1. Endocrine 3
Part 2

2. Acute complications of DM
Hypoglycemia
Diabetic Ketoacidosis
Hyperglycemia Hyperosmolar Non-ketonic Syndrome

3. Hypoglycemia AKA Insulin reaction
Definition:When blood glucose levels fall below 70mg/dl
< 50mg/dl = severe

4. Hypoglycemia: Etiology
Any time
Skip meal
Under-eating
Eating late
Unplanned exercise
Excess insulin or oral hypoglycemic meds

5. Hypoglycemia: Signs & Symptoms
Mild
Diaphoresis
Pallor
Paresthesia
Palpitations
Tremors
Anxiety
Adrenal Medulla

6. Hypoglycemia: Signs & Symptoms
Moderate:
Confusion/disorientation
Behavioral Changes

7. Hypoglycemia: Signs & Symptoms
Severe
Seizures
Loss of Consciousness
Shallow respirations

8. Hypoglycemia: Diagnosis
Signs & Symptoms
SMBG
FSBG
FSBS

9. Hypoglycemia: Medical Management
Follow protocol
P blood sugar level
Admin. fast sugar

10. Hypoglycemic Protocol: Sample
For BG <60 mg/dL
If patient can take PO, give 15g of fast acting carbohydrate. (4 oz fruit juice/non diet soda, 8 oz nonfat milk, or 3-4 glucose tablets)
If patient cannot take PO, give 25mL of D50 as IV push
Check FSBG q 15 minutes and repeat above if BG<80.

11. Glucose Fast! 10-15 mg fast acting carbohydrate Glucose tabs
4-6 oz. Juice or soda
6-10 lifesaver candies
2-3 tsp honey/sugar

12. Rules to remember Do not add sugar to OJ
Recheck FSBS q 15 min until WNL
Avoid high fat  slows absorption of glucose
Instruct: carry fast sugar
If meal is >1 hr away, follow with a protein and complex carbohydrate
NPO if “unconscious” or confused

13. Protein Sources
1 Tbsp peanut butter
1 oz cheese
1 oz meat

14. Hypoglycemia treatment Unconscious
IV mm of 50% dextrose in water
Glucagon 1 mg Sub-Q or IM
Action: (hormone)  raises BS levels
Onset:10 minutes
Duration 25 minutes
S/E: N/V
Position: side lying

15. Hypoglycemia Gerontological Consideration
Cognitive deficits 
not recognize S&S
Decreased renal function 
oral hypoglycemic meds stay in body longer
More likely to _________a meal
Skip
Vision problems 
inaccurate insulin draws

16. Hypoglycemia Nursing measures
Follow protocol
Teach
Carry simple sugar at all times
S&S or hypoglycemia
How to prevent Hypoglycemia
Check FSBS if you suspect  NOW!

17. Hypoglycemia Nursing measures
Enc. to wear ID bracelet
Teach family that belligerence is sign of hypoglycemia

18. Diabetic Ketoacidosis (DKA)
Serious complication of hyperglycemia due to lack of insulin
Usually occurs with type I DM

19. DKA: Etiology #1 cause illness, infection, stress
Absence or inadequate insulin
Initial or undiagnosed diabetes

20. Diabetic Ketoacidosis (DKA)
4 main clinical features
Hyperglycemia
Dehydration
Electrolyte loss
Metabolic Acidosis

21. Pathophysiology DKA No Insulin Hyperglycemia Metabolic Acidosis
Glucose stays in blood -
Hyperglycemia
Muscle not getting energy
h fat metabolism
Osmotic diuresis
Polyuria
Polydipsia
Electrolyte loss
Increased ketone in blood
Metabolic Acidosis
i serum pH
h respiratory rate
Dehydration

22. S&S of DKA Hyperglycemia ↑blood glucose Tired Polyphagia
Decreased attention, confusion
N/V, abdominal pain
Blurred vision

23. S&S of DKA Dehydration Polydipsia Polyuria Dry/flushed skin
Orthostatic hypotension
Tachycardia
Headaches
Decreased Na+ and K+ levels

24. S&S of DKA Acidosis ↑Resp. rate  Kussmaul’s
Fruity breath, acetone breath
Serum pH
Decreased
Normal Serum pH 7.35 – 7.45
i pH = acidic / acidosis
h pH = alkaline/ alkalosis

25. DKA: diagnosis Blood sugar levels Serum pH BUN Blood Urea Nitrate
Elevated
Serum pH
Decreased (< 7.35)
BUN Blood Urea Nitrate
increased = dehydration

26. DKA: diagnosis Urine Serum Osmolality Ketones+
Specific gravity of urine i
Serum Osmolality h
thick

27. DKA: diagnosis Hemoglobin Normal Elevated Decreased
Female : g/dL
Male: g/dL
Elevated
Dehydration
COPD
Decreased
Anemia, hemorrhaging, over-hydration

28. DKA: Diagnosis Hematocrit Normal Elevated Decreased Female: 37-47%
Dehydration & COPD
Decreased
Anemia, leukemia

29. DKA: diagnosis Serum Potassium levels Normal levels Purpose of K+
mEq/L
Increased K+ levels = Hyperkalemia
Decreased K+ levels = Hypokalemia
Purpose of K+
Skeletal & cardiac muscle activity
DKA  decreased K+ levels

30. Hypokalemia S&S Fatigue Anorexia N/V Muscle weakness Leg cramps
Dysrhythmias
↑sensitivity to digitalis

31. Treatment of DKA Focus on the four main clinical features
Hyperglycemia
Dehydration
Electrolyte loss
Acidosis

32. Treatment of DKA
Hyperglycemia
Give insulin  IV

33. Treatment of DKA Dehydration Rehydrate IV, push fluids I&O
Check vital signs
Check Lung sounds
Monitor lab values

34. Treatment of DKA Electrolyte loss
Polyuria  loss of K+
Treatment of DKA dehydration  drop in K+
5 K / 1 ml serum 5 K / 2 ml serum 5.0 mEq/L 2.5 mEq/L
K K K K K
K K K K K

35. Treatment of DKA: Electrolyte loss Replace K+
Monitor lab values closely

36. Treatment of DKA Acidosis Reversed with insulin Insulin 
glucose enters muscles 
i fat metabolism 
i in Ketones 
acidosis reversed

37. Prevention of DKA
#1 cause of DKA?
Illness
Sick Day Rules

38. Sick Day Protocol/Rules
Never omit insulin
If you are unable to eat normally, DO NOT stop taking insulin
Sliding scale
Test blood sugar every 3-4 hours
Test urine for ketones every 3-4 hours
Take liquid/fluids q hour

39. Sick Day Protocol/Rules
If you can not eat your usual meal, substitute soft foods
Have “sick day” food in house
If vomiting, diarrhea or fever persists, take liquids q half hour
If miss or replace 4 meals with fluids, call MD

40. Sick Day Protocol/Rules
Go to bed and keep warm
Friends: good to have someone around who understands and knows about insulin reactions and diabetes

41. Hyperglycemia Hyperosmolar Nonketonic Syndrome - HHNK
Definition
HHNK occurs when there is insufficient insulin to prevent hyperglycemia, but there is enough insulin to prevent Ketoacidosis
Occurs in all types of diabetes

42. Hyperglycemia Hyperosmolar Nonketonic Syndrome - HHNK
Etiology
Overeating
Stress
Illness
Too little insulin

43. S&S of HHNK syndrome Headache Mental status changes
Polyuria
Polydipsia
Polyphagia
Skin, hot, dry, decreased turgor
Dehydration
Seizures
Blurred vision
Weakness
Headache
Mental status changes
Lab values: FSBS 600 – 2,000 mg/dl
Serum osmolality h
Urine neg. for ketone

44. Medical Management/treatment
Confirm with glucose meter
If greater than 300 mg/dl check urine for ketones
Fluid and electrolyte replacement
Especially K+
Insulin
Treat precipitating factors

45. Nursing Responsibility
Same as with DKA
Insulin
Hydration
Electrolyte replacement and monitoring
Treat underlying cause

46. Summary Acute complications of DM Hypoglycemia Diabetic Ketoacidosis
Hyperglycemia Hyperosmolar Non-ketonic Syndrome