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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 • • • • • 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 • • • • • • 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 • • • • • • risk for injury imbalanced nutrition risk for impaired skin integrity deficient knowledge self-care deficit ineffective coping Complications • • • • • • • • 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)