Endocrine Clinical Assessment and Diagnostic Procedures DKA Charnelle Lee, RN, MSN

Identify the components of an endocrine history. Describe clinical findings of a patient with pancreatic and posterior pituitary dysfunction. Explain the clinical significance of laboratory and diagnostic tests in pancreatic dysfunction. Explain the clinical significance of laboratory and diagnostic tests in posterior pituitary dysfunction. Objectives

Overview Neuroendocrine stress associated with critical illness Disorders of three major endocrine glands o Pancreas o Posterior pituitary gland o Thyroid gland Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 3

Endocrine Function FIGURE 23-1 Location of endocrine glands with the hormones they produce, target cells or organs, and hormonal actions.

Neuroendocrinology of Stress and Critical Illness Acute neuroendocrine response to critical illness o Hypothalamic–pituitary–adrenal (HPA) axis in critical illness Release of ADH (vasopressin) Release of catecholamines (norepi, epi) Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 5

Neuroendocrinology of Stress and Critical Illness (Cont.) Acute neuroendocrine response to critical illness (Cont.) o Serum cortisol level o Cosyntropin stimulation test o Corticosteroid replacement o Liver and pancreas in critical illness Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 6

Neuroendocrinology of Stress and Critical Illness (Cont.) Hyperglycemia in critical illness o Clinical practice guidelines related to blood glucose management in critically ill patients Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 7

Systematic process incorporating history and physical examination Endocrine glands inaccessible to clinical examination Assessment is indirect Endocrine Assessment

Current health status Description of current illness Medical history General endocrine status Family history Health History Endocrine System

Pancreas Function Dysfunction usually presents as hyperglycemia Dx: Type I or Type II

Neuroendocrinology of Stress and Critical Illness (Cont.) Insulin management in the critically ill (Cont.) o Transition from continuous to intermittent insulin coverage o Corrective insulin coverage Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 11

Neuroendocrinology of Stress and Critical Illness (Cont.) Hypoglycemia management o Discontinue continuous infusion of insulin. o Blood glucose concentration is monitored every 15 minutes until blood glucose has risen above 70 mg/dL. Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 12

Neuroendocrinology of Stress and Critical Illness (Cont.) Insulin management in the critically ill o Frequent blood glucose monitoring o Continuous insulin infusion Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 13

Neuroendocrinology of Stress and Critical Illness (Cont.) Nursing management o Monitor hyperglycemic side effects of vasopressor therapy. o Administer prescribed corticosteroids. o Monitor blood glucose, insulin effectiveness, avoid hypoglycemia. o Provide nutrition. o Educate patient and/or family. Collaborative management Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 14

Diabetes Mellitus (DM) Diabetes Mellitus o Type 1 Diabetes B cells no longer secrete insulin Autoimmune disease Insulin dependent diabetes o Diabetic ketoacidosis (DKA) occurs without insulin

Diabetes Mellitus (DM) Diabetes Mellitus o Type 2 Diabetes Majority of people are adults Body mass index > 30% Imbalance between insulin production and use Oral medications for most patients o Complication of Type 2 diabetes is: Hyperglycemic Hyperosmolar Nonketotic Syndrome (HHNS)

Patient Compliance Only 40% with Type 1 Diabetes Only 26% with Type 2 Diabetes Monitor their blood glucose at least once a day.

Hyperglycemia Subjective Complaints o Blurred vision, headache, weakness, fatigue, drowsiness, anorexia, nausea, abdominal pain

Knowledge check Three hours after surgery, the nurse note that the breath of the client who is a type 1 diabetic has a “fruity” odor. What is the nurse’s best first action? 1.Document the finding as the only action. 2.Increase the IV fluid flow rate. 3.Call the physician for a arterial blood gas order 4.Perform oral care.

Hyperglycemia Inspection FLUSHED SKIN POLYURIA POLYDIPSIA VOMITING Fluid volume ? Amb what defining characteristics.

Hyperglycemia Abdomen Subjective: Hunger then anorexia NV Abdominal Cramps Hypoactive Bowel sounds Palpation – Abdominal Tenderness

Lab Tests Which of the following cells give us this laboratory test value Leukocytes Thrombocytes Erythrocytes Granulocytes Lymphyocytes How Long Have I had Diabetes? Diabetic Control – Yes/No (4%-6%) Normal Value Provides information about the average amount of glucose present in the bloodstream over the past previous 3 to 4 months. Most accurate test about either new onset or patient’s level of control of their sugar

Glucose Laboratory Levels  Laboratory Studies  Fasting serum glucose (FSG) 70 to 100 mg/dL – normal 70 to 100 mg/dL – normal 100 to 125 mg/dL – prediabetic 100 to 125 mg/dL – prediabetic >126 mg/dL – diagnostic of diabetes >126 mg/dL – diagnostic of diabetes mg/dL – target for critically ill patient mg/dL – target for critically ill patient <70 mg/dL – hypoglycemia <70 mg/dL – hypoglycemia <40 mg/dL – severe hypoglycemia <40 mg/dL – severe hypoglycemia  Urine glucose Not recommended Not recommended(continued)

Blood Ketones Blood ketones o 2 to 4 mg/dL – normal o Elevated in acute illness, fasting, type 1 diabetes with lack of insulin, illness, starvation

Urine Ketones Presence of urine ketones is an early warning sign before the onset of ketosis Should not be present in a healthy individual Exceptions- dieting, exercise, starvation and fasting o Normally ketones are not present in the urine o Elevated in diabetic ketoacidosis

Diabetes Mellitus Diabetic Ketoacidosis (DKA) o 20% DKA newly diagnosed Type 1 diabetics o 80% DKA in known Type 1 diabetics

Diabetes Mellitus Diabetic Ketoacidosis (DKA) o Characteristics Hyperglycemia – blood glucose >250 mg/dl Ketosis – Acidemia- Arterial ph < 7.3 Bicarb level < 18 mEq/L Decreased insulin availability Role of counter-regulatory hormones

Major Cause of DKA Infection #1 Changes in Insulin dose, type Increased metabolic demand Growth spurts Surgery Trauma Eating disorders

Lab Value

Diabetic Ketoacidosis (DKA) Assessment Clinical Findings o Headache o Polyuria o Malaise o Polydipsia o Nausea and vomiting o CNS depression and decreased LOC, stupor o Coma o Dehydration o Flushed dry skin o Tachycardia o Hypotension o Kussmaul air hunger o “Fruity” odor of acetone

DKA Diabetic Ketoacidosis (DKA) o Assessment and Diagnosis Diagnosis Bedside finger stick o Urine ketones o ABG o Serum osmolality o Hematocrit o Electrolyte panel o BUN and Creatinine

DKA Diabetic Ketoacidosis (DKA) o Medical Management Goals o Reverse dehydration o Restore insulin- glucagon ratio o Treat and prevent circulatory collapse o Replenish electrolytes o Reverse ketoacidosis o Collaborative Management Hydration Insulin Administration Intravenous Glucose Potassium and Phosphorus Administration

Fluid Volume Deficit r/t osmotic diuresis Fluid deficit of up to 6liters can occur o Isotonic saline 0.9% is infused immediately to reverse vascular deficits and hypotension. o Fluids after this are based on serum osmolarity and serum sodium. o Low sodium – 0.9% saline o High sodium – 0.45% saline o K+ is added after fluid volume deficit has been partially reversed and insulin has been started.

Hydration Assessment Assess Report Collaborate InterveneReassess Body weight Hourly intake and output Patient complaint of thirst Pulse strength Blood pressure changes Gradual increase from subnormal to baseline Tachycardia to normocardia Condtion of mucous membranes

Insulin Drip Patient is NPO IV bolus of ______ insulin 0.1 units/kg is administered. Continuous drip of 0.1 units per kg/hour is infused with other fluids. Goal is to decrease blood sugar by mg/dl q1h until it reaches 200

Rationale for moderation in blood sugar decrease Cerebral edema can occur with too rapid of a reversal Notify physician of rapid drops as well as elevations in blood sugar. Symptoms of cerebral edema are:

Nursing – Administration Fluids/Insulin/Electrolytes Rapid IV infusion via pump NPO until the blood glucose is < 200 Blood sugar checks are hourly Sliding scale insulin is administered per drip Labs are drawn q2h in the initial 24 hours until the patient sugar stabilizes and acidosis resolves. Monitor for complications: hypoglycemia, hypo & hyperkalemia, hyponatremia, cerebral edema, infection

Regular Insulin Continued until acidosis, ketonuria, and fluid volume deficit have resolved. Call physician when blood glucose is at 200 – at that time D5NS will be started or D51/2 NS based on the sodium level of the patient at this time.

Potassium & phosphorus Will drop as sugar drops Administer IV potassium based on lab results Assess for s/s of potassium imbalance during acute states of DKA Monitor phosphorus as well, replace phosphorus if less than 1 mg/dl.

Knowledge Check A client with type 1 diabetes is found unresponsive in the morning by a family member and is admitted to the emergency department. On admission to the emergency department, the client is unresponsive to stimuli and has fruity, sweet breath with Kussmaul’s respirations. Laboratory results include arterial blood gases of pH 7.32, PCO2 34 mm Hg, and HCO3 11 mEq\L (11 mmol\L) and a plasma glucose of 518 mg\dl (28.8 mmol\L). The intervention that a nurse anticipates will be prescribed initially for the client is

Knowledge Check Describe the blood gas in this scenario? Fluid replacement therapy in the initial rehydration hours would be? What type of insulin would be given to this patient? Based on how fast the sugar should be decreased to prevent cerebral edema, the blood sugar measured in the next hour would be? A physician orders sodium bicarbonate for this patient. Nursing action would be: Which electrolytes would the nurse monitor closely in the first 4 hours of rehydration and insulin therapy.

Case Study Ms. Baker, a 28 year old unemployed English teacher is brought in to the ER by her boyfriend She is difficult to arouse. Her mucus membranes are dry, and her skin is warm and dry. She has fruity odor to her breath, elevated heart rate and decreased blood pressure Copyright © 2014 Elsevier, Inc. All rights reserved. 42

Case Study Continued The following lab work is obtained on Ms. Baker BS – 496 ABGs – pH 7.16 – PCO PO – Bicarb – 11 –Sat 96% Her anion gap is 20 What is Ms. Baker’s probable diagnosis? What other tests might be ordered? Copyright © 2014 Elsevier, Inc. All rights reserved. 43

Case Study Continued IV fluids are ordered on Ms. Baker. She has a BS of 419 and a K of 5.0 What type and rate does the nurse anticipate? What lab work does the nurse anticipate will be repeated? Copyright © 2014 Elsevier, Inc. All rights reserved. 44

Case Study Continues Ms. Baker is now alert, oriented, with stable vital signs and is tolerating an ADA diet The insulin drip is off and she is receiving sliding scale insulin coverage for AC and HS finger sticks and long acting insulin SC She informs the nurse that since she lost her job and insurance she has been unable to afford her medications What discharge plans will she require? Copyright © 2014 Elsevier, Inc. All rights reserved. 45

Hyperglycemic Hyperosmolar State Epidemiology and etiology o Differences between hyperglycemic hyperosmolar state (HHS) and diabetic ketoacidosis (DKA) Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 46

Hyperglycemic Hyperosmolar State (Cont.) Pathophysiology o Deficit of insulin and excess of glucagon o Hypovolemia Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 47

Assessment and diagnosis o Clinical manifestations o Laboratory studies Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 48 Hyperglycemic Hyperosmolar State (Cont.)

Medical management o Rapid rehydration o Insulin administration Insulin resistance o Electrolyte replacement Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 49 Hyperglycemic Hyperosmolar State (Cont.)

Nursing management o Administering fluids, insulin, and electrolytes o Monitoring response to therapy Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 50 Hyperglycemic Hyperosmolar State (Cont.)

Nursing management (Cont.) o Surveillance for complications o Patient education Collaborative management Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 51 Hyperglycemic Hyperosmolar State (Cont.)

Summary Stress of critical illness o The endocrine system is complex. Assessment relies on laboratory tests. Critical care nurses must understand the intricacies of the endocrine system. o Physiologic stress associated with critical illness causes increased secretion of stress hormones by the HPA pathway. If critical illness lasts longer than 7 to 10 days, suppression of pituitary, thyroid, and adrenal gland function occurs. Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 52

Summary (Cont.) Pancreas: DKA and HHS o Diagnostic criteria for DKA include a blood glucose concentration greater than 250 mg/dL, an arterial pH value of less than 7.3, a serum bicarbonate level lower than 18 mEq/L, and moderate or severe ketonemia or ketonuria. o Diagnostic criteria for HHS include a blood glucose concentration greater than 600 mg/dL, an arterial pH value higher than 7.3, a serum bicarbonate level greater than 18 mEq/L, a serum osmolality greater than 320 mOsm/kg H2O (320 mmol/kg), and absent or mild ketonuria. Copyright © 2014, 2010 by Mosby, an imprint of Elsevier Inc. 53