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Endocrine
AACN CCRN Review
Endocrine
Presenter: Carol Rauen, RN, MS, PCCN, CCRN, CCNS, CEN
Adult CCRN Review Course 2013
The Body Harmony
Endocrine Disorders and Emergencies
I.
Introduction
Disorders of the endocrine system are related to either an excess or a deficiency of a specific hormone or
defect at its receptor site
AACN CCRN Exam Blueprint 5%
 Acute hypoglycemia
 Diabetes insipidus (DI)
 Diabetic ketoacidosis
 Hyperglycemic hyperosmolar nonketotic syndrome (HHNK)
 Syndrome of inappropriate secretion of antidiuretic hormone (SIADH)
Every cell in the body is under endocrine influence
II.
Acute Complications of Diabetes
 Acute hypoglycemia
 Diabetic ketoacidosis
 Hyperglycemia hyperosmolar nonketotic coma
A.
Acute Hypoglycemia
 Serum glucose <50mg/dL
 Causes
o Too much insulin
o Not enough calories
 Signs and symptoms
o Tachycardia
o  LOC: irritable, confused, unconscious
o Skin: pale, cool, clammy
o Seizures
o Blurred vision
 Treatment
o Give glucose
o Enteral
o Parental (if SG <20mg/dL)
o Determine cause
B.
Diabetic Ketoacidosis (DKA)
 Epidemiology
o Occurs in 2%‒5% of type I DM/year
o Most often precipitated by illness (infection)
o 1%‒10% of DKA victims will die
o Mortality is highest in >60-years-old
Adult CCRN Review Course 2013

Diagnosis
o
o
o
o
o
o
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Metabolic derangement resulting from absolute or relative insulin deficiency
Blood glucose >500
pH <7.32
HCO3 <15mEq/L
Increase anion gap
+ Ketones in urine
Azotemia
Anion Gap = Na+ - (Cl- + HC03); normal: 8‒16 mEq/L

Signs and symptoms
o Hypotension
o Tachycardia
o Tachypnea
o Kussmaul’s respirations
o Decreased skin turgor
o Dry mucous membranes
o ? Abd pain, nausea, and vomiting

Fluid therapy
o
o
o
o

Restore circulating volume
1-2 L of isotonic saline in 2 hr
D5/.45% NS after BS down to 250
May get 8‒10L in 1st 24 hr
Drug therapy
o Continuous IV or bolus regular insulin
o Lower 100 mg/dL/hr
o Monitor K levels carefully
o Bicarbonate for severe acidosis
C.
Hyperglycemic Hyperosmolar Nonketotic Coma (HHNK)
A hyperosmolar state from severe hyperglycemia without ketosis. Predominantly affects older adults and
patients with type II DM
 Diagnosis
o Glucose >800 mg/dL
o Osmolality >350 mOsm
o Ketones neg
o pH >7.3
o Severe dehydration

Fluid therapy
o 2 L normal saline in 1 hr
o Followed by fluid replacement

Drug therapy
Adult CCRN Review Course 2013
o
o
III.
Continuous IV regular insulin (10U/hr)
Monitor K+ closely
Acute Complications of Water Regulation
 Diabetes insipidus
 Syndrome of inappropriate ADH
A.
Diabetes Insipidus
A problem of impaired conservation of H20 by the kidneys
 Polyuria
 Low urine SG
 Hypernatremia
 Fluid deficit/dehydration
B.
Neurogenic or Central DI
Lack of ADH from the hypothalamus or posterior pituitary gland. Normal regulatory mechanisms are not
functioning typically from some type of neuro dysfunction
 Causes
o Idiopathic – autoimmune
o Head Trauma
o Hypoxic or Ischemic Encephalopathy
o Surgery (neuro)
C.
Nephrogenic DI
There is ADH but the Kidneys do not respond to the ADH
 Causes
o Osmotic Agents or States
o Renal Failure
o Decreased Osmotic Pressure
o Pregnancy
 DI signs and symptoms
o Polyuria
o Polydipsia
o Dehydration/hypovolemia
 Lab data
□
Plasma osmolality
□
High >295 mOsm/kg (normal: 285‒300)
o Serum sodium
□
Normal or >145 mEq/L (normal 135‒145)
o Urine osmolality
□
Low, <250 mOsm/kg (300-1400)
o Urine SG
□
Low <1.005 (1.005–1.030)
 Treatment:
o Correct the underlying cause
o Free water replacement
o Neurogenic: ADH replacement
Adult CCRN Review Course 2013
o
o
o
D.
Syndrome of Inappropriate Antidiruetic Hormone (SIADH)
Too much release of ADH, stimulating the kidneys to retain water resulting in water intoxication
o Overhydration
o Low-serum osmolality
o Hyponatremia
 Causes
o Malignancies: lung, pancreas, duodenum, lymph, prostate, thymus
o Meningitis
o Brain abscess or tumors
o Head injury (blunt trauma or bleeds)
o Mechanical ventilation
o Drugs (hypoglycemic meds, barbiturates, general anesthesia, nicotine, chemotherapy
agents, MS04, thiazide, hormones, TCD)
 Signs and symptoms
o Weight gain
o Edema
o Signs of overhydration
 Lab data
o Plasma osmolality
□
Low <280 mOsm/kg
o Serum sodium
□
Low <135 mEq/L
o Urine osmolality
□
Normal or high >100 mOsm/kg
o Urine SG
□
High >1.030

IV.
Nephrogenic: thiazide diuretics
Nutrition
Elimination problems
Summary
Treatment
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Correct the underlying cause
Fluid restriction
Give Na: saline, hypertonic saline
Diuretic Tx