Endocrine disorders

1
Endocrine disorders
2

• Diabetes Mellitus
• Type 1 Diabetes
• Beta cells no longer secrete insulin
• Autoimmune beta cell destruction
• Insulin dependent diabetes
• Diabetic ketoacidosis (DKA) occurs without insulin

3

• Diabetes Mellitus
• Type 2 Diabetes
• Majority of people are adults
• Body mass index gt 30
• Imbalance between insulin production and use
• Oral medications for most patients
• Complication of Type 2 diabetes is Hyperglycemic
  Hyperosmolar Nonketotic Syndrome (HHNS)

Type 2 Oral Medications Table 36-2 on pages 854-5
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Diabetes Mellitus

• Diabetic Ketoacidosis (DKA)
• 20 DKA newly diagnosed Type 1 diabetics
• 80 DKA in known Type 1 diabetics

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Diabetes Mellitus

• Diabetic Ketoacidosis (DKA)
• Hyperglycemia
• Ketosis
• Acidemia

Box 36-1 on page 856
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Diabetes Mellitus

• Diabetic Ketoacidosis (DKA)
• Pathophysiology
• Insulin deficiency
• Hyperglycemia
• Fluid volume deficit
• Thirst
• Ketoacidosis
• Acid-base balance
• Gluconeogenesis

Figure 36-1 on page 857
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Diabetes Mellitus

• Diabetic Ketoacidosis (DKA)
• Assessment and Diagnosis
• Clinical Findings
• Malaise
• Headache
• Polyuria
• Polydipsia
• Nausea and vomiting
• CNS depression and decreased LOC, stupor
• Coma

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Diabetes Mellitus

• Diabetic Ketoacidosis (DKA)
• Assessment and Diagnosis
• Clinical Findings
• Dehydration
• Flushed dry skin
• Tachycardia
• Hypotension
• Kussmaul air hunger
• Fruity odor of acetone

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Diabetes Mellitus

• Diabetic Ketoacidosis (DKA)
• Assessment and Diagnosis
• Diagnosis
• Bedside finger stick
• ABG
• Serum osmolality
• Hematocrit
• Electrolyte panel
• BUN and creatinine
• Urine ketones
• Anion gap

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Anion gap

• Helps differentiate DKA from other acidotic
  conditions

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• There are 2 kinds of metabolic acidosis
• From loss of bicarbonate ions
• From a build-up of acids in the serum

13

• Measuring the anion gap can help to determine
  which kind of metabolic acidosis the person has

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• Cations are positively charged particles
• Na, K
• Anions are negatively charged particles
• CO2, HCO3, Cl

15

• Anion gap is related to unmeasured serum anions
• Phosphates
• Sulfates
• Ketones
• Lactic acid

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• Normal anion gap 10 to 17 mEq/L

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• High anion gap acidosis (from an accumulation of
  fixed acids in the serum)
• Starvation
• Lactic acidosis
• DKA
• Normal anion gap acidosis (from loss of
  bicarbonate ions)
• Renal failure
• diarrhea

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Diabetes Mellitus

• Diabetic Ketoacidosis (DKA)
• Medical Management
• Goals
• Reverse dehydration
• Restore insulin-glucagon ratio
• Treat and prevent circulatory collapse
• Replenish electrolytes

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Diabetes Mellitus

• Diabetic Ketoacidosis (DKA)
• Medical Management
• Hydration
• Insulin Administration
• Potassium and Phosphorus Administration
• Bicarbonate Administration if indicated

Table 36-3 on page 859
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Diabetes Mellitus (DM)

• Hyperglycemic Hyperosmolar Nonketotic Syndrome
  (HHNS)
• Description
• HHNS can be lethal complication of Type 2 DM
• Differences between KDKA and HHNS

Table 36-4 on page 865
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Diabetes Mellitus

• Hyperglycemic Hyperosmolar Nonketotic Syndrome
  (HHNS)
• Etiology
• Insufficient insulin
• Increased endogenous glucose
• Increased exogenous glucose

Box 36-8 on page 866
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Diabetes Mellitus

• Hyperglycemic Hyperosmolar Nonketotic Syndrome
  (HHNS)
• Pathophysiology
• Deficit of insulin
• Excess of glucagon
• Hemoconcentration
• Hypovolemia
• Dehydration

Figure 36-2 on page 866
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Diabetes Mellitus

• Hyperglycemic Hyperosmolar Nonketotic Syndrome
  (HHNS)
• Assessment and Diagnosis
• Slow subtle onset
• Initial symptoms non-specific
• Very elevated glucose levels

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Diabetes Mellitus

• Hyperglycemic Hyperosmolar Nonketotic Syndrome
  (HHNS)
• Medical Management
• Interrupt glycemic diuresis
• Prevent vascular collapse
• Determine underlying cause
• Rapid rehydration
• Hypertonic vs. hypotonic solution

Table 36-4 on page 865
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Diabetes Mellitus

• Hyperglycemic Hyperosmolar Nonketotic Syndrome
  (HHNS)
• Nursing Management
• Hydration Status
• Neurologic Status
• Laboratory Analysis
• Electrolytes
• Hypokalemia vs. Hyperkalemia
• Patient Education

Box 36-3 on page 860 Box 36-9 on page 868 Table
36-5 on page 869 Box 36-10 on page 869
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Diabetes InsipidusHyposecretion of ADH

• Description
• ADH made in hypothalamus, stored in posterior
  pituitary
• Insufficiency or hypofunction of antidiuretic
  hormone (ADH)
• Inadequate ADH means that large quantities of
  dilute urine are passed

Table 34-4 on page 837
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Diabetes InsipidusHyposecretion of ADH

• Etiology
• 3 types
• Central DI
• Primary congenital defect
• Secondary destruction of hypothalamus or
  pituitary
• Nephrogenic DI kidneys cant respond to ADH
• Psychogenic DI compulsive water drinking

Table 36-11 on page 870
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Diabetes InsipidusHyposecretion of ADH

• Pathophysiology
• Injury to hypothalamus or pituitary gland
• Head Injury
• Free water excreted in urine
• Extracellular dehydration
• Hypernatremia
• Decreased cerebral perfusion

Figure 36-3 on page 871
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Diabetes InsipidusHyposecretion of ADH

• Assessment and Diagnosis
• Urine
• Urine output may be gt 300 ml/hr
• Low urine osmolality
• Urine is insipid or tasteless (not sweet)
• Laboratory Tests
• Serum osmolality
• Sodium
• Serum ADH

Table 36-6 on page 871
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Diabetes InsipidusHyposecretion of ADH

• Medical Management
• Diagnose and treat cause of DI
• Medications to manage Central DI
• Vasopressin (Pitressin)
• DDAVP
• Medications to manage Nephrogenic DI
• Thiazide diuretics

Table 36-7 on page 873
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Diabetes InsipidusHyposecretion of ADH

• Nursing Management
• Fluid status
• Laboratory studies
• ADH replacement
• Elimination issues
• Patient education

Box 36-12 on page 874 Box 36-13 on page 874
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Syndrome of Inappropriate Secretion of ADH
(SIADH) Hyper-secretion of ADH

• Description
• Opposite of DI
• Too much ADH
• Kidneys reabsorb too much water
• Dilutional hyponatremia

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Syndrome of Inappropriate Secretion of ADH
(SIADH) Hyper-secretion of ADH

• Etiology
• Head / CNS injury
• Other conditions
• PEEP with mechanical ventilation

Box 36-14 on page 875
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Syndrome of Inappropriate Secretion of ADH
(SIADH) Hyper-secretion of ADH

• Assessment and Diagnosis
• Clinical presentation in SIADH relates to water
  and sodium imbalance
• Lethargy
• Anorexia
• Mental confusion
• Seizures, coma, death

Figure 36-4 on page 876
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Syndrome of Inappropriate Secretion of ADH
(SIADH) Hyper-secretion of ADH

• Assessment and Diagnosis
• Serum Laboratory Values
• Serum ADH
• Serum Osmolality
• Urine Laboratory Values
• Serum Sodium
• Urine Osmolality
• Urine Specific Gravity

Table 36-6 on page 871
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Syndrome of Inappropriate Secretion of ADH
(SIADH) Hyper-secretion of ADH

• Medical Management
• Fluid restriction
• Sodium replacement
• Medications
• Stop drugs that may cause SIADH (hypoglycemics,
  thiazide diuretics, tricyclic antidepressants,
  narcotics, acetaminophen,etc.)

Box 34-4 on page 837
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Syndrome of Inappropriate Secretion of ADH
(SIADH) Hyper-secretion of ADH

• Nursing Management
• Hydration status
• Neurologic status
• Parental therapy
• Patient education

Box 36-15 on page 877 Box 36-16 on page 877
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Thyrotoxic Crisis

• Description
• Hyperthyroidism is the underlying condition
• Thyroid crisis a.k.a. Thyroid Storm
• Thyroid crisis critical stage of hyperthyroidism

Box 36-17 on page 878 Box 36-18 on page 878
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Thyrotoxic Crisis

• Pathophysiology
• Increased cellular oxygen consumption
• Heat production and fever
• Increased metabolic rate
• Metabolic acidosis

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Thyrotoxic Crisis

• Medical Management
• Emergency measures
• Decrease sympathetic nervous system response
• Beta blockers
• Cooling
• Cooling blankets
• Acetaminophen
• Dantrolene (for malignant hyperthermia)
• Rehydration
• Prevent multisystem organ failure (MODS)

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Myxedema Coma

• Etiology
• Deficiency of circulating thyroid hormone
• Decreased metabolic rate

Box 36-22 on page 883
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Myxedema Coma

• Assessment and Diagnosis
• End-stage hypothyroidism
• Weight gain
• Depression
• Somnolence
• Hypothermia

Differences Between Hyper and Hypothyroidism Box
36-23 on page 885
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Myxedema Coma

• Medical Management
• Determine underlying and associated conditions
• Treat hypothyroidism
• Medications
• Levrothyroxine
• Vasopressors
• Dopamine