1. Endocrine Disorders Dr. Naiema Gaber
Critical Care Nursing
Endocrine Disorders Dr. Naiema Gaber

2. I-Diabetic Emergencies
Endocrine Disorders
I-Diabetic Emergencies

3. Diabetic Disorders: Learning Outcomes
Identify the three main diabetic emergencies (D E)
Discuss the principal features of (DE)
Explain the management plan of (DE)
Develop nursing plans for managing (DE)

4. Diabetes mellitus (DM)
DM Is Hyperglycemia Due To The Decrease , Destruction Or Impaired Effectiveness Of Insulin.
Types :
1-type I: DM (IDDM) Its Onset Is In Childhood Or Adolescence
II-type 2:dm (NIDDM). Its Onset Is After 40 Years Of Age (Maturity Onset Dm

5. Types of DM cont.
III- Secondary DM (Insulin Resistance Which Is Due TO drug Therapy OR Metabolic Endocrine Diseases And Critical Illness

6. Diabetes mellitus (DM)
Primary D M
* drug therapy
* endocrine disease
*critical illness
Secondary DM
NIDDM
IDDM

7. The Three Main Diabetic Emergencies
1- Diabetic ketoacidosis (DKA)
2-Hyperosmolar, Hyperglycemic States (HHS)
3-hypoglycemis coma

8. 1- Diabetic ketoacidosis (DKA)
It is characterized by hyperglycemia, ketosis, and acidosis, often with coma.
It is life threatening condition even if the patient is not comatose.
About 1/3 of DKA patients are newly diagnosed diabetics.

9. 1- Diabetic ketoacidosis (DKA)
The causes of DKA include , infection, MI, thromboembolic episodes, non compliance with treatment and altered level of consciousness. Coma is not always present

10. What is pathophysiology of ketoacidosis?
The patient can not utilize glucose from food due to insufficient insulin.
Energy is provided by fat breakdown (lipolysis)
Some of the free fatty acids released by lipolysis are converted into ketones by the liver causing a profound metabolic acidosis.
This patient compensates for this acidosis by hyperventilation (Kussmaul respiration)

11. The Principal Features of DKA
Hyperglycemia
Dehydration
Electrolyte Loss
Ketoacidosis

12. Why DKA patient has dehydration?
1- Increased concentration of glucose in the blood the kidney does not reabsorb the excess glucose
which is excreted in urine. increase osmotic diuresis results large volume of water and electrolytes are lost.
2- loss of fluids through hyperventilation, vomiting, sweating, fever and decreased fluid intake due to coma

13. The Clinical Manifestations of Dehydration are
Extreme Thirst
Polydeipsic
And Later on, Hypovolemic Shock ( Hypotension And Tachycardia).

14. What is the management of DKA?
Every patient will differ in their:
* degree of hypovolemia
* blood glucose levels
* level of consciousness.
*underlying condition
Resuscitation must be guided
Patent airway

15. What is the management of DKA? Cont.
Intravenous fluid replacement
Cardiac output monitoring
A continuous infusion of insulin
Hourly blood glucose measurements
ECG monitoring
ABG. Monitoring
Prevent DVT formation
Treat the underlying causes

16. What is the nursing management of DKA?
Nursing diagnosis
1-Inadequate airway protection related to decreased level of consciousness
Intervention:
Maintain patent and protected airway
Mechanical ventilation for deeply comatose
Naso-gastric tube to decrease the risk of aspiration
Respiratory rate and pattern monitoring
Blood gases and oxygen therapy accordingly

17. What is the nursing diagnosis of DKA? cont
Hypovolemia related to dehydration
Hyperglycemia
Electrolyte depletion related to polyuria
Metabolic acidosis related to ketosis
Potential deep vein thrombosis

18. II hyperosmolar hyperglycemic states (HHS)
HHS Commonly occurs in undiagnosed patient with NDDM. It is much less common than DKA
Factors predisposing to HHS:
Elderly, infection, trauma including burn,
MI, pancreatitis, hepatitis
Renal failure, hypothermia
Carbohydrate overload
Drugs as phenytoin, thiazides

19. What is the difference between DKA and HHS?
In DKA the level of free fatty acids and counter regularity hormones is lower
This is properly due to sufficient insulin still being secreted to prevent lipolysis but not hyperglycemia.
Ketosis may thus be absent or mild

20. What is the management of HHS
Level of conscious: active management of coma
Fluid replacement as dehydration is often severe
Insulin therapy as ordered as patient is having insulin sensitivity and need lower doses.
Anticoagulation as prolonged immobility, hypervescosity of circulating blood

21. III- hypoglycemic coma
It result from a low blood glucose level. This may be due to
* insulin overdose(diabetic or accedental)
*excessive exercise for diabetic patients and
inadequate food intake.
The onset of coma is usually rapid
Most patient are aware of the onset of symptoms and can prevent it occurrence by taking sugar

22. How can we diagnose and manage a comatose patient
Bedside blood glucose analysis.
Treatment must be rapid as hypoglycemia can cause irreversible brain damage.
20-50 ml IV of 50% glucose

23. Deference between hyper and hypoglycemia
Hyperglycemia
Restlessness
Thirst
Vomiting
Abdominal pain
Hot dry flushed skin
Drowsiness
Tachycardia
deep sighing
Hypotension
coma
Hypoglycemia
Headache
Hunger, faintness
Cool moist skin
Sweating
Slurred speech
Tachycardia/ bradycardia
Irrational behavior, agitation
coma

24. Review questions
1-The term insulin resistance is applied to which type of diabetes?
a- type 1
b-type 2
c- insipetus
d-secondary
(D)

25. Review questions
2-Mr Ali admitted to ER in coma. His wife said that he is diabetic. To diagnose the cause of coma, the nurse need to:
a- observe the patient’ conditions
b- analysis bedside blood glucose levels
c-do urine analysis
d-do physical examination
(b)

26. Review questions
3-during your training in the critical care unit, you observed that Mr. hammed who is 60 year old with 2o% deep burn in chest, is having Restlessness, Thirst, Vomiting, Abdominal pain and Hot dry flushed skin. This feature is due to
a- hypoglycemia
b-ketoacidosis
c- hyperglycemia
d-thyroid crisis

27. Review questions 4-What is the difference between DKA and HHS? In HHS
a- Ketosis increased with acidosis
b-Ketosis increased without acidosis
c –Ketosis increased with free fatty acid
d-Ketosis may thus be absent or mild
(D)

28. Review questions
5- The level of free fatty acids and counter regularity hormones is low in
a- Diabetic Ketoacidosis
b- Hyperosmolar Hyperglycemic States
c- Diabetes Mellitus
d- Hypoglycemic Coma
6- This is may be due to
a- sufficient insulin
b- lipolysis
c- insufficient insulin
d- insufficient fluid intake
(b & a)

29. THANK YOU