3. 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

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

5. 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

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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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 15-30 minutes Order a meal tray STAT Cardiac Monitor

15.  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

16.  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

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

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

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

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

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

22.  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

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

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

25.  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

26.  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

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

28.  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

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

30.  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

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

32.  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

33.  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

34.  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

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

36.  Objective data  Physical exam  Fever: temp may exceed 104  Tachycardia (120-200), systolic hypertension  Chest: crackles

37.  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

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

39.  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

40.  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

41.  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

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

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