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ENDOCRINE DISEASES AND CONDITIONS
DIABETES
Type I or Type II
Type I
Type II
Juvenile diabetes
Most common form of
diabetes
Usually diagnosed in children
and young adults
Millions diagnosed and many
unaware they have it
Body will not produce insulin
Either the body does not
produce enough insulin or
the cells ignore the insulin
Only 5% of diabetics are a
type I
Symptoms – Type I
Frequent urination
Unusual thirst
Extreme hunger
Unusual weight loss
Extreme fatigue and irritability
Symptoms – Type II
Any of the type I symptoms
Frequent infections
Blurred vision
Cuts and bruises that are slow to heal
Tingling or numbness in the hands or feet
Recurring skin, gum or bladder infections
Prevention
Type II can be prevented or delayed
Lead a healthy lifestyle
Change your diet
Increase your physical activity
Maintain a health weight
Myths
• Diabetes is not that serious of a disease
• If you are over weight you will eventually
develop type II diabetes
• Eating too much sugar can cause diabetes
• People with diabetes must eat special foods
• People with diabetes cannot eat carbs or
sugars
• It is ok to eat as much fruit as you want
because it is healthy
Diabetic Ketoacidosis (DKA)
Insulin deficiency and excessive stress
hormone
Typically in Type I but can be in Type II
Elevated glucose promotes osmotic diuresis
and dehydration
• Stress hormones stimulate free fatty acids
which cause a release of ketones
• Causes decreased myocardial contractility
and cerebral function
• Usually brought on by infection and stress
Interventions
• Gradually return to normal metabolic
balances
• FSBS and notify the MD of the results
• 2 large bore IV’s
• NS at a rate of 1 liter per hour
• O2 and maintain ABC’s
• Insulin drip per protocol
• Monitor patient every 5-15 minutes until
stable
• Closely monitor intake and output
• Cardiac monitor
Hyperglycemic Hyperosmolar Nonketotic Coma
(HHNC)
• Occurs in type II
• Profound dehydration from elevated glucose
and osmotic diuresis
• No ketones-not enough insulin to start the
process
• Can be caused by infection, stroke or sepsis
• High mortality rates
Interventions
FSBS and notify the MD of the results
May require intubation
2 large bore IV’s
NS 1 liter over 1 hour
Insulin drip per protocol
Monitor the patient every 5-15 minutes until
stable
• Closely monitor the intake and output
• Cardiac monitor
•
•
•
•
•
•
Hypoglycemia
• Serum glucose drops below 50
• Below 35-the brain cannot adequately extract
oxygen
• Results in hypoxia and eventually coma
• Any person with an altered level of
consciousness should be considered to have
low glucose until proven otherwise
Interventions
• O2 and maintain ABC’s
• FSBS and notify MD of results
• If alert and oriented x3, give oral glucose
solutions (oj, milk, etc. )
• Establish IV
• ½ to 1 amp of 50% dextrose (D50) per MD’s
orders
• Monitor the mental status closely
• Monitor the FSBS every 15-30 minutes
• Order a meal tray STAT
• Cardiac Monitor
ADRENAL CRISIS

Addison’s Disease (adrenal insufficiency)

Adrenal cortex ceases to produce glucocorticoid and
mineralocorticoid hormones

Acute stressors, infection, hemorrhage, trauma,
surgery, burns, pregnancy, or abrupt cessation for
Addison’s disease

Life threatening because hormones are necessary for
the maintenance of blood volume, BP, and glucose
homeostasis
ADRENAL CRISIS

Suspect with patients who have septicemia with
unexplained deterioration, major illness who have
abdominal, flank, or chest pain, with dehydration,
fever, hypotension, or shock, and adrenal
hemorrhage

Death because of circulatory
collapse and hyperkalemiainduced dysrhythmia
ADRENAL CRISIS- ASSESSMENT
 Subjective
History
Rapid
data
of present illness
worsening of symptoms of adrenal
insufficiency
Fever
Nonspecific abdominal pain; may simulate
acute abdomen
N&V
ADRENAL CRISIS- ASSESSMENT

Medical history
 Primary
adrenal insufficiency
 Hyperpigmentation of skin
 Weakness, fatigue, lethargy
 Anorexia and weight loss
 Nausea, vomiting, diarrhea
 Salt craving
 Postural hypotension
 Allergies
 Medications
ADRENAL CRISIS
 Physical
examination
 Appears
acutely ill
 Signs of shock as a result of dehydration
 Hypotension,
but may have warm extremities
 Tachycardia
 Tachypnea
 Orthostatic
hypotension
ADRENAL CRISIS
 Physical
examination
Fever
Altered
mental status, confusion
Hyperpigmentation of skin
Very soft heart sounds
ADRENAL CRISIS
 Diagnostic
procedures
 CBC:
anemia of chronic disease
 Electrolyte levels
 Hyponatremia
 Hyperkalemia
 Blood
glucose level: hypoglycemia
 BUN: elevated (azotemia secondary to
dehydration)
 UA
ADRENAL CRISIS
UA
 Blood cultures
 Plasma cortisol level
 ECG

 Low
voltage
 Flat or inverted T wave
 Prolonged QT, QRS, or PR intervals
 CXR
 CT of abdomen: if diagnosis not clear
ADRENAL CRISIS

Interventions





O2, IV, monitor
VS, with Orthostatic VS
I&O
Weight
Monitor signs of adequate tissue perfusion: capillary refill
and skin temperature and moisture
ADRENAL CRISIS
 Medications
Dexamethasone
 Hydrocortisone
 Corticotropin
 Glucose
 Vasopressors

 Monitor
electrolytes
 Monitor cardiac function
 Prepare for admission
 Instruct about disease process
MYXEDEMA COMA
Severe form of hypothyroidism
 Marked impairment of CNS and cardiovascular
decompensation
 Recognition of this illness is hampered by its insidious
onset and rarity
 Winter, elderly women with HX of hypothyroidism
 Precipitating factors include: serious infection
(pneumonia and UTI), sedative or tranquilizer use,
stroke, exposure to cold environment, and termination
or thyroid hormone replacement
 Death is common, but can survive if prompt adequate
care

MYXEDEMA COMA
 History
of present illness
Recent illness
 Progressive decline in intellectual status
 Apathy, self-neglect
 Emotional labiality
 Anorexia
 Recent weight gain

 Medical
history
Hypothyroidism or thyroid surgery
 Allergies
 Medications: thyroid replacement hormone, recent use of
tranquilizers and sedatives

MYXEDEMA COMA
 Objective
 Physical
data
exam
 Decreased
mental status
 Depressed mental acuteness
 Confusion or psychosis
 Pale, waxy, edematous face with periorbital
edema
 Dry, cold, pale skin
MYXEDEMA COMA
 Objective
 Physical
data
exam
 Non-pitting
extremity edema
 Thin eyebrows
 Deep, coarse voice
 Scar form prior thyroidectomy
 Vital Signs
Hypothermia, usually above 95 F
 Bradycardia with distant heart sounds
 Hypoventilation, Hypotension

MYXEDEMA COMA
 Diagnostic
procedures
 Electrolytes:
hyponatremia
 ABG’s: hypoxia and hypercarbia
 Thyroid studies: low thyroxine (T4), elevated
thyrotropin (thyroid stimulating hormone
[TSH])
MYXEDEMA COMA

ECG
 Low
voltage
 Sinus bradycardia
 Prolonged QT interval
 CBC: anemia and decreased WBC
 BUN and creatinine: elevated
 Blood sugar: variable hypoglycemia
 CXR
 UA
 Obtain pretreatment plasma cortisol level
MYXEDEMA COMA
 Interventions
 Monitor
airway, breathing, circulation,
and other vital signs
 O2 as ordered
 IV, IV fluids
 Hypertonic
saline
 Crystalloids
 Whole blood
MYXEDEMA COMA
 Interventions

Meds as ordered
IV thyroid hormone
 Glucocorticoid
 Vasoconstrictors


Rewarm patient
Use passive rewarming with blankets and
increased room temperature
 Avoid rapid rewarming
 Be prepared for seizures

THYROID STORM
Extreme and rare form of thyrotoxicosis
 High mortality
 Untreated or inadequately treated
hyperthyroidism, who experiences surgery,
infection, trauma, or emotional upset; thyroid
surgery; radioactive iodine administration
 Cardiac decompensation with CHF (terminal
event), CNS dysfunction, GI disorders
 Life-threatening emergency

THYROID STORM- ASSESSMENT

History of present illness
 Fever
 N&V&D
 Abdominal pain
 Worsening of thyrotoxicosis symptoms
 Anxiety
 Restlessness, nervousness, irritability
 Generalized weakness
 Possible coma
 Precipitation event or intercurrent illness
THYROID STORM

Medical history
 Thyrotoxicosis
 Thyroid
disease
 Easy fatigability
 Weight loss
 Sweating
 Body heat loss and heat intolerance
THYROID STORM
 Objective
data
 Physical
exam
Fever:
temp may exceed 104
Tachycardia (120-200), systolic hypertension
Chest: crackles
THYROID STORM
 Warm,
moist, velvety skin; becomes dry as
dehydration develops
 Spider angiomas
 Tremulousness
 Delirium, agitation, confusion, coma
 Thin silky hair
 Enlarged thyroid gland with thrill or bruit
THYROID STORM
 Eye
signs
 Lid
lag
 Stare
 Exophthalmos
 Periorbital edema
 Hepatic
tenderness or jaundice
THYROID STORM
 Diagnostic
procedures
 Cardiac
monitoring/ECG: sinus
tachycardia wand atrial fibrillation/flutter
 Thyroid function studies
T4:
elevated
Triiodothyronine (T3): elevated resin uptake
TSH: decreased
 Serum
cholesterol level: decreased
THYROID STORM
 Diagnostic
procedures
Electrolyte levels
 Serum glucose increased
 CBC: increased WBC with left shift
 BUN or creatinine level
 Hepatic studies: increased liver enzymes
 UA
 Cultures and radiographs and indicated

THYROID STORM


Interventions
 O2,
airway,
breathing,
circulation, VS
 IV of D5 and
isotonic solution
 Cardiac
monitoring
Meds as ordered
Vasopressors
 Antipyretic
 D50
 Propylthiouracil every 8 hours
 Glucocorticoids, hydrocortisone
 Iodine: lugol’s solution,
potassium iodide
 Digitalis, propranolol
 Antibiotics
 Vitamins and thiamine
 Sedatives

THYROID STORM
 Use
cooling blanket, cold packs
 Prepare patient/significant others for
patient’s admission
 Explain procedures to
patient/significant others
References
American Diabetic Association
Emergency Nursing Core Curriculum, ENA
Fundamentals of Nursing, Potter and Perry