Type I or Type II Type IType II Juvenile diabetesMost common form of diabetes Usually diagnosed in children and young adults Millions diagnosed and many unaware they have it Body will not produce insulinEither the body does not produce enough insulin or the cells ignore the insulin Only 5% of diabetics are a type I

Symptoms – Type I Frequent urination Unusual thirst Extreme hunger Unusual weight loss Extreme fatigue and irritability

Symptoms – Type II Any of the type I symptoms Frequent infections Blurred vision Cuts and bruises that are slow to heal Tingling or numbness in the hands or feet Recurring skin, gum or bladder infections

Prevention Type II can be prevented or delayed Lead a healthy lifestyle Change your diet Increase your physical activity Maintain a health weight

Myths Diabetes is not that serious of a disease If you are over weight you will eventually develop type II diabetes Eating too much sugar can cause diabetes People with diabetes must eat special foods People with diabetes cannot eat carbs or sugars It is ok to eat as much fruit as you want because it is healthy

Diabetic Ketoacidosis (DKA) Insulin deficiency and excessive stress hormone Typically in Type I but can be in Type II Elevated glucose promotes osmotic diuresis and dehydration

Stress hormones stimulate free fatty acids which cause a release of ketones Causes decreased myocardial contractility and cerebral function Usually brought on by infection and stress

Interventions Gradually return to normal metabolic balances FSBS and notify the MD of the results 2 large bore IV’s NS at a rate of 1 liter per hour O2 and maintain ABC’s Insulin drip per protocol Monitor patient every 5-15 minutes until stable Closely monitor intake and output Cardiac monitor

Hyperglycemic Hyperosmolar Nonketotic Coma (HHNC) Occurs in type II Profound dehydration from elevated glucose and osmotic diuresis No ketones-not enough insulin to start the process Can be caused by infection, stroke or sepsis High mortality rates

Interventions FSBS and notify the MD of the results May require intubation 2 large bore IV’s NS 1 liter over 1 hour Insulin drip per protocol Monitor the patient every 5-15 minutes until stable Closely monitor the intake and output Cardiac monitor

Hypoglycemia Serum glucose drops below 50 Below 35-the brain cannot adequately extract oxygen Results in hypoxia and eventually coma Any person with an altered level of consciousness should be considered to have low glucose until proven otherwise

Interventions O2 and maintain ABC’s FSBS and notify MD of results If alert and oriented x3, give oral glucose solutions (oj, milk, etc. ) Establish IV ½ to 1 amp of 50% dextrose (D50) per MD’s orders Monitor the mental status closely Monitor the FSBS every minutes Order a meal tray STAT Cardiac Monitor

 Addison’s Disease (adrenal insufficiency)  Adrenal cortex ceases to produce glucocorticoid and mineralocorticoid hormones  Acute stressors, infection, hemorrhage, trauma, surgery, burns, pregnancy, or abrupt cessation for Addison’s disease  Life threatening because hormones are necessary for the maintenance of blood volume, BP, and glucose homeostasis

 Suspect with patients who have septicemia with unexplained deterioration, major illness who have abdominal, flank, or chest pain, with dehydration, fever, hypotension, or shock, and adrenal hemorrhage  Death because of circulatory collapse and hyperkalemia- induced dysrhythmia

 Subjective data  History of present illness  Rapid worsening of symptoms of adrenal insufficiency  Fever  Nonspecific abdominal pain; may simulate acute abdomen  N&V

 Medical history  Primary adrenal insufficiency  Hyperpigmentation of skin  Weakness, fatigue, lethargy  Anorexia and weight loss  Nausea, vomiting, diarrhea  Salt craving  Postural hypotension  Allergies  Medications

 Physical examination  Appears acutely ill  Signs of shock as a result of dehydration  Hypotension, but may have warm extremities  Tachycardia  Tachypnea  Orthostatic hypotension

 Physical examination  Fever  Altered mental status, confusion  Hyperpigmentation of skin  Very soft heart sounds

 Diagnostic procedures  CBC: anemia of chronic disease  Electrolyte levels  Hyponatremia  Hyperkalemia  Blood glucose level: hypoglycemia  BUN: elevated (azotemia secondary to dehydration)  UA

 UA  Blood cultures  Plasma cortisol level  ECG  Low voltage  Flat or inverted T wave  Prolonged QT, QRS, or PR intervals  CXR  CT of abdomen: if diagnosis not clear

 Interventions  O2, IV, monitor  VS, with Orthostatic VS  I&O  Weight  Monitor signs of adequate tissue perfusion: capillary refill and skin temperature and moisture

 Medications  Dexamethasone  Hydrocortisone  Corticotropin  Glucose  Vasopressors  Monitor electrolytes  Monitor cardiac function  Prepare for admission  Instruct about disease process

 Severe form of hypothyroidism  Marked impairment of CNS and cardiovascular decompensation  Recognition of this illness is hampered by its insidious onset and rarity  Winter, elderly women with HX of hypothyroidism  Precipitating factors include: serious infection (pneumonia and UTI), sedative or tranquilizer use, stroke, exposure to cold environment, and termination or thyroid hormone replacement  Death is common, but can survive if prompt adequate care

 History of present illness  Recent illness  Progressive decline in intellectual status  Apathy, self-neglect  Emotional labiality  Anorexia  Recent weight gain  Medical history  Hypothyroidism or thyroid surgery  Allergies  Medications: thyroid replacement hormone, recent use of tranquilizers and sedatives

 Objective data  Physical exam  Decreased mental status  Depressed mental acuteness  Confusion or psychosis  Pale, waxy, edematous face with periorbital edema  Dry, cold, pale skin

 Objective data  Physical exam  Non-pitting extremity edema  Thin eyebrows  Deep, coarse voice  Scar form prior thyroidectomy  Vital Signs  Hypothermia, usually above 95 F  Bradycardia with distant heart sounds  Hypoventilation, Hypotension

 Diagnostic procedures  Electrolytes: hyponatremia  ABG’s: hypoxia and hypercarbia  Thyroid studies: low thyroxine (T4), elevated thyrotropin (thyroid stimulating hormone [TSH])

 ECG  Low voltage  Sinus bradycardia  Prolonged QT interval  CBC: anemia and decreased WBC  BUN and creatinine: elevated  Blood sugar: variable hypoglycemia  CXR  UA  Obtain pretreatment plasma cortisol level

 Interventions  Monitor airway, breathing, circulation, and other vital signs  O2 as ordered  IV, IV fluids  Hypertonic saline  Crystalloids  Whole blood

 Interventions  Meds as ordered  IV thyroid hormone  Glucocorticoid  Vasoconstrictors  Rewarm patient  Use passive rewarming with blankets and increased room temperature  Avoid rapid rewarming  Be prepared for seizures

 Extreme and rare form of thyrotoxicosis  High mortality  Untreated or inadequately treated hyperthyroidism, who experiences surgery, infection, trauma, or emotional upset; thyroid surgery; radioactive iodine administration  Cardiac decompensation with CHF (terminal event), CNS dysfunction, GI disorders  Life-threatening emergency

 History of present illness  Fever  N&V&D  Abdominal pain  Worsening of thyrotoxicosis symptoms  Anxiety  Restlessness, nervousness, irritability  Generalized weakness  Possible coma  Precipitation event or intercurrent illness

 Medical history  Thyrotoxicosis  Thyroid disease  Easy fatigability  Weight loss  Sweating  Body heat loss and heat intolerance

 Objective data  Physical exam  Fever: temp may exceed 104  Tachycardia ( ), systolic hypertension  Chest: crackles

 Warm, moist, velvety skin; becomes dry as dehydration develops  Spider angiomas  Tremulousness  Delirium, agitation, confusion, coma  Thin silky hair  Enlarged thyroid gland with thrill or bruit

 Eye signs  Lid lag  Stare  Exophthalmos  Periorbital edema  Hepatic tenderness or jaundice

 Diagnostic procedures  Cardiac monitoring/ECG: sinus tachycardia wand atrial fibrillation/flutter  Thyroid function studies  T4: elevated  Triiodothyronine (T3): elevated resin uptake  TSH: decreased  Serum cholesterol level: decreased

 Diagnostic procedures  Electrolyte levels  Serum glucose increased  CBC: increased WBC with left shift  BUN or creatinine level  Hepatic studies: increased liver enzymes  UA  Cultures and radiographs and indicated

 Interventions  O2, airway, breathing, circulation, VS  IV of D5 and isotonic solution  Cardiac monitoring  Meds as ordered  Vasopressors  Antipyretic  D50  Propylthiouracil every 8 hours  Glucocorticoids, hydrocortisone  Iodine: lugol’s solution, potassium iodide  Digitalis, propranolol  Antibiotics  Vitamins and thiamine  Sedatives

 Use cooling blanket, cold packs  Prepare patient/significant others for patient’s admission  Explain procedures to patient/significant others

References American Diabetic Association Emergency Nursing Core Curriculum, ENA Fundamentals of Nursing, Potter and Perry