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Endocrine System Disorder
Endocrine System
• The foundations of the endocrine system are the hormones and
glands. As the body's chemical messengers, hormones transfer
information and instructions from one set of cells to another.
• The major glands that make up the human endocrine system are t
– hypothalamus
- pituitary
- thyroid
- parathyroids
- adrenals pineal body
- and the reproductive glands, which include the ovaries and
testes.
• The pancreas is also part of this hormone-secreting system, it is
also associated with the digestive system because it also produces
and secretes digestive enzymes.
Pancreas
• The pancreas is a glandular organ that
secretes digestive enzymes (internal
secretions) and hormones (external
secretions). In humans, the pancreas is a
yellowish organ about 7 inches (17.8 cm) long
and 1.5 inches. (3.8 cm) wide.
• The pancreas lies beneath the stomach and is
connected to the small intestine at the
duodenum
Pancreas - Functions
• The pancreas contains enzyme producing cells that
secrete two hormones.
• The two hormones are insulin and glucagon. Insulin
and glucagon are secreted directly into the
bloodstream, and together, they regulate the level of
glucose in the blood.
• Insulin lowers the blood sugar level and increases the
amount of glycogen (stored carbohydrate) in the
liver.
• Glucagon slowly increases the blood sugar level if it
falls too low. If the insulin secreting cells do not work
properly, diabetes occurs.
Pancreas - Function
• The pancreas also helps neutralize chyme and helps
break down proteins, fats and starch.
• Chyme is a thick semi-fluid mass of partly digested
food that is passed from the stomach to the
duodenum.
• If the pancreas is not working properly to neutralize
chyme and break down proteins, fats and starch,
starvation may occur.
• Conditions of the Pancreas
• Pancreatitis is a condition that affects the pancreas.
Pancreas – location anatomically
Pancreas
Endocrine Disorder
Diabetes Millitus
• Diabetes Mellitus –is a chronic multisystem disease
related to abnormal insulin production, impaired
insulin use, or both.
• Insulin is a hormone that helps the glucose get into
the cells to give them energy. With Type 1
diabetes, the body does not make insulin. With
Type 2 diabetes, the more common type, the body
does not make or use insulin well. Without enough
insulin, the glucose stays in your blood.
Diabetes Mellitus
• DM is a serious health problem throughout
the world.
• Leading cause of end-stage renal disease.
• Adult blindness.
• Non-traumatic limb amputation.
Major contributing Factor in:
• Heart disease and stroke
• Decreased tissue perfusion in D.M. may lead
to cardiovascular disease, hypertension, renal
failure, blindness, and stroke
Diabetes Mellitus
• Over time, having too much glucose in blood can
cause serious damage to eyes (retinopathy),
kidneys (nephropathy), and nerves (neuropathy).
• Diabetes can also cause:
- heart disease
- stroke
- amputation (need to remove a limb).
- Pregnant women can also get diabetes, called
gestational diabetes.
Current Theories leading to its Etiology
• Genetic
• Autoimmune
• Viral
• Environmental factors (e.g. viral and stress).
Two Most Common Types:
• Type 1 – IDDM, Juvenile Diabetes
• Type 2 – NIDDM, Adult Onset DM
• Gestational, pre-diabetes, & secondary diabetes
Diagnostic tests
Diagnostic criteria:
• Two findings (separate days) of one of the following:
•
Symptoms of DM plus casual plasma
glucose concentration of greater than 200
mg/dL ( without regard to time since last
meal).
• Fasting Blood Glucose greater than 126 mg/dL (8 hour
fasting).
• Two-hour glucose greater than 200 mg/dL with an oral
glucose tolerance test (10 to 12 hr. fasting).
DM Diagnostic Tests – Nursing Intervention
• FBG or FBS – ensure client has fasted for 8
hours prior to the blood draw. Antidiabetic
(hypoglycemic agents) medications should be
postponed until after the level is drawn.
• Pre-meal glucose – The target is 90 – 130
mg/dL. Follow or ensure that the client follow
the procedure for blood sample collection
and use of glucose meter. Supplemental
short-acting insulin maybe prescribed for
elevated pre-meal glucose levels.
DM Diagnostic Tests – Nursing Intervention
• Oral Glucose Tolerance Test (OGTT) – Instruct
the client to consume a balanced diet for the
three days prior to the test. Then instruct the
client to fast for 10 – 12 hr. prior to the test.
A FBS is drawn at start of the test. The client
is then instructed to consume a specified
amount of glucose. BG level or CBG level are
drawn every 30 min. for 2 hr. Client must be
assessed for hypoglycemia throughout the
procedure
DM Diagnostic Tests – Nursing Intervention
• Glycosylated Hemonglobin (Hgb A1- C)
- This is used to determine the long-term
compliance of client to DM treatment
regimen.
• The target is 4 to 6% Hgb A1-C. HgbA1-C is the
best indicator of average blood glucose for
past 120 days. Assist for evaluating treatemtn
effectiveness and compliance.
Assessments – Sign and Symptoms to look for:
Start prioritizing
Type 1
Polyuria, polydipsia, polyphagia
Type 2
Polyuria, polydipsia, polyphagia
Weight Loss
Obesity
Fatigue
Fatigue
Increase frequency of infections
Increase frequency of infections
Rapid Onset
Gradual Onset
Controlled by exogenous insulin
Controlled by Oral hypoglycemic
medications and insulin
Sign and Symptoms by Glucose Alteration
Hypoglycemia ( equal or less than 50
mg/dL)
Cool clammy skin
Diaphoresis (sweating)
Anxiety, irritability, confusion, blurred
vision
Hunger
General weakness, seizure ( severe
hypoglycemia
Hyperglycemia (equal or more than 250
mg/dL)
Hot, dry skin
Absence of diaphoresis (absence of
sweating)
Alert to coma ( varies)
Nausea and vomiting, abdominal pain
(with ketoacidosis)
Rapid deep respiration (Kaussmal’s
breathing) acetone/fruity odor due to
ketones – this is resulting from Diabetic
ketoacidosis
Blood Glucose monitors
Glucose Continuum
Normal Insulin Secretion
Insulin Preparations
Insulin Pen
Insulin Pump
Subcutaneous Injection Sites
Type 1 – DM (Insulin Dependent DM)
• Type 1 diabetes ( Juvenile Diabetes Mellitus)
• When the pancreas fails to produce enough
insulin, type 1 diabetes (previously known as
juvenile diabetes) occurs. Often occurs in people
who are less than 40 years old.
• Symptoms include excessive:
- thirst, hunger, urination, and weight loss.
• In children and teens, the condition is usually an
autoimmune disorder in which specific immune
system cells and antibodies produced by the
immune system attack and destroy the cells of
the pancreas that produce insulin.
Diabetes Millitus
• The disease can cause long-term
complications including kidney problems,
nerve damage, blindness, and early coronary
heart disease and stroke.
• To control blood sugar levels and reduce the
risk of developing diabetes complications,
kids with this condition need regular
injections of insulin
Type I - DM
• Autoimmune disorder due to beta cell
destruction
• Occurs in genetically susceptible individuals
(islet cell antibodies)
• Typical onset is before the age of 30
• Can result in ketoacidosis (DKA).
Pathophysiology
• Type 1 DM is auto-immune mediated disease.
The body’s own T-Cell attack and destroy the
pancreatic beta cells which are the source of
insulin. In addition, autoantibodies to the islet
cells cause a reduction of 80% to 90 % of
normal B –cell before hyperglycemia and
other manifestations occur.
• A genetic predisposition and exposure to virus
may contribute to the pathogenesis of Type 1
DM.
Pathophysiology
• Type 1 is associated with long preclinical
period. Islet cell antibodies responsible for Bcell destruction are present for months to
years before onset of symptoms.
• Manifestation develops when the person’s
pancreas can no longer produce sufficient
amount of glucose to maintain normal
glucose. Once this occur, the onset of
symptoms is usually rapid.
Type I - DM
• Clinical Characteristics
– serum glucose of 350 and above
– ketonuria in large amounts
– venous pH of 6.8 to 7.2
– serum bicarbonate below 15 mEq/dl
– 3 Ps
– Sudden weigh loss
– Without insulin, the cleint develops diabetic
ketoacidosis (DKA), a life threatening
condition resulting in metabolic acidosis.
Prediabetes
• It is a condition in which individuals are at
increased risk for developing diabetes.
• Blood glucose are high but not high enough to
meet diagnostic criteria for DM.
• Impaired Fasting Glucose (IFG) or Impaired
glucose tolerance (IGT).
• Most people with prediabetes are at
increased risk for developing Type 2 DM, and
if no preventive measures are taken, they will
usually develop it within 10 years.
DM- Type 1 Collaborative Care and Treatment
The goal of DM management is to reduce
symptoms and promote well-being, prevent
acute complications of hyperglycemia, and
prevent or delay the onset and progression of
long term complications.
• Nutrition
• Drug therapy
• Exercise
• And self-monitoring of blood glucose are the
tools used in management of DM.
Drug Therapy
• The two major types of glucose lowering
agents (GLAs) used in treatment of DM are
insulin and oral hypoglycemic agents.
• Insulin – exogenous insulin is needed when a
client has inadequate insulin to meet specific
metabolic needs.
• Type 1 – requires insulin to survive.
• Type 2 – requires insulin during period of
severe stress such as illness or surgery.
Insulin
• Insulin is prepared through the use of genetic
engineer ( derived from common bacteria
(e.g. E. Coli) or yeast cells using recombinant
DNA technology.
• They differ in regards to onset, peak, and
duration.
• Categorized as rapid acting, short-acting,
intermediate-acting, and long acting.
Drug Therapy – Types of Insulin
Classification
Example
Clarity of Solution
Characteristics
Rapid-Acting Insulin Humalog ( Lispro)
Aspart (Novolog)
Glulisine (Aapidra)
Clear
Onset : less than 15 minutes. Peak:
0.5 to 1.5 hr.
Duration: 2- 6 hr.
Administer 5 to 15 min before meals
Short-Acting Insulin
Clear
Onset : 30 – 60 min.
Peak: 2 - 3 hr.
Duration: 3 – 10 hr.
Administer: 30 min before meals
Intermediate-Acting NPH ( Humulin N, Novolin
Insulin
N, ReliOn N)
Cloudy
Onset : 2 - 4 hr.
Peak: 4 – 10 hr.
Duration: 10 - 18 hr.
Long –Acting
Insulin
Glargine (Lantus)
Detemir (Levemir)
Clear
Peak: None
Duration: 24 hour acting
Combination
Therapy
NPH/Regular – 70/30
(humulin 70/30, Novolin
70/30, ReliOn 70/30
NPH/Regular 50/50
Lispro protamine/lispro
50/50 (Humalog Mix
Aspart protamine/aspart
70/30 (Novolog mix 70/30
Cloudy
Regular (Humulin R,
Novolin R, ReliOn R)
insulin pump
insulin pen
Subcutaneous Injection Sites
Self-administration of insulin
• Rotate injection sites
• Inject at a 90° angle (45° if thin). do not
aspirate
• When missing rapid or short with long acting
insulin: draw up the shorter-acting insulin into
the syringe first and than the longer-acting
insulin (reduces the risk of introducing longeracting insulin into shorter-acting insulin vial).
• Observe client perform self-administration and
offer additional instruction as indicated.
Nursing Related to Insulin Therapy
• Proper administration assessment of client’s
response to insulin therapy, and education of the
client regarding administration of insulin , and
adjustment to, and monitoring and reporting of side
effects of insulin.
• Assess the client who is new to insulin and evaluate
ability to manage this therapy safely. This include the
ability to understand interaction of isulin, diet, and
activity, and to be able to recognize and treat
appropriately the sysmptoms of hypoglycemia.
Nursing Related to Insulin Therapy
• The client and the caregiver must also be able to
prepare and inject the insulin ( see Table 49-5 Lewis
et al., 2011 pg. 1226. Additional teaching or
resources is needed if client or caregiver lacks the
ability.
• Follow-up assessment of the client ( e.g.
lipodystrophy, hypoglycemic episodes, and handling
of hypoglycemic episodes).
• A review of the client record of urine and blood
glucose test is also important overall glycemic
control.
Type II
• Often due to the development of
resistance to endogenous insulin
• Individuals with a family disposition,
individuals who are obese and over the
age of 40
• obesity, physical inactivity, high triglycerides (>250
mg/dl), and hypertension are the hallmark risk factors
for the development of insulin resistance.
Type II - DM
• Type 2 diabetes, the most common type, can start
when the body doesn't use insulin as it should. If body
can't keep up with the need for insulin, the individual
may need to take pills (hypoglycemic agents).
• Some individuals need both insulin and pills. Along
with meal planning and physical activity, diabetes pills
help people with type 2 diabetes or gestational
diabetes keep their blood glucose levels on target.
• Several kinds of pills are available. Each works in a
different way. Many people take two or three kinds of
pills.
• Some people take combination pills. Combination
pills contain two kinds of diabetes medicine in one
tablet. Some people take pills and insulin.
Type II
• Clinical Characteristics (sign and symptoms)
– hyperglycemia
– plasma hyperosmolality
– dehydration
– changed mental status
• Treatment
– isotonic IV fluid replacement and careful monitoring of
potassium and glucose levels
– intravenous insulin (not always necessary)
signs & symptoms of glucose alteration
hypoglycemia (
50 mg/dL)
hyperglycemia (>250 mg/dL)
cool, clammy skin
hot, dry skin
diaphoresis
absence of diaphoresis
anxiety, irritability, confusion, blurred vision
alert to coma (varies)
hunger
nausea, vomiting, abdominal pain (with
ketoacidosis)
general weakness, seizures (severe
hypoglycemia)
rapid deep respirations (acetone/fruity odor
due to ketones)
slurred speech
blurred vision
weight loss
hunger
weakness
lethargy
syncope
confusion
Oral Agents
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Sulfonylureas
Biguinides
Alpha-glucosidase inhibitors
Thiazolidinediones
Meglitindes
oral anti-diabetic medications
• administer as prescribed
• avoid alcohol with sulfonylurea agents (disulfiram-like
reaction)
• monitor renal function (biguanides)
• monitor liver function (thiazolidinediones and alphaglucosidase inhibitors
• women of childbearing age may need to take additional
contraception methods since the drugs reduce the blood
levels of some oral contraceptives
Sick Day Management
• Illness and or infection can raise blood glucose
– the body’s response to illness and stress is to produce
glucose. any illness may result in hyperglycemia
• Patient teachings
– teach client to keep taking insulin or oral anti-diabetic
agents
– monitor glucose more frequently (every 4 hours)
– watch for signs of hyperglycemia
– rest
Exercise
• regular, non-strenuous exercise
• exercise after mealtime
• exercise with a partner or let someone know where the
exercise will take place to ensure safety.
• a snack may be needed before or during exercise
Diet
Diabetic Diet
Type 1 Diabetes Diet - Type 1 diabetes always requires
insulin treatment, the main focus is to find a balance
between the food intake and insulin.
Type 2 Diabetic Diet - Type 2 diet focus on controlling
weight in order to improve the body's ability to utilize
insulin. In most cases Type 2 diabetes can be controlled
through proper diet and exercise alone.
Gestational Diabetes Diet - unlike the Type 2 diet,
gestational diabetes diet focus on adequate energy and
nutrients to support both the mother’s body and
growing baby while maintaining stable blood glucose
levels for the pregnant mother.
Diabetic Diet
• Healthy eating helps to reduce blood sugar. It is a critical part of
managing diabetes, because controlling blood sugar can prevent
the complications of diabetes.
• Wise food choices are a foundation of diabetes treatment.
• Diabetes experts suggest meal plans that are flexible and take
lifestyle and other health needs into account.
• Healthy diabetic eating includes
- Limiting sweets
- Eating often
- Being careful about when and how many carbohydrates is being
eaten.
• Eating lots of whole-grain foods, fruits and vegetables
• Eating less fat
• Limiting your use of alcohol
Diabetic Diet Goal
• The diet goal is to eat a balanced, portion
controlled meal that will allow body to stay on
an even keel throughout the day as the
components of each meal hit the system.
• Eating every two to three hours is best, five or
six small meals being recommended, and light
exercise after each meal will help kick start
the digestive system and prevent a spike in
sugar levels.
Diabetic Diet Sample Meal And Food
• One serving of protein (3 oz of chicken, lean beef or fish)
• One serving of bread (whole grain roll, tortilla or ½ cup
pasta)
• One serving of dairy (cheese, milk or low-fat sour cream)
• One serving vegetables (fist sized portion or a small bowl
of salad)
• One serving fruit (tennis ball sized or ½ cup sliced)
• Small amounts of unsaturated fats are needed, so add a
little dressing or a pat of soft margarine. Avoid sweets;
consider the fruit your dessert!
• Foods that should be avoided include; fatty red meat,
organ meat, highly processed food, fried food, fast food,
high cholesterol food and foods rich in saturated fat.
Diabetic Diet
• Generally Type 2 diabetic patients need 1500-1800
calorie diet per day to promote weight loss.
• Calories requirement may vary depending upon
patients age, sex, activity level and body weight.
• Half of total daily required calories should come from
carbohydrates.
• One gram of carbohydrate is about 4 calories. A
diabetic patient on a 1600 calorie diet should get half
of these calories from carbohydrate. In other words it
will be equal to 800 calories from carbohydrates, it
means they need 200gms of carbohydrates everyday.
Improving The Sensitivity For Insulin
• When glucose balance is improved, the sensitivity of all
cells to the hormone insulin also improves.
• Very important because insulin is the hormone which
opens the doors in all cells to allow glucose to enter, in
order to supply fuel for the production of energy.
• Once this process is ineffective or out of balance diabetic
symptoms, signs of diabetes, pre diabetes, or the cause of
diabetes can occurs.
Hypoglycemia
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check blood glucose levels
treat with 15 g carbohydrates
recheck blood glucose in 15 minutes
if still low, give 15 more g of carbs
recheck blood in 15 minutes
if normal, take 7 g of protein (if next meal is more than an
hour away)
●15 g of carbs (examples): 4 oz orange juice, 2 oz grape, 8 oz milk, glucose tablets
●7 g protein (example): 1 oz string cheese
* fluid is more readily absorbed (juice, non-diet drink, skim milk
NANDA nursing diagnosis
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risk for injury
imbalanced nutrition
risk for impaired skin integrity
deficient knowledge
self-care deficit
ineffective coping
Complications
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eye problems: damage to blood vessels in the
eyes (retinopathy), pressure in the eye
(glaucoma), and clouding of the eye (cataract)
tooth and gum problems (periodental disease)
:loss of teeth and bone
blood vessel (vascular) disease leading to
circulation problems, heart attack, or stroke
problems with sexual function
kidney disease (nephropathy)
nerve problems (neuropathy), causing pain or
loss of feeling in your feet and other parts of
your body
hight blood pressure (HTN), putting strain on
your heart and blood vessels
serious infections possibly leading to loss of
toes, feet or limbs
Diabetic retinopathy
• can cause blindness
• encourage yearly exams – refer to
opthalmologist.
• encourage management of glucose
levels
• diet: low fat, high in fruits, vegetables ad
whole grains
• encourage a dietary consult
Foot care for the diabetic clients
• inspect feet daily and wash with mild soap and warm
water
• pat feet gently especially between the toes
• use mild foot powder on sweaty feet
• do not use commercial remedies for calluses or corns
• consult a podiatrist
• cut toenails even with rounded contour of toes
• cut toe nails after a bath or shower
• separate overlapping toes with cotton or lamb’s wool
• do not go out barefoot
• wear clean absorbent socks
• do not use water bottles or heating pads to warm feet.
wear socks for warmth.
complications
diabetic foot ulcer
diabetic retinopathy
Diabetic Ketoacidosis
DKA
Acute, life threatening condition characterized by
hyperglycemia (>300 mg/dL) resulting in breakdown of
body fat for energy and an accumulation of ketones on
the blood and urine.
The onset is rapid, and the mortality rate of DKA is 1 to
10%
* most common in individuals with type I diabetes
Diabetic Ketoacidosis
Diabetic Ketoacidosis
Hyperglycemic-Hyperosmolar Nonketonic Syndrome
(HHNS)
Acute life-threatening condition characterized by
profound hyperglycemia (>600 mg/dL), dehydration,
and absence of ketosis. the onset it generally over
several day, and the mortality rate of HHNS is up to
15% or more
* more common in older adult clients and in individuals with untreated or
diagnosed type II diabetes
Nursing management DKA/HHS
– Patient closely monitored
• Administration
– IV fluids
– Insulin therapy
– Electrolytes
• Assessment
– Renal status
– Cardiopulmonary status
– Level of consciousness
– Patient closely monitored
• Signs potassium imbalance
• Cardiac monitoring
• Vital signs
laboratory analysis
Diagnostic Procedure
DKA
HHNS
serum glucose levels
>300 mg/dL
>600 mg/dL
serum electrolytes
● sodium
●potassium
Na+ increased due to water loss
K+ initially low due to diuresis, may
increase due to acidosis
increased secondary to
dehydration
serum renal studies
● BUN
●Creatinine
increased secondary to
dehydration
increased secondary to
dehydration
present
present
absent
absent
metabolic acidosis with respiratory
compensation (Kussmaul
respirations)
absence of acidosis
ketone levels
● serum
●urine
serum pH (ABG)