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Endocrine 3

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					Endocrine 3

   Part 2
     Acute complications of DM
• Hypoglycemia
• Diabetic Ketoacidosis
• Hyperglycemia Hyperosmolar Non-ketonic
  Syndrome
              Hypoglycemia
• AKA Insulin reaction
• Definition:When blood glucose levels fall
  below 70mg/dl
• < 50mg/dl = severe
          Hypoglycemia: Etiology
•   Any time
•   Skip meal
•   Under-eating
•   Eating late
•   Unplanned exercise
•   Excess insulin or oral hypoglycemic meds
                   Hypoglycemia:
                 Signs & Symptoms
• Mild
  –   Diaphoresis
  –   Pallor
  –   Paresthesia
  –   Palpitations
                         • Adrenal Medulla
  –   Tremors
  –   Anxiety
              Hypoglycemia:
            Signs & Symptoms
• Moderate:
  – Confusion/disorientation
  – Behavioral Changes
              Hypoglycemia:
            Signs & Symptoms
• Severe
  – Seizures
  – Loss of Consciousness
  – Shallow respirations
       Hypoglycemia: Diagnosis
•   Signs & Symptoms
•   SMBG
•   FSBG
•   FSBS
            Hypoglycemia:
          Medical Management
• Follow protocol
• P blood sugar level
• Admin. fast sugar
Hypoglycemic Protocol: Sample

• For BG <60 mg/dL
  – If patient can take PO, give 15g of fast acting
    carbohydrate. (4 oz fruit juice/non diet soda, 8
    oz nonfat milk, or 3-4 glucose tablets)
  – If patient cannot take PO, give 25mL of D50 as
    IV push
  – Check FSBG q 15 minutes and repeat above if
    BG<80.
              Glucose Fast!
10-15 mg fast acting carbohydrate
• Glucose tabs
• 4-6 oz. Juice or soda
• 6-10 lifesaver candies
• 2-3 tsp honey/sugar
          Rules to remember
• Do not add sugar to OJ
• Recheck FSBS q 15 min until WNL
• Avoid high fat à slows absorption of glucose
• Instruct: carry fast sugar
• If meal is >1 hr away, follow with a protein
  and complex carbohydrate
• NPO if “unconscious” or confused
            Protein Sources
• 1 Tbsp peanut butter
• 1 oz cheese
• 1 oz meat
         Hypoglycemia treatment
              Unconscious
• IV 25-50 mm of 50% dextrose in water
• Glucagon 1 mg Sub-Q or IM
  – Action: (hormone) à raises BS levels
  – Onset:10 minutes
  – Duration 25 minutes
  – S/E: N/V
• Position: side lying
             Hypoglycemia
       Gerontological Consideration
• Cognitive deficits à
   – not recognize S&S
• Decreased renal function à
   – oral hypoglycemic meds stay in body longer
• More likely to _________a meal
   – Skip
• Vision problems à
   – inaccurate insulin draws
             Hypoglycemia
            Nursing measures
• Follow protocol
• Teach
  – Carry simple sugar at all times
  – S&S or hypoglycemia
  – How to prevent Hypoglycemia
  – Check FSBS if you suspect à NOW!
              Hypoglycemia
             Nursing measures
• Enc. to wear ID
  bracelet
• Teach family that
  belligerence is sign of
  hypoglycemia
     Diabetic Ketoacidosis (DKA)
• Serious complication of hyperglycemia due to
  lack of insulin
• Usually occurs with type I DM
                DKA: Etiology
• #1 cause illness, infection, stress
• Absence or inadequate insulin
• Initial or undiagnosed diabetes
      Diabetic Ketoacidosis (DKA)
4 main clinical features
1.   Hyperglycemia
2.   Dehydration
3.   Electrolyte loss
4.   Metabolic Acidosis
                         Pathophysiology DKA
No Insulin


Glucose stays in blood     Muscle not getting   h fat metabolism
-                          energy

                                                Increased ketone in
                                                blood
Hyperglycemia


                                                   Metabolic
Osmotic diuresis
                                                   Acidosis


Polyuria                   Electrolyte loss     i serum pH



Polydipsia
                                                h respiratory
                                                rate


Dehydration
                 S&S of DKA
• Hyperglycemia
  – ↑blood glucose
  – Tired
  – Polyphagia
  – Decreased attention, confusion
  – N/V, abdominal pain
  – Blurred vision
                S&S of DKA
• Dehydration
  – Polydipsia
  – Polyuria
  – Dry/flushed skin
  – Orthostatic hypotension
  – Tachycardia
  – Headaches
  – Decreased Na+ and K+ levels
                    S&S of DKA
• Acidosis
  – ↑Resp. rate à Kussmaul’s
  – Fruity breath, acetone breath
  – Serum pH
     • Decreased
        – Normal Serum pH 7.35 – 7.45
        – i pH = acidic / acidosis
        – h pH = alkaline/ alkalosis
               DKA: diagnosis
• Blood sugar levels
  – Elevated
• Serum pH
  – Decreased (< 7.35)
• BUN Blood Urea Nitrate
  – increased = dehydration
               DKA: diagnosis
• Urine
  – Ketones
     •+
  – Specific gravity of urine
     •i
• Serum Osmolality
  – h
  – thick
                DKA: diagnosis
• Hemoglobin
  – Normal
    • Female : 12-16 g/dL
    • Male: 14-18 g/dL
  – Elevated
    • Dehydration
    • COPD
  – Decreased
    • Anemia, hemorrhaging, over-hydration
                DKA: Diagnosis
• Hematocrit
  – Normal
    • Female: 37-47%
    • Male 42-52%
  – Elevated
    • Dehydration & COPD
  – Decreased
    • Anemia, leukemia
                DKA: diagnosis
• Serum Potassium levels
  – Normal levels
     • 3.5-5.5 mEq/L
     • Increased K+ levels = Hyperkalemia
     • Decreased K+ levels = Hypokalemia
  – Purpose of K+
     • Skeletal & cardiac muscle activity
  – DKA à decreased K+ levels
              Hypokalemia S&S
•   Fatigue
•   Anorexia N/V
•   Muscle weakness
•   Leg cramps
•   Dysrhythmias
•   ↑sensitivity to digitalis
             Treatment of DKA
• Focus on the four main clinical features
  – Hyperglycemia
  – Dehydration
  – Electrolyte loss
  – Acidosis
            Treatment of DKA
• Hyperglycemia
  – Give insulin à IV
              Treatment of DKA
• Dehydration
  – Rehydrate
    •   IV, push fluids
    •   I&O
    •   Check vital signs
    •   Check Lung sounds
    •   Monitor lab values
             Treatment of DKA
• Electrolyte loss
   – Polyuria à loss of K+
   – Treatment of DKA dehydration à drop in K+
 5 K / 1 ml serum                 5 K / 2 ml serum
   5.0 mEq/L                  2.5 mEq/L


     KKKKK                             KKKKK
          Treatment of DKA:
• Electrolyte loss
  – Replace K+
  – Monitor lab values closely
               Treatment of DKA
• Acidosis
  – Reversed with insulin
     •   Insulin à
     •   glucose enters muscles à
     •   i fat metabolism à
     •   i in Ketones à
     •   acidosis reversed
              Prevention of DKA
• #1 cause of DKA?
  – Illness
• Sick Day Rules
       Sick Day Protocol/Rules
• Never omit insulin
• If you are unable to eat normally, DO NOT
  stop taking insulin
• Sliding scale
• Test blood sugar every 3-4 hours
• Test urine for ketones every 3-4 hours
• Take liquid/fluids q hour
        Sick Day Protocol/Rules
• If you can not eat your usual meal, substitute
  soft foods
• Have “sick day” food in house
• If vomiting, diarrhea or fever persists, take
  liquids q half hour
• If miss or replace 4 meals with fluids, call MD
       Sick Day Protocol/Rules
• Go to bed and keep warm
• Friends: good to have someone around who
  understands and knows about insulin
  reactions and diabetes
   Hyperglycemia Hyperosmolar
   Nonketonic Syndrome - HHNK
• Definition
  – HHNK occurs when there is insufficient insulin to
    prevent hyperglycemia, but there is enough
    insulin to prevent Ketoacidosis
  – Occurs in all types of diabetes
   Hyperglycemia Hyperosmolar
   Nonketonic Syndrome - HHNK
• Etiology
  – Overeating
  – Stress
  – Illness
  – Too little insulin
            S&S of HHNK syndrome
•   Polyuria
•   Polydipsia                  • Headache
•   Polyphagia                  • Mental status changes
•   Skin, hot, dry, decreased
                                • Lab values: FSBS 600 –
    turgor
                                  2,000 mg/dl
•   Dehydration
•   Seizures                    • Serum osmolality h
•   Blurred vision              • Urine neg. for ketone
•   Weakness
 Medical Management/treatment
• Confirm with glucose meter
• If greater than 300 mg/dl check urine for
  ketones
• Fluid and electrolyte replacement
  – Especially K+
• Insulin
• Treat precipitating factors
        Nursing Responsibility
• Same as with DKA
  – Insulin
  – Hydration
  – Electrolyte replacement and monitoring
  – Treat underlying cause
                 Summary
• Acute complications of DM
  – Hypoglycemia
  – Diabetic Ketoacidosis
  – Hyperglycemia Hyperosmolar Non-ketonic
    Syndrome

				
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posted:7/24/2013
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