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Chapter 84

Unit 12: Nursing care of clients with endocrine disorders

Complications of DM (Pg. 927) 1. DKA.. what is it? onset? Diabetic ketoacidosis: acute, life threatening hyperglycemia -Rapid onset
DKA hyperglycemia > ___ & resulting in .. >300 Breakdown of body fat for energy; accumulation of ketones in the blood & urine
2. HHS Hyperglycemic-hyperosmolar state; acute, life-threatening profound hyperglycemia -Generally occurs gradually over several days
HHS hyperglycemia > ___ >600 Hyperosmolarity that leads to dehydration, & an absence of ketones -can lead to coma & death -alteration in the sense of awareness; caused by insulin resistance = loss of fluids & lytes
DKA risk factors; type __ DM insulin needs carbs Type 1 DM Missed or reduced dose of insulin Any condition that increases carb metabolism; physical/emotional stress, illness/infection (#1 cause), surgery/trauma
Why does infection/stress/trauma etc. create a decreased effect of insulin? BC increased hormone production occurs; (cortisol, epi/norepi, glucagon) & stimulates liver to produce glucose
HHS risk factors; -Residual insulin secretion; enough to prevent production of ketones but not keep glucose down -Type 2 dm -poor kidney function; can't excrete glucose into urine -Infection/stress
HHS; older adults w/ poor fluid intake become ___ & experience ____ d/t high BG Dehydrated osmotic diuresis
Which meds could lead to HHS? Glucocorticoids, diuretics, phenytoin (Dilantin), Propranolol (Inderal), & CCB
S/S (listed and say whether its DKA, HHS, or both) Pg. 928 1. Polyuria DKA & HHS (osmotic diuresis causing excess fluid loss)
2. Polydipsia DKA & HHS (osmotic diuresis causing excess fluid loss causing increased thirst)
3. Polyphagia DKA
4. Wt Loss DKA
5. GI effects (Nausea, vomit, abdominal pain) DKA (increased ketones & acidosis lead to this)
6. Blurred vision, headache, weakness DKA & HHS (fluid volume depletion caused by osmotic diuresis = dehydration)
7. Orthostatic hypotension DKA & HHS (dehydration)
8. Fruity odor of breath DKA (elevated ketone bodies (small fatty acids) used for energy that collect in the blood, which leads to metabolic acidosis)
9. Kussmaul respirations DKA (deep rapid respirations in attempt to excrete CO2 when in metabolic acidosis)
10. Metabolic acidosis DKA (caused by breakdown of stored glucose, protein, & fat to produce ketone bodies)
11. Mental status changes DKA & HHS (alert, sleepy or comatose)
12. Seizures, myoclonic jerking HHS (related to serum osmolarity > 350)
13. Reversible paralysis HHS (r/t to high serum osmolarity)
Lab tests (Pg. 929) DKA & HHS 1. Serum glucose DKA: >300 HHS: >600
2. Serum lytes -sodium & potassium DKA: Na+ ^ d/t water loss, K+ initial decrease d/t diuresis, may ^ d/t acidosis HHS: Na+ ^ d/t water loss, K+ initial decrease d/t diuresis
3. Serum renal studies BUN & creatinine DKA & HHS; ^ d/t dehydration BUN; >30 Creat; >1.5
Normal BUN & creatinine BUN: 10-20 Creatinine: .5-1.1
4. Ketones -serum & urine DKA: present in both HHS: absent in both
5. Serum osmolarity DKA: high HHS: >320
6. Serum pH (ABG) DKA: <7.3 d.t metabolic acidosis (respiratory compensation/kussmaul) HHS; normal PH >7.4
Nursing care: Fluids start & follow w/ Rapid isotonic (0.9% NS) replacement (monitor for FVE) Follow with: hypotonic fluid (0.45% NS)
Nursing care con't: When serum glucose levels get down to 250... Add glucose to IV fluids; -Minimizes risk of cerebral edema d/t drastic changes in serum osmolarity & prevent hypoglycemia
Nursing care con't again: Insulin Administer regular insulin (Humulin R) 0.1 unit/kg as an IV bolus dose & then follow w a con't IV infusion of regular insulin at 0.1 unit/kg/hr
Why is IV regular insulin administered? 4 minute half life -avoiding delay of onset
What is the goal of BG & how often should it be monitored? <200 & monitor hourly
Nursing care: Potassium Initially increased w insulin then will decrease into the cells; monitor for hypokalemia -k+ replacement therapy in IV fluids -make sure urinary output is ok before giving k+
Nursing care for severe acidosis: Administer sodium bicarbonate by slow IV infusion for slow acidosis (pH <7.0)
Client education; Medical alert bracelets encouraged Hydrate; at least 3L water/day -glucose q4h when ill -carbs/lyte sport drinks when unable to eat food
Created by: mary.scott260!