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Endocrine 3 Part 2
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Acute complications of DM
Hypoglycemia Diabetic Ketoacidosis Hyperglycemia Hyperosmolar Non-ketonic Syndrome
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Hypoglycemia AKA Insulin reaction
Definition:When blood glucose levels fall below 70mg/dl < 50mg/dl = severe
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Hypoglycemia: Etiology
Any time Skip meal Under-eating Eating late Unplanned exercise Excess insulin or oral hypoglycemic meds
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Hypoglycemia: Signs & Symptoms
Mild Diaphoresis Pallor Paresthesia Palpitations Tremors Anxiety Adrenal Medulla
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Hypoglycemia: Signs & Symptoms
Moderate: Confusion/disorientation Behavioral Changes
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Hypoglycemia: Signs & Symptoms
Severe Seizures Loss of Consciousness Shallow respirations
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Hypoglycemia: Diagnosis
Signs & Symptoms SMBG FSBG FSBS
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Hypoglycemia: Medical Management
Follow protocol P blood sugar level Admin. fast sugar
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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.
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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
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Rules to remember Do not add sugar to OJ
Recheck FSBS q 15 min until WNL Avoid high fat 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
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Protein Sources 1 Tbsp peanut butter 1 oz cheese 1 oz meat
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Hypoglycemia treatment Unconscious
IV mm of 50% dextrose in water Glucagon 1 mg Sub-Q or IM Action: (hormone) raises BS levels Onset:10 minutes Duration 25 minutes S/E: N/V Position: side lying
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Hypoglycemia Gerontological Consideration
Cognitive deficits not recognize S&S Decreased renal function oral hypoglycemic meds stay in body longer More likely to _________a meal Skip Vision problems inaccurate insulin draws
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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 NOW!
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Hypoglycemia Nursing measures
Enc. to wear ID bracelet Teach family that belligerence is sign of hypoglycemia
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Diabetic Ketoacidosis (DKA)
Serious complication of hyperglycemia due to lack of insulin Usually occurs with type I DM
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DKA: Etiology #1 cause illness, infection, stress
Absence or inadequate insulin Initial or undiagnosed diabetes
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Diabetic Ketoacidosis (DKA)
4 main clinical features Hyperglycemia Dehydration Electrolyte loss Metabolic Acidosis
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Pathophysiology DKA No Insulin Hyperglycemia Metabolic Acidosis
Glucose stays in blood - Hyperglycemia Muscle not getting energy h fat metabolism Osmotic diuresis Polyuria Polydipsia Electrolyte loss Increased ketone in blood Metabolic Acidosis i serum pH h respiratory rate Dehydration
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S&S of DKA Hyperglycemia ↑blood glucose Tired Polyphagia
Decreased attention, confusion N/V, abdominal pain Blurred vision
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S&S of DKA Dehydration Polydipsia Polyuria Dry/flushed skin
Orthostatic hypotension Tachycardia Headaches Decreased Na+ and K+ levels
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S&S of DKA Acidosis ↑Resp. rate Kussmaul’s
Fruity breath, acetone breath Serum pH Decreased Normal Serum pH 7.35 – 7.45 i pH = acidic / acidosis h pH = alkaline/ alkalosis
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DKA: diagnosis Blood sugar levels Serum pH BUN Blood Urea Nitrate
Elevated Serum pH Decreased (< 7.35) BUN Blood Urea Nitrate increased = dehydration
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DKA: diagnosis Urine Serum Osmolality Ketones
+ Specific gravity of urine i Serum Osmolality h thick
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DKA: diagnosis Hemoglobin Normal Elevated Decreased
Female : g/dL Male: g/dL Elevated Dehydration COPD Decreased Anemia, hemorrhaging, over-hydration
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DKA: Diagnosis Hematocrit Normal Elevated Decreased Female: 37-47%
Dehydration & COPD Decreased Anemia, leukemia
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DKA: diagnosis Serum Potassium levels Normal levels Purpose of K+
mEq/L Increased K+ levels = Hyperkalemia Decreased K+ levels = Hypokalemia Purpose of K+ Skeletal & cardiac muscle activity DKA decreased K+ levels
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Hypokalemia S&S Fatigue Anorexia N/V Muscle weakness Leg cramps
Dysrhythmias ↑sensitivity to digitalis
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Treatment of DKA Focus on the four main clinical features
Hyperglycemia Dehydration Electrolyte loss Acidosis
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Treatment of DKA Hyperglycemia Give insulin IV
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Treatment of DKA Dehydration Rehydrate IV, push fluids I&O
Check vital signs Check Lung sounds Monitor lab values
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Treatment of DKA Electrolyte loss
Polyuria loss of K+ Treatment of DKA dehydration drop in K+ 5 K / 1 ml serum 5 K / 2 ml serum 5.0 mEq/L 2.5 mEq/L K K K K K K K K K K
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Treatment of DKA: Electrolyte loss Replace K+
Monitor lab values closely
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Treatment of DKA Acidosis Reversed with insulin Insulin
glucose enters muscles i fat metabolism i in Ketones acidosis reversed
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Prevention of DKA #1 cause of DKA? Illness Sick Day Rules
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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
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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
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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
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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
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Hyperglycemia Hyperosmolar Nonketonic Syndrome - HHNK
Etiology Overeating Stress Illness Too little insulin
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S&S of HHNK syndrome Headache Mental status changes
Polyuria Polydipsia Polyphagia Skin, hot, dry, decreased turgor Dehydration Seizures Blurred vision Weakness Headache Mental status changes Lab values: FSBS 600 – 2,000 mg/dl Serum osmolality h Urine neg. for ketone
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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
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Nursing Responsibility
Same as with DKA Insulin Hydration Electrolyte replacement and monitoring Treat underlying cause
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Summary Acute complications of DM Hypoglycemia Diabetic Ketoacidosis
Hyperglycemia Hyperosmolar Non-ketonic Syndrome
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