommendations would you give to a patient with diabetes who is also
suffering from diabetic retinopathy
1. Damage to the ____________________ due to ____________________
2. Most common _______________________ of DM
3. Various types of neuropathies
B. Sensory-motor polyneuropathy AKA: ____________________________________
1. Signs and Symptoms
a. Paresthesias: Primarily _________________________
b. ________ deep tendon _________________
c. _____________ feet
d. __________ proprioception
e. __________ sensation
f. _______________ gait
g. ________ risk of foot infections
a. Control serum _____________ levels
b. Pain control
a. Analgesics (non-___________________)
b. Tri-cyclic ____________________________________
c. Anti - _______________________________________
C. Autonomic neuropathy can affect almost any organ system including
a. __________ cardia
b. _______________ __________ tension
a. ____________ gastric emptying
b. ________________ or _________________
b. ___________________ bladder
a. Male ________________________
5. Adrenal Gland
b. Adrenal __________________ ____________________ symptoms
c. No longer feel _______________ of hypoglycemia
d. Strict ___________________ and ____________________monitoring
6. Sudomotor neuropathy:
a. No ______________________
a. ____________ feet
b. Foot ___________________
XVII. Small Group Questions
A. What is the definition of neuropathy and what is its cause?
B. What are the symptoms of sensory-motor neuropathy?
C. What is autonomic neuropathy?
D. Autonomic neuropathy of the adrenal gland causes what condition? Describe.
E. What are the S&S of sudomotor neuropathy? Is it a form of sensory-motor neuropathy
or autonomic neuropathy?
F. How the is the pain associated with neuropathy treated?
G. What is the definition of nephropathy and what is its cause?
A. High risk for foot infections due to:
a. _______ pain sensation
b. _______ pressure sensation
c. _______ dryness
d. _______ fissures
2. Peripheral vascular disease
a. _________ circulation
b. _________ WBC
c. _________ Oxygen
d. _________ wound healing
e. _________ antibiotics
a. WBC + Hyperglycemia = ___________________________
b. Infections, once they occur, can often be difficult to treat and heal slowly
a. ____________ circulation
b. ___________________ not get there
c. ___________________ WBC’s
d. ___________________ wounds
c. Infections of particular concern to diabetics include ________________
B. Common types of infections
1. Boils (AKA furuncles)
a. ______________, pus filled bumps on the skin
b. D/T __________________________ aureus bacteria
a. Noncontagious inflammation of the connective tissue of the _______
b. D/T _______________________ infection
c. Treatment: _______________________ & _________________
4. Yeast Infections
5. Periodontal disease
a. Term to describe ____________ or ____________ of an organ or tissue
b. D/T ________ _________________ supply
7. Necrotizing fasciitis
a. Flesh eating disease
C. High-risk characteristics for foot infection includes:
1. ________________ of diabetes
4. _____________ peripheral pulses
5. ______________________ or pressure areas
6. _________________ of foot ulcers
D. Progression of events:
1. Soft tissue injury
2. Injury is not __________________
4. ____________________, swelling, redness
1. _____________ rest
2. _______________________ Topical vs. IV
4. Control __________________ levels
5. ? _____________________________
F. Nursing Management
1. ________________ foot care & prevention
2. Teach __________________ care
G. Guidelines for healthy feet
1. _____________ daily
a. ___________________ between toes
b. ___________________ dry feet
a. Use a mirror
c. Between toes
3. Avoid activities that __________ circulation
b. ______________________ legs
c. ______________________ sock
4. Good _________________
b. __________________ toed
c. No ___________________ feet
d. New shoes break them in ___________________
5. Prevent injuries
a. Wear ______________
a. Cotton, light color & no wrinkles
b. Check _______________ of shoe
6. No _____________________________ extremes
a. Check _______________ water
b. No __________________ bottles
c. No __________________ pads
7. See doctor regularly
b. Trim toe nails ____________________ across
c. Do not _____________ calluses or corns
8. Range of ______________________
H. Diabetics & Surgery
1. BS levels __________ during stress, surgery or illness
2. If not controlled ____________________ ___________________
3. Risk of ____________ if give shot of NPH and then NO surgery or
a. Check BSbefore _______________
b. No _____________________ insulin
I. Hospitalized Diabetic
2. _______________ scale
b. Clear liquids
a. Mostly ________________ carbs
b. ____________ sugar if possible
XIX. Small group Questions
A. Mr. Jones is a 54 year-old banker with type 2 diabetes admitted to your unit with a tiny
red area on his right heel. His admitting blood glucose is 360 mg/dl. The lesion is so
small you wonder what the fuss is about. While doing his assessment, you find that he
wore a new pair of shoes to work all day about a month ago and has been avoiding
seeing his physician about the resulting red area. He is placed on bed rest and
antibiotics, and within 3 days the red area has broken open and has yellow drainage. It
takes 6 months to fully heal.
1. List three risk factors for foot problems
2. Why did the sore take so long to heel?
3. Why was bed rest important?
4. Why might topical antibiotics work better than IV antibiotics
5. What nursing measures could be done to increase circulation to the foot?
XX. Case Study:
A. Jennie is a 56-year-old woman admitted to your medical unit with cellulitis of the left
leg. Her blood sugar is 436. She tells you that she takes Human N insulin 38 units
every morning and Human R insulin 10 units with each meal and at bedtime.
1. Chart the action of Jennie’s insulin over the course of 24 hours
0600 1200 1800 2400 0600
2. Jennie tells you that her physician wants her to keep her blood sugar
between 100 and 150 mg/dL. You know that a normal lod sugar is 70-115.
Why the discrepancy?
3. When you enter Jennie’s room to check her 4PM vital signs, she says she
has a headache. By the time you finish taking her blood pressure, she has
developed a cold sweat. What is happening? What should you do? Why did it
occur at 4PM?
4. At 5PM you check Jennie’s blood sugar and find that it is 80 mg/dL.
What is your next step?
5. List three things that may have caused Jennie’s blood sugar to drop.
6. You explain to Jennie the importance of eating three meals a day on a
regular schedule. She asks why? How do you explain this to her?
7. Jennie is discharged and follows her diet, exercise and insulin regimen
carefully. She even loses 50 pounds. One year after her first admission, she is
brought into the emergency department with a blood sugar of 32. Why had her
blood sugar dropped?
8. Jennie’s physician discontinues her insulin and starts her on glipizide
(Glucotrol) 5mg BID. What are two ways this oral hypoglycemic works?
9. You teach Jennie to take her Glucotrol at what times each day? Why?
10. Does Jennie have type 1 or type 2 diabetes? How do you know?
XXI. Endocrine Midterm Review:
A. Know the signs and symptoms of hypo & hyperglycemia and be able to distinguish
between the two.
B. What conditions lead to hypoglycemia? What conditions lead to hyperglycemia?
C. Normal lab values, and nursing protocol, for diabetic management and diagnosis
D. Understand the normal protocol for glucagon administration
E. Medication interaction with insulin and oral hypoglycemic medications
F. Understanding of diabetic ketoacidosis, who gets it, what causes it, sign and symptoms,
G. Know the sick protocol for someone with diabetes
H. Know the pathophysiology of the complications of diabetes, i.e. arteriosclerosis,
peripheral vascular disease, diabetic retinopathy, neuropathy and nephropathy
I. Understand the differences between the different neuropathies
J. What is hypoglycemia unawareness
K. Infections with a diabetic: causes, risk factors, treatment, prevention
L. Know the onset, peak and duration of the various insulin
M. Protocol for insulin injections, and storage
N. What effect does exercise and alcohol have for a diabetic
O. What stimulates the release of the pancreatic endocrine glands (what conditions cause
them to be released) & what effect does each of the endocrine glands have.
P. What is a hormone
Q. What affect does insulin have on protein, fat, glucose, glycogen, etc?
R. Be able to define the differences between type 1 and Type 2 diabetes mellitus
S. What are the endocrine glands
T. What is negative feedback & insulin resistance
U. Know the definition, cause, and treatment for; insulin waning, dawn phenomenon, and
V. Protocol for hypoglycemic medications