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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 o 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 o o o o Correct the underlying cause Fluid restriction Give Na: saline, hypertonic saline Diuretic Tx