COMMON ENDOCRINE DISORDERS

Iril I. Panes, RN, MAN

NURSING CARE OF CLIENTS WITH ENDOCRINE DISORDERS OF THE PANCREAS

DIABETES MELLITUS
Is a metabolic disorder characterized by glucose intolerance It is a systemic disease caused by an imbalance between insulin supply and insulin demand Also causes disturbances of protein and fat metabolism

< 60 mg/dl

> 110 mg/dl

60-110 mg/dl

Accelerates facilitated diffusion of glucose into cells Speeds glycogenesis (glucose to glycogen) Increases uptake of amino acids & increases protein synthesis Speeds lipogenesis (fatty acid synthesis) Slows glycogenolysis (glycogen to glucose) Slows gluconeogenesis (amino acids & glycerol to glucose)

INSULIN ACTIONS ARE THE FOLLOWING:

GLYCOGENESIS: Glucose to glycogen GLYCOGENOLYSIS: Glycogen to Glucose

GLUCONEOGENESIS: Amino Acids & Glycerol to glucose

TYPES
1. Insulin Dependent Diabetes Mellitus (IDDM) TYPE 1 2. Non-insulin Dependent Diabetes Mellitus (NIDDM): TYPE 2 3. Gestational Diabetes

ETIOLOGY and RISK FACTORS

IDDM
HEREDITY : siblings of clients with diabetes have 10 times the risk of developing the disease AUTOIMMUNE: the body produces islet cell antibodies and anti-insulin antibodies that attack the beta cells of the pancreas and insulin molecules VIRAL INFECTION: mumps and rubella virus attack the islets cells of the pancreas

ETIOLOGY and RISK FACTORS

NIDDM
Obesity: 80% of clients with NIDDM are obese; hyperglycemia develops when the pancreas cannot secrete enough insulin to match the bodys needs or when the number of insulin receptor sites is decreased or altered Age: increasing age may be a risk because the pancreas becomes more sluggish with age

FACTORS SYNONYMS AGE OF ONSET

IDDM (TYPE 1) JUVENILE DIABETES USUALLY BEFORE AGE 30 BUT MAY OCCUR AT ANY AGE USUALLY ABRUPT LITTLE OR NONE 10% MAY OCCUR REQUIRED IDEAL BODY WEIGHT OR THIN DIET, EXERCISE AND INSULIN

NIDDM (TYPE 2) ADULT/MATURITY ONSET OR MILD DIABETES USUALLY OCCURS IN CLIENT OVER AGE 35, BUT CAN OCCUR IN CHILDREN INSIDIOUS BELOW NORMAL, NORMAL OR ABOVE NORMAL 85-90% UNLIKELY TO OCCUR ONLY FOR 20-30% OF CLIENTS 80% OF THE CLIENTS ARE OBESE DIET, EXERCISE, ORAL HYPOGLYCEMIC AGENTS AND/OR INSULIN

TYPE OF ONSET EXOGENOUS INSULIN PRODUCTION INCIDENCE KETOSIS INSULIN INJECTIONS BODY WEIGHT AT ONSET MANAGEMENT

METABOLIC EFFECTS OF DIABETES

DECREASED UTILIZATION OF GLUCOSE - this results to:
a. Hyperglycemia (increase blood glucose level) b. Glucosuria since kidney excretes the excess glucose: results in osmotic diuresis that can lead to fluid volume deficit

METABOLIC EFFECTS OF DIABETES

INCREASED FAT METABOLISM: the body can rely on fat stores for energy when glucose is not available but the process of fat metabolism leads to the formation of breakdown products called KETONES (interfere with acid-base balance and can lead to acidosis; increase osmotic pressure that leads to fluid depletion; sodium depletion and increase body lipid level that can result to ATHEROSCLEROSIS)

METABOLIC EFFECTS OF DIABETES

INCREASED PROTEIN UTILIZATION- insulin is needed for protein synthesis, its absence leads to increased protein catabolism
Amino Acids are being converted into glucose in the liver If untreated, the person appears thin and emaciated

CLINICAL MANIFESTATIONS
CARDINAL SIGNS OF DIABETES
1. POLYURIA (frequent urination): water not absorbed from the renal tubules because of the osmotic activity of glucose in the tubules 2. POLYDIPSIA (excessive thirst): polyuria causes severe dehydration which causes thirst

CLINICAL MANIFESTATIONS
CARDINAL SIGNS OF DIABETES
3. POLYPHAGIA (excessive hunger): tissue breakdown and wasting cause a state of starvation that compels the client to eat excessive amounts of food

4. WEIGHT LOSS (primarily IDDM): glucose not available to cells, thus the body breaks down fat and protein stores for energy

Other Assessment Findings

Fatigue Blurred vision Susceptibility to infection TYPE 1: anorexia, nausea, vomiting, weight loss TYPE 2: obesity, frequently no other symptoms

DIAGNOSTIC TESTS
1. FASTING BLOOD SUGAR 2. POSTPRANDIAL BLOOD SUGAR: elevated 3. ORAL GLUCOSE TOLERANCE TEST (most sensitive test): elevated 4. GLYCOSYLATED HEMOGLOBIN (Hemoglobin A): elevated

PATHOPHYSIOLOGY
a. Lack of insulin causes hyperglycemia (Insulin is necessary for the transport of glucose across the cell membrane) b. Hyperglycemia leads to osmotic diuresis as large amounts of glucose pass through the kidney; results in polyuria and glycosuria c. Diuresis leads to cellular dehydration and fluid and electrolyte depletion causing polydipsia (excessive thrist) d. Polyphagia (hunger and increased appetite) results from cellular starvation

e. The body turns to fats and proteins for energy; but in the absence of glucose in the cell, fats cannot be completely metabolized and ketones (intermediate products of fat metabolism) are produced f. This leads to ketonemia, ketonuria (contributes to osmotic diuresis) and metabolic acidosis (ketones are acid bodies) g. Ketones acts as CNS depressants and can cause coma h. Excess loss of fluids and electrolytes leads to hypovolemia, hypotension, renal failure and decreased blood flow to the brain resulting in coma and death unless treated.

MEDICAL MANAGEMENT
1. TYPE 1: Insulin, diet, exercise 2. TYPE 2: ideally managed by diet and exercise; may need oral hypoglycemics or occasionally insulin if diet and exercise are not effective in controlling hyperglycemia; insulin needed for acute stresses; e.g. surgery, infection 3. DIET a. Type 1: consistency is imperative to avoid hypoglycemia b. Type 2: weight loss is important since it decreases insulin resistance c. High fiber, low fat diet also recommended

4. DRUG THERAPY a. Insulin: used for type 1 (occasionally in Type 2) b. Types:

a. b. c. d. e. Very rapid-acting or Rapid-acting Insulin Short-acting Intermediate acting Long-acting Premixed insulin

DRUG VERY RAPID-ACTING OR RAPID ACTING INSULIN

a. HUMALOG (LISPRO) b. NOVOLOG ( INSULIN ASPART)

ONSET

PEAK

DURATION

15 MINS 5-10 MINS

- 1 HRS 1-3 HRS

4-5 HRS 3-5 HRS

SHORT-ACTING INSULIN
a. REGULAR: HUMULIN R NOVOLIN R INTERMEDIATE ACTING INSULIN a. NPH (HUMULIN N NOVOLIN N) b. LENTE (HUMULIN L NOVOLIN L) 1-2 HRS 1-3 HRS 6-14 HRS 6-14 HRS 24 HRS 24 HRS - 1 HR 2-4 HRS 5-7 HRS

DRUG LONG-ACTING INSULIN

ONSET

PEAK
18-24 HRS

DURATION
24 HRS 24 HRS

a. ULTRALENTE (HUMULIN 6 HRS U) b. INSULIN GLARGINE (LANTUS)

PREMIXED INSULIN
a. HUMULIN 70/30 (70% NPH/30% REGULAR) b. HUMULIN50/50 (50% NPH/50% REGULAR) c. LISPRO/PROTAMINE 75/25 (75% LISPRO/25% PROTAMINE) - 1 HR HR 10-15 MINS 2-12 HRS 3-5 HRS 5 18-24 HRS 24 HRS 24 HRS

Complications of Insulin Therapy

Hypoglycemia Lipoatrophy Dawn phenomenon Somogyi's phenomenon

INSULIN PUMPS
Are small, externally worn devices that closely mimic normal pancreatic functioning. Insulin pumps contain a 3 ml syringe attached to a long (42 inch), narrow lumen tube with a needle or teflon catheter at the end. The needle or teflon catheter is inserted into the subcutaneous tissue (usually on the abdomen) and secured with a tape or a transparent dressing. The needle or catheter is changed at least every 3 days. The pump is worn either on a belt or in a pocket. The pump only uses regular insulin, which can be administered via the basal rate (0.5-2.0 units/hr) and by a bolus dose prior to each meal.

5. EXERCISE: helpful adjunct to therapy as exercise decreases the bodys need for insulin 6. ORAL HYPOGLYCEMIC AGENTS
a. Used by type 2 diabetics who are not controlled by diet and exercise b. Increase the ability of islet cells of the pancreas to secrete insulin; may have some effect on cell receptors to decrease resistance to insulin

NURSING INTERVENTIONS
Administer insulin or oral hypoglycemic agents as ordered; monitor for hypoglycemia, especially during period of drugs peak action Provide special diet as ordered
a. Ensure that the client is eating all meals b. If all food is not ingested, provide appropriate substitutes according to the exchange lists or give measured amount of orange juice to substitute for leftover food; provide snack later in the day

 Monitor urine sugar and acetone (freshly voided specimen) Perform finger sticks to monitor blood glucose levels as ordered (more accurate than urine tests)

 Observe for signs of hypo/hyperglycemia Provide meticulous skin care and prevent injury Maintain I and O, weigh daily Provide emotional support; assist client in adapting to change in lifestyle and body image

 Observe for chronic complications and plan care accordingly

1. Atherosclerosis: leads to coronary artery disease, MI, CVA and PVD 2. Microangiopathy: most commonly affects eyes and kidneys
a. Kidney diseases
a. b. Recurrent pyelonephritis Diabetic nephropathy Premature cataracts Diabetic retinopathy Affects peripheral and ANS Causes diarrhea, constipation, neurogenic bladder, impotence, decreased sweating

b.

Ocular disorders
a. b.

c.

Peripheral neuropathy
a. b.

 Provide client teaching and discharge planning concerning a. Disease process b. Diet Client should be able to plan meals using exchange lists before discharge Emphasize importance of regularity of meals; never skip meals

c. Insulin
1. How to draw up into syringe Use insulin at room temperature Gently roll vial between palms of hands Draw up insulin using sterile technique If mixing insulins, draw up clear insulin before cloudy insulin 2. Injection technique Systematically rotate sites to prevent lipodystrophy (hypertrophy/atrophy of tissue) Insert needle at a 45 or 90 degree angle depending on amount of adipose tissue 3. May store current vial of insulin at room temperature; refrigerate extra supplies 4. Provide opportunities for RD

d. Oral Hypoglycemic agents 1. Stress importance of taking the drug regularly 2. Avoid alcohol intake while on medication
e. Urine testing (not very accurate reflection of blood glucose level) 1. May be satisfactory for type II diabetics since they are more stable 2. Perform tests before meals and at bedtime 3. Use freshly voided specimen

f. Blood Glucose Monitoring

Used for type I diabetic clients since it gives exact blood glucose level and also detects hypoglycemia

g. General Care
1. Perform good oral hygiene and have regular dental exams 2. Have regular eye exams 3. Care for sick days (cold or flu)

Do not omit insulin or oral hypoglycemic agents since infection causes increased blood sugar Notify physician Monitor urine or blood glucose levels and urine ketones frequently If nausea and/or vomiting occurs, sip on clear liquids with simple sugars

h. Foot Care
1. Wash feet with mild soap and water and pat dry 2. Apply lanolin to feet to prevent drying and cracking 3. Cut toenails straight across 4. Avoid constricting garments such as garters 5. Wear clean, absorbent socks (cotton or wool) 6. Purchase properly fitting shoes 7. Never go barefoot 8. Inspect feet daily and notify physician if cuts, blisters or breaks in skin occurs

i. Exercise
1. Have regular exercise; avoid sporadic, vigorous exercise 2. Food intake may need to be increased before exercising 3. Exercise is best performed after meals when the blood sugar is rising

COMPLICATIONS
1. 2. 3. 4. 5. 6. Diabetic Ketoacidosis(DKA)/Diabetic Coma Hypoglycemia Visual changes Recurrent infections Cardiovascular changes Amputations related to peripheral vascular disease/gangrene 7. Renal insufficiency progressing to renal failure 8. Neuropathy 9. Peripheral vascular disease 10. MI 11. CAD 12. Sexual dysfunction 13. Impaired healing

DIABETIC KETOACIDOSIS(DKA)

General Information
1. Acute complication of DM characterized by hyperglycemia and accumulation of ketones in the body; causes metabolic acidosis 2. Occurs in IDDM clients 3. Precipitating factors:
1. 2. 3. 4. 5. 6. Undiagnosed DM Neglect of treatment Infection Cardiovascular disorder Other physical or emotional stress Onset: slow, may be hours to days

ASSESSMENT FINDINGS
1. 2. 3. 4. 5. Polydipsia, polyphagia, polyuria Nausea, vomiting, abdominal pain Skin warm, dry, flushed Dry mucous membranes, soft eyeballs Kussmauls respiration or tachypnea, acetone breath 6. Alterations in LOC 7. Hypotension, tachycardia

Diagnostic Tests
1. Serum glucose and ketones elevated 2. BUN, creatinine, hct elevated (due to dehydration) 3. Serum sodium decreased 4. ABGs: metabolic acidosis with compensatory respiratory alkalosis

NURSING INTERVENTIONS
1. Maintain a patent airway 2. Maintain fluid ad electrolyte balance
a. Administer IV therapy as ordered
a. b. c. Normal saline (0.9% NaCl); then hypotonic (0.45% NaCl) sodium chloride When blood sugar drops to 250 mg/dl, may add 5% dextrose to IV Potassium will be added when urine output is adequate

b. Observe for fluid and electrolyte imbalances, especially fluid overload, hypokalemia and hyperkalemia

3. Administer insulin as ordered

a. Regular insulin IV (drip or push) and/or subcutaneously b. If given IV drip, give with small amounts of albumin since insulin adheres to IV tubing c. Monitor blood glucose frequently

4. Check urine output every hour 5. Monitor vs 6. Assist client with self-care 7. Provide care for the unconscious client if in a coma 8. Discuss with the client the reasons ketosis developed and provide additional diabetic teaching if indicated

INSULIN REACTION/HYPOGLYCEMIA

General Information
Abnormally low blood sugar, usually below 50mg/dl Usually caused by insulin overdosage, to little food, nutritional and fluid imbalances from nausea and vomiting, excessive exercise Onset rapid; may develop in minutes to hours

Assessment Findings
1. Headache, dizziness, difficulty with problem solving, restlessness, hunger, visual disturbances 2. Slurred speech; alterations in gait, decreasing LOC, pallor, cold, clammy skin, diaphoresis 3. Diagnostic test: serum glucose level 5060mg/dl or lower

Nursing Interventions
Administer oral sugar in the form of candy or orange juice with sugar added of client is alert If the client is unconscious, administer 20-50 ml 50%dextrose IV push, or 1mg glucagon IM, IV or SC, as ordered Explore with client reasons for hypoglycemia and provide additional diabetic teaching as indicated

HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC COMA (HHNK)

General Information
Complications of DM, characterized by hyperglycemia and a hyperosmolar state without ketosis Occurs in non-insulin dependent DM clients or nondiabetic persons (typically elderly clients) Precipitating factors: undiagnosed diabetes, infections or other stress; certain medications; dialysis, major burns

Assessment Findings
Similar to ketoacidosis but without Kussmaul respirations and acetone breath Laboratory test:
Blood glucose level extremely elevated BUN, creatinine, hct elevated Urine positive for glucose

Nursing interventions: treatment similar to DKA, excluding measures to treat ketosis and metabolic ketoacidosis

Gerontological Considerations
DIABETES may go undetected in older clients because signs and symptoms are mistaken for normal aging (fatigue, incontinence) The presence of other chronic illness may interfere with the older adults ability to perform self-care There is an increased risk for occurrence of complication