ENDOCRINE SYSTEM

Main gland Pituitary gland located at base of brain of Stella Turcica - Master gland of body - Master clock of body 1. Anterior pituitary gland adenohypophysis 2. Posterior pituitary gland neurohypophysis Posterior Pituitary Gland 1.) Oxytocin a.) Promotes uterine contraction preventing bleeding/ hemorrhage. - Give after placental delivery to prevent uterine atony. b.) Milk letdown reflex with help of prolactin. 2.) ADH (vasopressin) antidiuretic hormone -Prevents urination conserve H2O Anterior Pituitary Gland adeno Growth hormone (GH) - Somatotropic hormone - Elongation of long bones

1.)

1. Decrease GH dwarfism
2. 3.

children Increase GH gigantism Increase GH acromegaly adult Puberty 9 yo 21 yo Epiphyseal plate closes at 21 yo Square face Square jaw

2.)
3.)

Drug of choice in acromegaly: Ocreotide (Sandostatin) S/E dizziness Somatostatin Hormone antagonizes the release of of GH Melanocytes stimulating hormone (MSH) - Skin pigmentation Prolactin/luteotrpic hormone/ lactogenic hormone - Promotes development of mammary gland (Oxytocin-Initiates milk letdown reflex) Adrenocorticotropic hormone (ACTH) - Development & maturation of adrenal cortex Luteinizing hormone produces progesterone Follicle Stimulating Hormone - produces estrogen

4.)
5.)

6.)

DIABETIS INSIPIDUS (DI)

(DI- dalas ihi) hyposecretion of ADH * alcohol inhibits release of ADH

Cause: idiopathic/ unknown Predisposing Factor: 1. Pituitary surgery 2. Trauma/ head injury 3. Tumor 4. Inflammation Signs & Symptoms: 1. Polyuria 2. Sx of dehydration - Excessive thirst (adult) (1st sx of dehydration in children-tachycardia) - Agitation - Poor skin turgor - Dry mucus membrane 3. Weakness & fatigue 4. Hypotension if left untreated 5. Hypovolemic shock Anuria late sign hypovolemic shock Diagnostic Procedure: 1. Decrease urine specific gravity- concentrated urine N= 1.015 1.035 2. Serum Na = increase (N=135 -145 meq/L) Hypernatremia Nursing Management: 1. Force fluid 2,000 3,000ml/day 2. Administer IV fluid replacement as ordered 3. Monitor VS, I&O 4. Administer meds as ordered a.) Pitresin (vasopressin) IM 5. Prevent complications Most feared complication Hypovolemic shock

SYNDROME OF INAPPROPRIATE ANTI-DIURETIC HORMONE (SIADH)

- Increase ADH - Idiopathic/ unknown Predisposing Factor: 1. Head injury 2. Related to Bronchogenic cancer or lung canerEarly Sign of Lung Ca - Cough 1. non productive 2. productive 3. Hyperplasia of Pit gland Increase size of organ Signs 1. 2. 3. 4. 5. 6. & Symptoms: Fluid retention Increase BP HPN Edema Wt gain Danger of H2O intoxication Complications: 1. cerebral edema increase ICP 2. seizure

Diagnostic Procedure: 1. Urine specific gravity increase diluted urine 2. Hyponatremia Decreased Na Nursing Management: 1. Restrict fluid 2. Administer meds as ordered eg. Diuretics: Loop and Osmotic

3. 4. 5. 6. 7.

Monitorstrictly V/S, I&O, neuro check increase ICP Weigh daily Assess for presence edema Provide meticulous skin care Prevent complications increase ICP & seizures activity

PINEAL GLAND 1. Secretes Melatonin inhibits lutenizing hormone (LH) secretion THYROID GLAND (TG) Question: Normal physical finding on TG: a. With tenderness thyroid never tender b. With nodular consistency- answer c. Marked asymmetry only 1 TG d. Palpable upon swallowing - Normal TG never palpable unless with goiter THYROID GLAND HORMONES

1.) Triodothyronine T3
- 3 molecules of iodine Metabolic hormone

2.) Tetraiodothyronine/ Tyroxine T4

- 4 molecules of iodine 3.) Thyocalcitonin antagonizes effects of parathormone Hypo T3 T4 - lethargy & memory impairment Hyper T3 T4 - agitation, restlessness, and hallucination

SIMPLE GOITER
enlarged thyroid gland - iodine deficiency Predisposing Factor: 1. Goiter belt area - Place far from sea no iodine. Seafoods rich in iodine 2. Mountainous area increase intake of goitrogenic foods (US: Midwest, NE, Salt Lake) Cabbage has progoitrin an anti thyroid agent with no iodine Example: Turnips (singkamas), radish, peas, strawberries, potato, beans, kamote, cassava (root crops), all nuts. 3. Goitrogenic drugs: Anti thyroid agents :(PTU) prophylthiouracil Lithium carbonate, Aspirin PASA Cobalt, Phenyl butasone Endemic goiter cause # 1 Sporadic goiter caused by #2 & 3 Signs & Symptoms: enlarged TG Mild restlessness Mild dysphagia Diagnostic Procedure: 1. Thyroid scan reveals enlarged TG 2. Serum TSH increase (confirmatory) 3. Serum T3, T4 N or below N

Nursing Management: 1. Administer meds a.) Iodine solution Lugols solution or saturated solution of potassium (K) iodide SSKI Nursing Management: Lugols sol violet color 1. use straw prevent staining teeth 2. Prophylaxis 2 -3 drops Treatment 5 to 6 drops Use straw to prevernt staining of teeth 1. Lugols sol., 2. tetracycline 3. nitrofurantin (macrodantin)-urinary anticeptic-pyelonephritis. 4. Iron solution. B. Thyroid hormone replacement 1. Levothyroxine (Synthroid) 2. Liothyronine (cytomel) 3. Thyroid extract Nursing Management: for TH/agents 1. Monitor vs. HR due tachycardia & palpitation 2. Take it early AM SE insomnia 3. Monitor S/E: Tachycardia, palpitations Signs of Insomnia Hyperthyroidism restlessness agitation Heat intolerance HPN 3. Encourage increase intake iodine iodine is extracted from seaweeds (!) Seafood- highest iodine content oysters, clams, crabs, lobster Lowest iodine shrimps Iodized salt easily destroyed by heat take it raw not cooked 4. Assist surgery- Sub total thyroidectomyComplication: 1. Hemorrhage check dressing & anterior/posterior part of the neck; vital signs 2. Hoarseness damage to recurrent laryngeal nerve assess patients voice 3. Hypothyroidism thyroid has been removed assess heart rate for brady cardia 4. Hypoparathyroidim accidental removal of parathyroid look for s/sx of hypocalcemia 5. Hypocalcemia due to hypoparathyroidism (+) chvosteks sign, (+) trousseaus sign, muscle twitching, brocho & laryngeal spasm calcium gluconate & tracheostomy set @ the bedside HYPOTHYROIDISM decrease secretion of T3, T4 can lead to MI / Atherosclerosis Adult myxedema Child- cretinism only endocrine dis lead to mental retardation Predisposing Factor: 1. `Iatrogenic causes caused by surgery 2. Atrophy of TG due to: a. Irradiation b. Trauma c. Tumor, inflammation 3. Iodine def 4. Autoimmune Hashimoto disease Signs & Symptoms:

* everything decreased except wt gain & mens increase) Early signs weakness and fatigue Loss of appetite increased lypolysis breakdown of fats causing atherosclerosis = MI Wt gain Cold intolerance myxedema - coma Constipation Late Sx brittle hair/ nails - Myxedema Non pitting edema due increase accumulation of mucopolysacharide in SQ tissue -Horseness voice - Decrease libido - Decrease VS hypotension bradycardia, bradypnea, and hypothermia - Lethargy - Memory impairment leading to psychosis-forgetfulness - Menorrhagia Diagnostic Procedure: 1. Serum T3 T4 decrease 2. Serum cholesterol increase can lead to MI 3. RA IU radio iodine uptake decrease Nursing Management: 1. Monitor strictly V/S. I&O to determine presence of myxedema coma! Myxedema Coma - Severe form of hypothyroidism Hypotension, hypoventilation, bradycardia, bradypnea, hyponatremia, hypoglycemia, hypothermia *Might lead to progressive stupor & coma Important Nursing Management: for Myxedema coma 1. Assist mech vent priority a/w 2. Adm thyroid hormone 3. Adm IVF replacement force fluid 4. Monitor VS, I&O 5. Provide dietary intake low in calories due to wt gain 6. Skin care due to dry skin 7. Comfortable & warm environment due to cold intolerance 8. Administer IVF replacements 9. Force fluid 10. Administer meds take AM S/E insomia. Monitor HR. Thyroid hormones Levothyroxine(Synthroid), Liothyronine (cytomel) Thyroid extracts Health Teaching & Discharge Plan a. Avoidance precipitating factors leading to myxedema coma: 1. Exposure to cold environment 2. Stress 3. Infection 4. Use of sedative, narcotics, anesthetics not allowed CNS depressants V/S already down Complications: 2. Hypovolemic shock, myxedema coma 3. Hormonal replacement therapy - lifetime 4. Importance of follow up care

HYPERTHYROIDISM - Graves disease or thyrotoxicosis (everything up except wt and mens) -Increased T3 & T4

Predisposing Factor: 1. Autoimmune disease release of long acting thyroid stimulator (LATS) Exopthalmos Enopthalmos severe dehydration depressed eye 2. Excessive iodine intake 3. Hyperplasia of TG Signs 1. 2. 3. 4. 5. 6. 1. 7. 8. 9. & Symptoms: Increase in appetite hyperphagia wt loss due to increase metabolism Skin is moist - perspiration Heat intolerance Diarrhea increase motility All VS increase = HPN, tachycardia, tachypnea, hyperthermia CNS changes Irritability & agitation, restlessness, tremors, insomnia, hallucinations Goiter Exopthalmos pathognomonic sx Amenorrhea

Diagnostic Procedure: 1. Serum T3 & T4 - increased 2. Radio iodine uptake increase 3. Thyroid scan reveals enlarged TG Nursing Management: 1. Monitor VS & I & O determine presence of thyroid storm or most feared complication: Thyrotoxicosis 2. Administer meds a. Antithyroid agents 1. Prophylthiuracil (PTU) 2. Methimazole (Tapazole) Most toxic s/e agranulocytosis- fever, sore throat, leukocytosis=inc wbc: check cbc and throat swab culture Most feared complication : Thrombosis stroke CVS 3. 4. 5. 6. 7. 8. Diet increase calorie to correct wt loss Skin care Comfy & cool environment Maintain siderails- due agitation/restlessness Provide bilateral eye patch to prevent drying of eyes- exopthalmos Assist in surgery subtotal thyroidectomy Nsg Mgt: pre-op Adm Lugols solution (SSKI) K iodide 2. To decrease vascularity of TG 3. To prevent bleeding & hemorrhage Complication: 1. Watch out for signs of thyroid storm or thyrotoxicosis Triad signs of thyroidstorm; a. Tachycardia /palpitation b. Hyperthermia c. Agitation Nursing Management Thyroid Storm: 1. Monitor VS & neuro check - Agitated might decrease LOC 2. Antipyretic fever Tachycardia - blockers (-lol) 3. Siderails agitated

Complication 2. Watch for inadvertent (accidental) removal of parathyroid gland Secretes Parath hormone If removed, hypocalcemia Signs & Symptoms: tetany 1. .(+) Trousseau sign 2. Chvostecks sign Nursing Management: - Adm calcium gluconate slowly to prevent arrhythmia - Ca gluconate toxicity antidote MgSO4 Complication 3.Laryngeal (voice box) nerve damage (accidental) Signs & Symptoms: - hoarseness of voice ***Encourage pt to talk or speak post operatively asap to determine laryngeal nerve damage Notify physician! 4. Signs of bleeding post subtotal thyroidectomy - Feeling of fullness at incision site Nursing Management: Check soiled dressing at nape area 5. Signs of laryngeal spasm a. DOB b. SOB Prepare at bedside tracheostomy 6. Hormonal replacement therapy - lifetime 7. Importance of follow up care PARATHYROID GLAND pair of small nodules located behind the TG 1.) Parathyroid Hormone promotes Ca reabsorption Thyrocalcitonin antagonises secretion of parathyroid hormone

1. Hypoparthroidism of parathyroid hormone 2. Hyperparathroidsm -

HYPOPARATHYROIDISM
decreased parathormone Hypocalcemia (Or tetany) Hyperphosphatemia

[If Ca decreases, phosphate increases] Predisposing Factor: 1. Following subtotal thyroidectomy 2. Atrophy of parathyroid gland due to a. Irradiation b. Trauma

Signs & Symptoms: 1. Acute tetany a. Tingling sensation b. Paresthesia c. Dysphagia d. Laryngospasm e. Bronchospasm f. Seizure complication g. Arrhythmia Pathognomonic Sign of TETANY (+) Trousseaus or carpopedial spasm (+) Chvostecks sign 2. Chronic tetany a. Loss of tooth enamel b. Photophobia & cataract formation c. GIT changes anorexia, n/v, general body malaise d. CNS changes memory impairment, irritability Diagnostic Procedure: 1. Serum calcium decrease (N 8.5 11 mg/100ml) 2. Serum phosphate increase (N 2.5 4.5 mg/100ml) 3. X-ray of long bone decrease bone density 4. CT Scan reveals degeneration of basal ganglia 1. Nursing Management: Administration of meds: a.) Acute tetany -Ca gluconate IV, slowly b.) Chronic tetany 1. Oral Ca supplements Ex. Ca gluconate Ca carbonate Ca lactate Vit D (Cholecalceferol) Drug Cholecalceferol diet calcidiol sunlight calcitriol 7am 9am

2. Phosphate binder - Alumminum DH gel (ampho gel) S/E constipation Antacid AAC MAD Aluminum containing acids Mg containing antacids Ex. Milk or magnesia Aluminum OH gel Diarrhea Constipation Maalox magnesium & aluminum - Less s/e

2. Avoid precipitating stimulus such as bright lights & noise: photophobia leading to seizure 3. Diet increase Ca & decrease phosphorus - Dont give milk due to increase phosphorus Example: a.)anchovies increase Ca, decrease phosphorus + uric acid.

b.)Tuna & green turnips- Ca. 4. Bedside tracheostomy set due to laryngospasm 5. Encourage to breath with paper bag in order to produce mild respiratory acidosis to promote increase ionized Ca levels 7. Hormonal replacement therapy - lifetime 8. Important fallow up care

HYPERPARATHYROIDISM
- increase parathormone. Complication: Renal failure Hypercalcemia can lead to Hypophosphatemia Bone disease demineralization kidney stones

Leading to bone fracture Ca 99% bones 1% serum blood Predisposing Factor: 1. Hyperplasia parathyroid gland (PTG) 2. Over compensation of PTG due to Vit D deficiency Children Rickets Vit D Adults Osteomalacia deficiency Sippys diet Vit D diet not good for pt with ulcer 2 -4 cups of milk & butter Karrels diet Vit D diet not good for pt with ulcer 6 cups of milk & whole cream Food rich in CHON eggnog combination of egg & milk Signs & Symptoms: Bone fracture 1. Bone pain (especially at back), bone fracture 2. Kidney stone a. Renal colic b. Cool moist skin 3. GIT changes anorexia, n/v, ulcerations 4. CNS involvement irritability, memory impairment Diagnostic Procedure: 1. Serum Ca increase 2. Serum phosphorus decreases 3. X-ray long bones reveals bone demineralization Nursing Management: for Kidney Stone 1. Force fluids 2,000 3,000/day or 2-3L/day 2. Isotonic solution 3. Warm sitz bath for comfort 4. Strain all urine with gauze pad 5. Acid ash diet cranberry, plum, grapefruit, vit C, calamansi to acidify urine 6. Administration of meds a. Narcotic analgesic Morphine SO4, Demerol (Meperidine Hcl) S/E resp depression. Monitor RR) *Narcan/ Naloxone antidote Naloxone toxicity tremors 7. Siderails

8. Assist in ambulation 9. Diet low in Ca, increase phosphorus lean meat 10. Assist surgical procedure parathyroidectomy 11. Impt ff up care 12. Hormonal replacement- lifetime ADRENAL GLAND - Atop of @ kidney 2 Parts 1.) Adrenal cortex outermost layer

a) Zona fasiculata secrets glucocorticoids

Ex. Cortisol - Controls glucose metabolism (SUGAR) M testosterone F estrogen & progesterone Fx promotes development of secondary sexual characteristics

b) Zona reticularis secrets traces of glucocorticoids & androgenic hormones

c)

Zona glomerulosa - secretes mineralcortisone Ex. Aldosterone Fx: promotes Na & H2O reabsorption & excretion of potassium (SALT)

2.) Adrenal medulla - innermost layer a.)Secrets cathecolamines b.)Epinephrine / Norephinephrine potent vasoconstrictor adrenaline=Increase BP

Adrenal Medullas only disease:

PHEOCHROMOCYTOMA
presence of tumor at adrenal medulla increase nor/epinephrine with HPN and resistant to drugs drug of choice: beta blockers complication: HPN crisis = lead to stroke

- no valsalva maneuver

ADDISONS DISEASE Steroids-lifetime

Decreased adrenocortical hormones leading to: a.) Metabolic disturbances (sugar) b.) F&E imbalances- Na, H2O, K c.) Deficiency of neuromuscular function (salt & sex) Predisposing Factor: 1. Atrophy of adrenal gland 2. Fungal infections 3. Tubercular infections Signs & Symptoms: 1. Decrease sugar Hypoglycemia Decreased glucocorticoids - cortisol T tremors, tachycardia I - irritability R - restlessness E extreme fatigue D diaphoresis, depression 2. Decrease plasma cortisol Decrease tolerance to stress lead to Addisonians crisis

3. Decrease salt Hyponatermia Decreased mineralocorticoids - Aldosterone

Hypovolemia a.) Hypotension b.) Signs of dehydration extreme thirst, agitation c.) Wt loss 4. Hyperkalemia a.) Irritability b.) Diarrhea c.) Arrhythmia 5. Decrease sexual urge or libido- Decreased Androgen 6. Loss of pubic and axillary hair To Prevent STD Local practice monogamous relationship CGFNS/NCLEX condom

7. Pathognomonic sign bronze like skin pigmentation due to decrease cortisol will stimulate
pituitary gland to release melanocyte stimulating hormone. Diagnostic Procedure: 1. FBS decrease FBS (N 80 120 mg/dL) 2. Plasma cortisol decreased Serum Na decreased (N 135 145 meg/L) 3. Serum K increased (N 3.5 5.5 meg/L) Nursing Management: 1. Monitor VS, I&O to determine presence of Addisonian crisis Complication of Addisons dse : Addisonian crisis Results the acute exacerbation of Addisons dse characterized by : Hypotension, hypovolemia, hyponatremia, wt loss, arrhythmia Lead to progressive stupor & coma Nsg Mgt Addisonian Crisis (Coma) 1. Assist in mechanical ventilation 2. Adm steroids 3. Force fluids 2. Administer meds a.) Corticosteroids - (Decadron) or Dexamethazone - Hydrocortisone (cortisone)- Prednisone Nsg Mgt with Steroids 1. Adm 2/3 dose in AM & 1/3 dose in PM in order to mimic the normal diurnal rhythm. 2. Taper the dose (w/draw, gradually from drug) sudden withdrawal can lead to addisonian crisis 3. Monitor S/E (Cushings syndrome S/Sx) a.) HPN b.) Hirsutism c.) Edema d.) Moon face & buffalo hump e.) Increase susceptibility to infection sue to steroids- reverse isolation b.) Mineralocorticoids ex. Flourocortisone 3. Diet increase calorie or CHO Increase Na, Increase CHON, Decrease K 4. Force fluid 5. Administer isotonic fluid as ordered 6. Meticulous skin care due to bronze like 7. HT & discharge planning a) Avoid precipitating factors leading to Addisonian crisis 1. Sudden withdrawal crisis

2. Stress 3. Infection 4. Trauma 5. Surgery b.)Prevent complications Addisonian crisis & Hypovolemic shock 8. Hormonal replacement therapy lifetime 9. Important: follow up care

CUSHINGS SYNDROME
increase secretion of adrenocortical hormone Predisposing Factor: 1. Hyperplasia of adrenal gland 2. Tubercular infection milliary TB Signs & Symptoms: 1. Increase sugar Hyperglycemia 3 Ps 1. Polyuria 2. Polydipsia increase thirst 3. Polyphagia increase appetite Classic Sx of DM 3 Ps & glycosuria + wt loss 2. Increase susceptibility to infection due to increased corticosteroid 3. Hypernatrermia a. HPN b. Edema c. Wt gain d. Moon face Buffalo hump Obese trunk Pendulous abdomen Thin extremities 4. Hypokalemia a. Weakness & fatigue b. Constipation c. ECG (+) U wave 5. Hirsutism increase sex 6. Acne & striae 7. Increase muscularity of female Diagnostic Procedure: 1. FBS increase (N: 80-120mg/dL) 2. Plasma cortisol increase 3. Na increase (135-145 meq/L) 4. K- decrease (3.5-5.5 meq/L) Nursing Management: 1. Monitor VS, I&O 2. Administer meds a. K- sparing diuretics (Aldactone) Spironolactone - promotes excretion of NA while conserving potassium Not lasix due to S/E hypoK & Hyperglycemia! 3. Restrict Na 4. Provide Dietary intake low in CHO, low in Na & fats High in CHON & K

classic signs

5. Weigh pt daily & assess presence of edema- measure abdominal girth- notify doc. 6. Reverse isolation 7. Skin care due acne & striae 8. Prevent complication - Most feared arrhythmia & DM (Endocrine disorder lead to MI Hypothyroidism & DM) 9. Surgical bilateral Adrenolectomy 10. Hormonal replacement therapy lifetime due to adrenal gland removal- no more corticosteroid! PANCREAS behind the stomach, mixed gland both endocrine and exocrine gland Acinar cells (exocrine gland) Secrete pancreatic juices at pancreatic ducts. Aids in digestion (in stomach) Islets of Langerhans (endocrine gland ductless) cells secrets glucagon Fxn: hyperglycemia (high glucose) Cells Secrets insulin Fxn: hypoglycemia Delta Cells Secrets somatostatin Fxn: antagonizes growth hormone

3 disorders of the Pancreas 1. DM 2. Pancreatic Cancer 3. Pancreatitis

PANCREATITIS
- acute inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to - Autodigestion self-digestion Cause: unknown/idiopathic 4. Or alcoholism Pathognomonic sign- (+) Cullens sign - Ecchymosis of umbilicus (bluish color)- pasa (+) Grey turners sign ecchymosis of flank area Both sx means hemorrhage PANCREATITIS acute or chronic inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to auto digestion. Bleeding of pancreas - Cullens sign at umbilicus Predisposing Factor: 1. Chronic alcoholism

2. 3. 4. 5. 6. 7. Signs 1. 2. 3. 4. 5. 6.

Hepatobilary disease Obesity Hyperlipidemia Hyperparathyroidism Drugs Thiazide diuretics, pills Pentamidine HCL (Pentam) Diet increase saturated fats

& Symptoms: Severe Lt epigastric pain radiates from back &flank area Aggravated by eating, with DOB N/V Tachycardia Palpitation due to pain Dyspepsia indigestion Decrease bowel sounds 7. (+) Cullens sign - ecchymosis of umbilicus hemorrhage 8. (+) Grey Turners spots ecchymosis of flank area 9. Hypocalcemia

Diagnostic Procedure: 1. Serum amylase & lipase increase 2. Urine lipase increase 3. Serum Ca decrease Nursing Management: 1. administration of Medicines a.) Narcotic analgesic - Meperidine Hcl (Demerol) Dont give Morphine SO4 will cause spasm of sphincter. b.) Smooth muscle relaxant/ anti cholinergic - Ex. Papavarine Hcl Prophantheline Bromide (Profanthene) c.) Vasodilator NTG d.) Antacid Maalox e.) H2 receptor antagonist - Ranitidin (Zantac) to decrease pancreatic stimulation f.) Ca gluconate 2. Withold food & fluid aggravates pain 3. Assist in Total Parenteral Nutrition (TPN) or hyperalimentation Complications of TPN 1. Infection 2. Embolism 3. Hyperglycemia 4. Institute stress mgt tech a.) DBE b.) Biofeedback 5. Comfy position - Knee chest or fetal like position 6. If pt can tolerate food, give increase CHO, decrease fats, and increase CHON 7. Complications: Chronic hemorrhagic pancreatitis

CHRONIC HEMORRHAGIC PANCREATITIS

bangugot Predisposing Factor: - unknown Risk factor: 1. 2. 3. 4. History of hepatobiliary disorder Alcohol Drugs thiazide diuretics, oral contraceptives, aspirin, penthan Obesity

5. Hyperlipidemia 6. Hyperthyroidism 7. High intake of fatty food saturated fats

DIABETES MELLITUS
- metabolic disorder characterized by non utilization of CHO, CHON,& fat metabolism

I. Type I DM (IDDM) Juvenile onset, common in children, non-obese

- brittle disease - Insulin dependent diabetes mellitus Incidence Rate 1.) 10% of population with DM have Type I Predisposing Factor: 1. 90% hereditary total destruction of pancreatic dells 2. Virus 3. Toxicity to carbon tetrachloride 4. Drugs Steroids both cause hyperglycemia Lasix - loop diuretics Signs & Symptoms: - 3 PS + G 1.) Polyuria 2.) Poydipsia 3.) Polyphagia 4.) Glycosuria 5.) Weight loss 6.) Anorexia 7.) N/V 8.) Blurring of vision 9.) Increase susceptibility to infection 10.) Delayed/ poor wound healing Nursing Management: 1. Insulin Therapy Diet Exercise Complications Diabetic Ketoacidosis (DKA) Diabetic Ketoacidosis (DKA) due to increase fat catabolism or breakdown of fats DKA (+) fruity or acetone breath odor Kassmauls respiration rapid, shallow breathing Diabetic coma (needs oxygen) II. Type II DM (NIDDM) Adult/ maturity onset type age 40 & above, obese Incidence Rate 1. 90% of pop with DM have Type II Mid 1980s marked increase in type II because of increase proliferation of fast food chains! Predisposing Factor: 1. Obesity obese people lack insulin receptors binding site 2. Hereditary Signs & Symptoms:

1. Asymptomatic 2. 3 Ps and 1G Treatment Management 1. Oral Hypoglycemic Agents (OHA) 2. Diet 3. Exercise Complication: HONKC H hyper O osmolar N non K ketotic C coma GESTATIONAL DM occurs during pregnancy & terminates upon delivery of child Predisposing Factor: 1. Unknown/ idiopathic 2. Influence of maternal hormones Signs & Symptoms: Same as type II 1. Asymptomatic 2. 3 Ps & 1G Type of delivery CS due to large baby Sx of hypoglycemia on infant 1. High pitched shrill cry 2. Poor sucking reflex IV. DM ASSOCIATED WITH OTHER DISORDER a.) Pancreatic tumor b.) Cancer c.) Cushings syndrome 3 MAIN FOOD GROUPS Anabolism 1. CHON glucose 2. CHON amino acids 3. Fats fatty acids

I.

Catabolism glycogen nitrogen free fatty acids (FFA) Cholesterol & Ketones

Pancreas glucose ATP (Main fuel/energy of cell ) Reserve glucose glycogen Liver will undergo glucogenesis synthesis of glucagons & Glycogenolysis breakdown of glucagons & Gluconeogenesis formation of glucose form CHO sources CHON & fats

HYPERGLYCEMIA
pancreas will not release insulin. Glucose cant go to cell, stays at circulation causing hyperglycemia. increase osmotic diuresis glycosuria Lead to cellular starvation

Lead to wt loss

stimulates the appetite/ satiety center polyuria (Hypothalamus) Cellular dehydration Polyphagia Stimulates thirst center (hypothalamus) Polydipsia

Increased CHON catabolism Lead to (-) nitrogen balance Tissue wasting (cachexia)

Increase fat catabolism Free fatty acids Cholesterol Atherosclerosis HPN MI stroke ketones DKA

coma death

DIABETIC KETOACIDOSIS (DKA)

Acute complication of Type I DM due to severe hyperglycemia leading to CNS depression & Coma. Ketones- a CNS depressant

Predisposing Factor: 1. Stress between stress and infection, stress causes DKA more. 2. Hyperglycemia 3. Infection Signs 3 Ps 1. 2. 3. 4. 5. 6. & Symptoms: & 1G Polyuria Polydipsia Polyphagia Glycosuria Wt loss Anorexia, N/V (+) Acetone breath odor- fruity odor

7.

pathognomonic DKA

8. Kussmaul's resp-rapid shallow respiration

9. CNS depression 10. Coma Diagnostic Procedure: 1. FBS increase, Hct increase (compensate due to dehydration) N =BUN 10 -20 mg/100ml --increased due to severe dehydration Crea - .8 1 mg/100ml Hct 42% (should be 3x high)-nto hgb Nursing Management: 1. Can lead to coma assist mechanical ventilation 2. Administer .9NaCl isotonic solution Followed by .45NaCl hypotonic solution To counteract dehydration. 3. Monitor VS, I&O, blood sugar levels 4. Administer meds as ordered: a.) Insulin therapy IV push Regular Acting Insulin clear (2-4hrs, peak action) b.) To counteract acidosis Na HCO3 c.) Antibiotic to prevent infection Insulin Therapy A. Sources: 1. Animal source beef/ pork-rarely used. Causes severe allergic reaction. 2. Human has less antigenecity property Cause less allergic reaction. Humulin If kid is allergic to chicken dont give measles vaccine due it comes from chicken embryo. 3. Artificially compound B. Types of Insulin 1. Regular Insulin - Ex. Regular acting I 2. Intermediate acting I - Ex. NPH (non-protamine Hagedorn I) 3. Long acting I - Ex. Ultra lente Types of Insulin 1. Regular 2. Intermediate 3. Long acting color & consistency onset peak duration clear 2-4h cloudy 6-12h cloudy 12-24h -

Ex. 5am Hemoglucose test (HGT) 250 mg/dl Adm 5 units of RA I Peak 7-9am monitor hypoglycemic reaction at this time- TIRED Nursing Management: upon injection of insulin: 1.Administer insulin at room temp! To prevent lipodystrophy = atrophy/ hypertrophy of SQ tissues 2. Insulin is only refrigerated once opened! 3. Gently roll vial bet palms. Avoid shaking to prevent formation of bubbles. 4. Use gauge 25 26needle tuberculin syringe 5. Administer insulin at either 45(for skinny pt) or 90 (taba pt)depending on the client tissue deposit. 6. Dont aspirate after injection 7. Rotate injection site to prevent lipodystrophy 8. Most accessible site abdomen

9. When mixing 2 types of insulin, aspirate 1st regular/ clear before cloudy to prevent contaminating clear insulin & to promote accurate calibration. 10. Monitor signs of complications: a. Allergic reactions lipodystrophy b. Somogyis phenomenon hypoglycemia followed by periods of hyperglycemia or rebound effect of insulin. 11. 1ml or cc of tuberculin = 100 units of insulin - - 1 cc = 100 units - - .5cc = 50 units

- - .1 cc = 10 units 6 units RA Most Feared Complication of Type II DM Hyper osmolarity = severe dehydration Osmolar Non Ketotic - absence of lipolysis - no ketone formation headache, restlessness, seizure, decrease LOC

COMA Signs & Symptoms:

Nursing Management: - same as DKA except dont give NaHCO3! 1.Can lead to coma assist mechanical ventilation 2. Administer .9NaCl isotonic solution Followed by .45NaCl hypotonic solution (To counteract dehydration.) 3.Monitor VS, I&O, blood sugar levels 4.Administer meds a.) Insulin therapy IV b.) Antibiotic to prevent infection Treatment Management O ral H ypoglycemic A gents 5. Stimulates pancreas to secrete insulin Classifications of OHA 1. First generation Sulfonylureas a. Chlorpropamide (diabenase) b. Tolbutamide (orinase) c. Tolazamide (tolinase)

2.

2nd generation sulfonylureas a. Diabeta (Micronase) b. Glipizide (Glucotrol) c.

Nursing Management: or OHA 1. Administer with meals to lessen GIT irritation & prevent hypoglycemia 2. Avoid alcohol (alcohol + OHA = severe hypoglycemic reaction=CNS depression=coma) Antabuse-Disufram 3. Diagnostic Procedure: for DM 1. FBS N 80 120 mg/dl = Increased for 3 consecutive + 3 Ps & 1G 2. Oral glucose tolerance (OGTT) - Most sensitive test 3. Random blood sugar increased 4. Alpha Glucosylated Hgb elevated Nursing Management: 1. Monitor for PEAK action of OHA & insulin Notify Doc 2. Monitor VS, I&O, neurocheck, blood sugar levels. 3. Administer insulin & OHA therapy as ordered. 4. Monitor signs of hyper & hypoglycemia. Pt DM hinimatay You dont know if hypo or hyperglycemia. Give simple sugar (Brain can tolerate high sugar, but brain cant tolerate low sugar!) Cold, clammy skin hypo Orange Juice or simple sugar / Warm to touch hyper administer insulin

times

=confirms DM!!

5. Provide nutritional intake of diabetic diet:

CHO 50% CHON 30% Fats 20% -Or offer alternative food products or beverage. -Glass of orange juice. 6. Exercise after meals when blood glucose is rising. 7. Monitor complications of DM a. Atherosclerosis HPN, MI, CVA b. Microangiopathy small blood vessels Eyes diabetic retinopathy , premature cataract & blindness Kidneys recurrent pyelonephritis & Renal Failure (2 common causes of Renal Failure : DM & HPN) c. Gangrene formation d. Peripheral neuropathy 1. Diarrhea/ constipation 2. Sexual impotence e. Shock due to cellular dehydration 8. Foot care mgt a. Avoid waking barefooted b. Cut toe nails straight c. Apply lanolin lotion prevent skin breakdown d. Avoid wearing constrictive garments 9. Annual eye & kidney exam 10. Monitor urinalysis for presence of ketones Blood or serum more accurate 11. Assist in surgical wound debridement 12. Monitor signs or DKA & HONKC 13. Assist surgical procedure

BKA or above knee amputation