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Endocrine 3

Endocrine 3. Part 2. Acute complications of DM. Hypoglycemia Diabetic Ketoacidosis Hyperglycemia Hyperosmolar Non-ketonic Syndrome. Hypoglycemia. AKA Insulin reaction Definition:When blood glucose levels fall below 70mg/dl < 50mg/dl = severe. Hypoglycemia: Etiology. Any time Skip meal

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Endocrine 3

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  1. Endocrine 3 Part 2

  2. Acute complications of DM • Hypoglycemia • Diabetic Ketoacidosis • Hyperglycemia Hyperosmolar Non-ketonic Syndrome

  3. Hypoglycemia • AKA Insulin reaction • Definition:When blood glucose levels fall below 70mg/dl • < 50mg/dl = severe

  4. Hypoglycemia: Etiology • Any time • Skip meal • Under-eating • Eating late • Unplanned exercise • Excess insulin or oral hypoglycemic meds

  5. Hypoglycemia: Signs & Symptoms • Mild • Diaphoresis • Pallor • Paresthesia • Palpitations • Tremors • Anxiety • Adrenal Medulla

  6. Hypoglycemia:Signs & Symptoms • Moderate: • Confusion/disorientation • Behavioral Changes

  7. Hypoglycemia:Signs & Symptoms • Severe • Seizures • Loss of Consciousness • Shallow respirations

  8. Hypoglycemia: Diagnosis • Signs & Symptoms • SMBG • FSBG • FSBS

  9. Hypoglycemia: Medical Management • Follow protocol • P blood sugar level • Admin. fast sugar

  10. 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.

  11. 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

  12. 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

  13. Protein Sources • 1 Tbsp peanut butter • 1 oz cheese • 1 oz meat

  14. Hypoglycemia treatmentUnconscious • IV 25-50 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

  15. HypoglycemiaGerontological 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

  16. HypoglycemiaNursing measures • Follow protocol • Teach • Carry simple sugar at all times • S&S or hypoglycemia • How to prevent Hypoglycemia • Check FSBS if you suspect  NOW!

  17. HypoglycemiaNursing measures • Enc. to wear ID bracelet • Teach family that belligerence is sign of hypoglycemia

  18. Diabetic Ketoacidosis (DKA) • Serious complication of hyperglycemia due to lack of insulin • Usually occurs with type I DM

  19. DKA: Etiology • #1 cause illness, infection, stress • Absence or inadequate insulin • Initial or undiagnosed diabetes

  20. Diabetic Ketoacidosis (DKA) 4 main clinical features • Hyperglycemia • Dehydration • Electrolyte loss • Metabolic Acidosis

  21. No Insulin Glucose stays in blood - Muscle not getting energy h fat metabolism Increased ketone in blood Hyperglycemia Metabolic Acidosis Osmotic diuresis Polyuria Electrolyte loss i serum pH Polydipsia Pathophysiology DKA h respiratory rate Dehydration

  22. S&S of DKA • Hyperglycemia • ↑blood glucose • Tired • Polyphagia • Decreased attention, confusion • N/V, abdominal pain • Blurred vision

  23. S&S of DKA • Dehydration • Polydipsia • Polyuria • Dry/flushed skin • Orthostatic hypotension • Tachycardia • Headaches • Decreased Na+ and K+ levels

  24. S&S of DKA • Acidosis • ↑Resp. rate  Kussmaul’s • Fruity breath, acetone breath • Serum pH • Decreased • Normal Serum pH 7.35 – 7.45 • ipH = acidic / acidosis • hpH = alkaline/ alkalosis

  25. DKA: diagnosis • Blood sugar levels • Elevated • Serum pH • Decreased (< 7.35) • BUN Blood Urea Nitrate • increased = dehydration

  26. DKA: diagnosis • Urine • Ketones • + • Specific gravity of urine • i • Serum Osmolality • h • thick

  27. DKA: diagnosis • Hemoglobin • Normal • Female : 12-16 g/dL • Male: 14-18 g/dL • Elevated • Dehydration • COPD • Decreased • Anemia, hemorrhaging, over-hydration

  28. DKA: Diagnosis • Hematocrit • Normal • Female: 37-47% • Male 42-52% • Elevated • Dehydration & COPD • Decreased • Anemia, leukemia

  29. DKA: diagnosis • Serum Potassium levels • Normal levels • 3.5-5.5 mEq/L • Increased K+ levels = Hyperkalemia • Decreased K+ levels = Hypokalemia • Purpose of K+ • Skeletal & cardiac muscle activity • DKA  decreased K+ levels

  30. Hypokalemia S&S • Fatigue • Anorexia N/V • Muscle weakness • Leg cramps • Dysrhythmias • ↑sensitivity to digitalis

  31. Treatment of DKA • Focus on the four main clinical features • Hyperglycemia • Dehydration • Electrolyte loss • Acidosis

  32. Treatment of DKA • Hyperglycemia • Give insulin  IV

  33. Treatment of DKA • Dehydration • Rehydrate • IV, push fluids • I&O • Check vital signs • Check Lung sounds • Monitor lab values

  34. 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

  35. Treatment of DKA: • Electrolyte loss • Replace K+ • Monitor lab values closely

  36. Treatment of DKA • Acidosis • Reversed with insulin • Insulin  • glucose enters muscles  • i fat metabolism  • i in Ketones  • acidosis reversed

  37. Prevention of DKA • #1 cause of DKA? • Illness • Sick Day Rules

  38. 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

  39. 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

  40. 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

  41. 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

  42. Hyperglycemia Hyperosmolar Nonketonic Syndrome - HHNK • Etiology • Overeating • Stress • Illness • Too little insulin

  43. S&S of HHNK syndrome • 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

  44. 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

  45. Nursing Responsibility • Same as with DKA • Insulin • Hydration • Electrolyte replacement and monitoring • Treat underlying cause

  46. Summary • Acute complications of DM • Hypoglycemia • Diabetic Ketoacidosis • Hyperglycemia Hyperosmolar Non-ketonic Syndrome

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