Nutritional-Metabolic Patterns/Responses to Altered
Endocrine Function
The endocrine system plays a significant role in human
growth, metabolism, and environmental adaptation
Along with the nervous system, the endocrine system
provides a communication system for the body
By releasing hormones from various ductless glands, the
endocrine system carefully regulates many physiologic
functions
Nursing history
▪ The nurse asks the patient about his chief
complaint
A patient with an endocrine disorder may report:
o abnormalities of fatigue, mental status
changes, polydipsia (extreme thirstiness),
polyuria (excessive urination), weakness,
and weight changes
o The patient with an endocrine disorder
may also report problems of sexual
maturity and function
▪ The nurse then questions the patient about his
present illness
Ask the patient about his:
o symptom, including when it started,
associated symptoms, location, radiation,
intensity, duration, frequency, and
precipitating and alleviating factors
o the use of prescription and over-the-
counter drugs, herbal remedies, and
vitamin and nutritional supplements
▪ The nurse asks about medical history
Question the patient about other endocrine
disorders such as
o diabetes mellitus, height and weight
problems, sexual problems, and thyroid
disease
o about past reproductive problems and
use of oral contraceptives and hormones;
also ask whether she’s premenopausal or
postmenopausal
▪ The nurse then assesses the family history
Ask about a family history of endocrine disorders:
o such as diabetes mellitus and thyroid
disorders
o about his cultural background and
heredity
▪ The nurse obtains a social history
o Ask about work, exercise, diet, use of
recreational drugs, alcohol use, and
hobbies
o Also ask about stress, support systems,
and coping mechanisms
▪ The nurse obtains a social history
o Ask about work, exercise, diet, use of
recreational drugs, alcohol use, and
hobbies
o Also ask about stress, support systems,
and coping mechanisms
Physical assessment
▪ The nurse begins with inspection
o Observe the patient’s general
appearance and development, height,
weight, posture, body build,
proportionality of body parts, and
distribution of body fat and hair
o Note affect, speech, level of
consciousness, orientation,
appropriateness of behavior, grooming
and dress, and activity level
o Assess overall skin color and, for areas of
abnormal pigmentation, note any
bruising, lesions, petechiae, or striae
o Assess the face for erythematous areas,
note facial expression, shape, and
symmetry of the eyes; also note abnormal
lid closure, eyeball protrusion, and
periorbital edema, if present
o Inspect the tongue for color, size, lesions,
tremor, and positioning
o Inspect the neck area for symmetry
o Evaluate the overall size, shape, and
symmetry of the chest, noting
o any deformities, especially around the
nipples
o Check for truncal obesity, supraclavicular
fat pads, and buffalo hump
o Inspect the external genitalia for normal
development
o Inspect the arms and legs for tremors,
muscle development and strength,
symmetry, color, and hair distribution
 o Examine the feet, noting size, deformities,
lesions, marks from shoes and socks,
maceration, dryness, or fissures
▪ Next, the nurse uses palpation
o Palpate the thyroid gland for size,
symmetry, and shape; note any nodules
or irregularities
o Palpate the testes for size, symmetry, and
shape; note any nodules or deformities
▪ Then the nurse uses auscultation
o Auscultate the thyroid gland to identify
systolic bruits
o Auscultate the heart, noting heart rhythm
disturbances that may occur in endocrine
disorders
Rapid Endocrine Assessment
The endocrine system interacts with every cell in the body
to maintain homeostasis.
It consists primarily of several glands that secrete
hormones; however, many organs, such as the kidneys
and liver, have secondary endocrine functions.
The main glands of the endocrine system (excluding the
ovaries and testes) include the
✓ Hypothalamus
✓ Pituitary.
✓ Thyroid and parathyroid glands.
✓ Adrenals.
✓ Pancreas.
Physical assessment of the endocrine system is difficult in
that the thyroid is the only palpable gland and signs and
symptoms can be vague or attributable to other causes.
Laboratory and diagnostic tests consist of
radioimmunoassay of
✓ hormone levels, blood glucose levels, and other
laboratory tests
✓ 24-hour urine studies; and radiological scans
Some physical signs and symptoms that may result from
endocrine malfunction include:
✓ Change in appearance of hair, nails, and skin.
✓ Increased or decreased energy, insomnia, fatigue.
✓ Heat or cold intolerance, hypothermia, or fever.
✓ Tremors, tetany, muscle aches.
✓ Tachycardia, hypertension, or hypotension.
✓ Kidney stones, pathological fractures, muscle
weakness, memory loss.
✓ Polyuria, polydipsia, polyphagia (excessive eating
and drinking, excessive urination).
✓ Anorexia, weight gain or loss, constipation,
dehydration.
✓ Change in thought processes, restlessness,
agitation, confusion.
Most common endocrine disorders include
✓ diabetes mellitus (DM)
✓ hyperlipidemia
✓ osteoporosis
✓ hypo- or hyperthyroidism
✓ metabolic syndrome
The endocrine glands produce many hormones, and many
more are secreted by other organs. Major functions of the
main glands and the major hormones of each are shown
in the following table.
ADDISON’S DISEASE
is a chronic adrenocortical insufficiency most commonly
caused by autoimmune destruction of the adrenal cortex
▪ Other causes of adrenal insufficiency include
fungal infection and infectious disease such as
tuberculosis; hemorrhage; metastatic disease
(rarely); therapy with drugs, such as ketoconazole,
phenytoin, and rifampin; after sudden withdrawal
of steroid therapy; and surgical removal of both
adrenal glands
▪ Addison’s disease leads to impaired metabolism,
inability to maintain a normal glucose level, and
fluid and electrolyte imbalances
▪ Primary insufficiency results from low levels of
glucocorticoids and mineralocorticoids; secondary
insufficiency results from inadequate pituitary
secretion of corticotropin
▪ Lack of cortisol (a glucocorticoid), aldosterone (a
mineralocorticoid), and androgens diminish
gluconeogenesis, decrease liver glycogen, and
increase the sensitivity of peripheral tissues to
insulin
▪ Because cortisol is required for a normal stress
response, patients with cortisol insufficiency can’t
withstand surgical stress, trauma, or infection
Signs and symptoms ▪ Ensure strict adherence to the medication
schedule to prevent crisis
▪ history of fatigue, muscle weakness, and weight
▪ Decrease environmental stressors as much as
loss
possible
▪ skin and mucous membranes may appear bronze
▪ Teach the patient and his family how to prevent
(due to increased levels of melanocyte-stimulating
complications of Addison’s disease by never
hormone)
omitting a dose of medication, notifying the
▪ GI effects: anorexia, nausea, vomiting, and
practitioner if the patient can’t take the medication,
diarrhea
avoiding undue stress, and wearing a medical
▪ Other effects: dehydration, hyperkalemia,
identification bracelet
hypoglycemia, hyponatremia, hypotension, and
▪ Instruct the patient and his family to report any
loss of axillary, extremity, and pubic hair
symptoms of adrenal crisis to a practitioner
Diagnosis
CUSHING’S SYNDROME
▪ low levels of plasma and urine cortisol and
is hyperfunction of the adrenal cortex caused by an
elevated levels of plasma corticotropin,
overabundance of cortisol
hyperkalemia, hyponatremia, leukocytosis, and
metabolic acidosis It’s classified as corticotropin-dependent or corticotropin-
▪ In a corticotropin stimulation test, plasma independent
corticotropin levels may not increase
o With corticotropin-dependent Cushing’s
Treatment syndrome, cortical hyperfunction results from
excessive corticotropin secretion by the pituitary
▪ replacing glucocorticoids and mineralocorticoids;
gland; in 80% of cases, excessive corticotropin
cortisone is given in two daily doses (usually on
secretion is related to a pituitary adenoma
arising and at 6 p.m.) to mimic the body’s diurnal
o With corticotropin-independent Cushing’s
variations; doses are increased during periods of
syndrome, cortical hyperfunction is independent
stress
of corticotropin regulation; high levels of cortisol
▪ prevention of adrenal crisis, which may develop
are caused by a neoplasm in the adrenal cortex,
after trauma, infection, or GI upset; prevention
or islet cell tumor
requires consistent replacement therapy (without
o Cushing’s syndrome may be caused by abnormal
abrupt withdrawal); treatment of crisis requires
cortisol production or excessive corticotropin
immediate replacement of sodium, water, and
stimulation (spontaneous disorder) or long-term
cortisone
glucocorticoid (such as prednisone)
▪ Adrenal hemorrhage after septicemia is a rare
administration (iatrogenic disorder)
complication of Addison’s disease; it’s treated with
o For patients with this disorder, excessive cortisol
aggressive antibiotic therapy, an I.V. vasopressor,
leads to excessive glucose production and
and massive doses of a steroid
interferes with the cells’ ability to use insulin;
Nursing interventions sodium retention, potassium excretion, and
protein breakdown occur; body fat is redistributed
▪ Monitor the patient for signs and symptoms of from the arms and legs to the face, shoulders,
adrenal crisis, such as fever, changes in GI trunk, and abdomen; and the immune system
function (which may alter drug absorption), becomes less effective at preventing infection
decreased sodium and cortisol levels with
increased potassium levels (which may signal an
impending crisis), dehydration, headache,
hypotension, nausea, severe fatigue, tachycardia,
and confusion
Signs and symptoms
▪ Muscle weakness and atrophy may be
accompanied by fat deposits on the trunk,
abdomen, over the upper back (“buffalo hump”),
and face (“moon face”)
▪ Skin changes: acne, bruising, facial flushing,
hyperpigmentation, and striae
▪ Gynecomastia in men; clitoral enlargement and
menstrual irregularities in women
▪ Other effects: Arrhythmias, edema, emotional
lability, GI disturbances, headaches, hirsutism
(fine, downy hair on face and upper body),
infection, vertebral fractures, & wt. changes
Diagnosis and treatment
▪ Dexamethasone suppression test and urine-free
cortisol test
▪ Laboratory tests: coagulopathies,
hyperglycemia, hypokalemia, hypernatremia,
increased aldosterone and cortisol levels, and
suppressed plasma corticotropin levels; computed
tomography or magnetic resonance imaging may
show a tumor
The goal of treatment is normal cortisol activity
Surgery:
▪ Confirmed pituitary tumor
- transsphenoidal resection; suspected pituitary
tumor - cobalt irradiation of the pituitary gland
▪ Confirmed adrenal cortex tumor
- bilateral adrenalectomy; after surgery: lifelong
corticosteroid and mineralocorticoid
replacement
▪ Drug therapy is (used if something else is
causing corticotropin release): aminoglutethimide,
mitotane, and trilostane interfere with adrenal
hormone synthesis or corticotropin production;
bromocriptine and cyproheptadine interfere with
corticotropin secretion; and glucocorticoids (such
as cortisone, dexamethasone, and prednisone)
treat congenital adrenal hyperplasia
Nursing interventions
▪ Encourage the patient to express concerns about
altered body image
▪ Protect the patient from injury related to loss of
bone matrix and abnormal fat distribution by
maintaining a safe environment, teaching him how
to use a walker or cane, encouraging the use of
well-fitting shoes or slippers, and attending to
complaints of lower back pain or joint pain
▪ Protect the patient from injury related to easy
bruising and protein wasting by avoiding
unnecessary venipunctures, using paper tape for
dressing changes, avoiding over inflation of the
blood pressure cuff, keeping the skin clean and dry,
and using a convoluted foam mattress, a water
mattress, or an air bed for a patient with skin
breakdown
▪ Provide care related to limited mobility and muscle
weakness resulting from protein catabolism by
planning rest periods, encouraging range-of-motion
exercises or daily muscle-strengthening exercises,
and referring the patient for physical therapy, if
needed
▪ Protect the patient from infection related to
decreased immune function by using strict aseptic
technique (when appropriate) and discouraging ill
family members from visiting the patient
▪ Provide postoperative care after adrenalectomy,
including monitoring vital signs frequently, ensuring
adequate pain relief and fluid intake and output,
and monitoring for complications of hypoglycemia
and signs of adrenal crisis
▪ Administer replacement medication as prescribed,
and be familiar with its adverse effects
▪ Suggest that the patient wear a medical
identification bracelet
▪ Teach the patient and his family about the disease
and its treatment
DIABETES INSIPIDUS
is a deficiency of antidiuretic hormone (ADH), resulting in
water imbalance; vasopressin is a natural ADH
Central diabetes insipidus results from the destruction of
vasopressin producing cells; nephrogenic diabetes
insipidus results when the renal tubules don’t respond to
vasopressin
Syndrome of inappropriate antidiuretic hormone (SIADH)
causes the release of excessive ADH, resulting in water
retention (see Comparing diabetes insipidus and SIADH
Nursing interventions
▪ Support the patient during the water deprivation
test
▪ For diabetes insipidus: Treat altered fluid volume
related to excessive urine output by maintaining
fluid and electrolyte balance, administering
replacement therapy as prescribed, and
monitoring the patient for signs of therapy-related
water intoxication, notifying the practitioner of
significant changes in urine output and specific
gravity, and observing patient for vital sign
changes related to dehydration, such as increased
heart rate and decreased blood pressure
▪ For SIADH: Treat altered fluid volume status
related to water retention by weighing the patient
at the same time daily, reporting weight gains or
losses to the practitioner, so treatment with
vasopressin or desmopressin can begin, and
monitoring patient for signs of water retention,
such as dyspnea, edema, hypertension, and
tachycardia
▪ Provide oral and skin care, and reposition the
patient frequently to prevent skin breakdown
▪ Conserve energy for a patient who is up often
during the night to void or drink; encourage short
naps to prevent sleep deprivation
▪ Protect the patient from injury related to fatigue,
weakness, dehydration, or confusion by providing
a safe environment, encouraging a weak patient
to request assistance in walking to and from the
bathroom, teaching a patient to sit up gradually to
prevent dizziness resulting from orthostatic
hypotension, and taking seizure precautions for a
patient with a low serum sodium level
▪ Teach the patient and family to recognize the
signs of diabetes insipidus and SIADH
▪ Teach the patient how to administer intranasal
medications
This chart summarizes the major characteristics of
central and nephrogenic diabetes insipidus and
syndrome of inappropriate antidiuretic hormone
(SIADH).
 DIABETES MELLITUS Risk Factors/Causes
is a chronic systemic disease that alters carbohydrate, fat, 1. Type 1 diabetes (5-10%)
and protein metabolism.
a. Usually <30 y/o
it’s the most common endocrine disorder and the third b. Genetic
leading cause of death in the United States. c. Immunologic (autoimmune)
d. Environmental Factor
3rd leading cause of death
2. Type 2 (90-95%)
General classifications:
a. Usually over 30 y/o
▪ Prediabetes - can occur when the fasting blood
b. Obesity (80%); Non-obese (20%)
glucose is > 100 mg/dl and < 126 mg/dl or
c. Heredity
postprandial (kakatapos lang kumain) blood
d. Gestational diabetes (hyperglycemia)
glucose > 140 mg/dl and < 200 mg/dl
▪ Type 1 diabetes mellitus - is an absolute Clinical Manifestations
deficiency of insulin secretion and may be
1. “Three Ps”: Polyuria; Polydipsia; Polyphagia
hereditary; it’s associated with histocompatibility
2. Weight loss
antigens, some viruses, abnormal antibodies that
3. Other symptoms: fatigue and weakness, sudden
attack the islet of Langerhans cells, and toxic
vision changes, tingling or numbness in hands or
chemicals; it causes symptoms when 90% of the
feet, dry skin, skin lesions or wounds that are slow
pancreatic beta cells have been destroyed
to heal, and recurrent infections (vaginal).
▪ Type 2 diabetes mellitus - may be hereditary, is
associated with obesity, and results from different DKA: sudden weight loss, nausea, vomiting, abdominal
causes than type 1 diabetes; it’s caused by pains, hyperventilation, and a fruity breath odor,
defects in insulin secretion and decreased insulin
effectiveness; it accounts for 90% of diabetic Assessment and Diagnostic Findings
patients 1. Fasting Plasma glucose (FPG): fasting for at least 8
▪ Gestational diabetes mellitus causes glucose hours
intolerance during pregnancy; it usually o Normal: less than 100 mg/dL (< 5.6 mmol/L)
disappears after delivery but may develop into o Prediabetes: 100 to 125 mg/dL (5.6 to 6.9
type 1 or type 2 diabetes mmol/L)
Other: disorder & use of a drug or a chemical o Diabetes: 126 mg/dL or higher (7 mmol/L or
higher) on two separate tests
Notes: Other types of diabetes mellitus can be linked to 2. Random Plasma glucose: a blood sample for a
either a disorder (such as an endocrinopathy, a genetic random plasma glucose test can be taken at any time.
syndrome, an insulin receptor disorder, or a pancreatic o Normal: less than 200 mg/dL (<11.1 mmol/L)
disease) or to the use of a drug or a chemical (such as a o Diabetes: 200 mg/dL or higher (11.1 mmol/L
corticosteroid, epinephrine, furosemide, glucagon, lithium, or higher)
or phenytoin) 3. 2-hour Postload Glucose
o Normal: less than 140 mg/dL (< 7.8 mmol/L)
Impaired glucose tolerance when glucose levels are
o Prediabetes: 140 to 199 mg/dL (7.8 to 11.0
outside the normal range following a glucose tolerance test
mmol/L)
but the patient doesn’t meet the criteria for diabetes
o Diabetes: 200 mg/dL or higher (11.1 mmol/L
mellitus
or higher)
Signs and symptoms
▪ Polydipsia (excessive thirst)
▪ Polyphagia (eats excessive amt of food)
▪ Polyuria (excessive urine)
▪ Weight loss
▪ Other: fatigue and somnolence
Criteria for the Diagnosis of Diabetes Mellitus
1. Random/Casual Plasma Glucose: Equal to or
greater than 200 mg/dL (11.1 mmol/L or higher)
OR
2. Fasting Plasma Glucose: Equal to or greater than
126 mg/dL (7.0 mmol/L or higher)
OR
3. Two-hour Postload Glucose: Equal to or greater
than 200 mg/dL (11.1 mmol/L or higher) during an
oral glucose tolerance test: using a glucose load
containing 75 g anhydrous glucose dissolved in
water.
Diagnosis
▪ plasma glucose level greater than 200 mg/dl, an
8-hour fasting plasma glucose level greater than
126 mg/dl, or a 2-hour post load glucose level
greater than 200 mg/dl during an oral glucose
tolerance test; testing must be confirmed on a
subsequent day
▪ Hemoglobin A1C levels reflect the plasma
glucose level during the past 2 to 3 months
Notes:
For people without diabetes, the normal range for the
hemoglobin A1c level is between 4% and 5.6%.
Hemoglobin A1c levels between 5.7% and 6.4% mean you
have prediabetes and a higher chance of getting diabetes.
Levels of 6.5% or higher mean you have diabetes.
Diabetic ketoacidosis (DKA) and hyperosmolar
hyperglycemic nonketotic syndrome (HHNS), both
acute complications associated with diabetes, share some
similarities, including changes in level of consciousness
and extreme volume depletion, but they’re two distinct
conditions. The following chart helps determine which
condition your patient is experiencing.
Treatment
▪ First/Primary goal of treatment: maintain a
normal blood glucose level through oral
antidiabetic or insulin therapy, diet control, and
physical activity
▪ Second goal of treatment: prevent or delay the
complications
Notes:
Hypoglycemia (insulin shock) is a condition in which the
blood glucose level falls below the level required to sustain
homeostasis (usually under 60 mg/dl); it may result from
too little food, too much insulin or oral antihypoglycemics,
or too much exercise and can cause perma_x0002_nent
neurologic damage or rebound hyperglycemia
Onset occurs in minutes to hours, but most often before
meals, especially if meals are delayed or snacks omitted
Hypoglycemia is treated with:
✓ candy or orange juice if the patient’s awake,
followed by a snack of protein and starch within 20
to 60 minutes
✓ I.V. bolus of 50% dextrose solution, if the patient
is unconscious, 1 mg glucagon may be given I.V.,
I.M., or subcutaneously and, when awake, give a
simple sugar followed by a snack
Medical Management (reduce vascular/idiopathic)
1. Nutritional Therapy
For obese/type 2 DM:
o 500 to 1000 calories are subtracted from the
daily total intake:1- to 2-pound weight loss per
week
For type 1 DM:
o diet with enough/high calories
o to regain weight loss
Caloric Distribution
1. Carbohydrates: 50% to 60% (whole grains); Fats: 20%
to 30%; Protein: 10% to 20% (plant sources)
2. Fiber: Increase fiber in the diet (25 g daily)
Soluble fiber - legumes, oats, and some fruits—
plays more of a role in lowering blood glucose and
Insoluble fiber - whole-grain breads and cereals
and in some vegetables.
Other Dietary Concerns
1. Alcohol Consumption
- moderate amount only
- May lead to excessive weight gain (kse
mataas caloric content)
- Large fats lead to DKA
- Hypoglycemia
- Low calorie/less sweet drinks + food intake
2. Sweeteners – Moderate amount; sorbitol/xylitol
3. Misleading Food Labels
2. Exercise (lowers blood glucose level, improve blood
circulation and muscle tone, reduce cardiovascular factors
and weight)
Note:
✓ Exercise at the same time and each day
✓ Encourage walking as regular daily exercise
Exercise Precautions
1. Begin exercising until the urine test results are
negative for ketones and the blood glucose level
is closer to normal.
2. Patients Taking insulin:
✓ eat a 15-g carbohydrate snack (a fruit exchange)
or a snack of complex carbohydrates with a
protein before engaging in moderate exercise.
✓ eat a snack at the end of the exercise
(strenuous/prolonged) and at bedtime and monitor
the blood glucose level more frequently.
✓ should test their blood glucose levels before,
during, and after the exercise period.
3. Patients with type 2 diabetes who are not taking insulin
or an oral agent may not need extra food before exercise.
General Precautions for exercise:
▪ Use proper footwear and, if appropriate, other
protective equipment.
▪ Avoid exercise in extreme heat or cold.
▪ Inspect feet daily after exercise.
▪ Avoid exercise during periods of poor metabolic
control.
3. Monitoring Glucose Levels and Ketones
(cornerstone)
A. Self-Monitoring of Blood Glucose
Frequency of Self-Monitoring of Blood Glucose:
1. Patients with insulin: two to four times daily
2. Those not receiving insulin: at least two or
three times per week, including a 2-hour
postprandial test.
3. For all patients: hypoglycemia or
hyperglycemia is suspected
B. Testing for Glycated Hemoglobin (HgbA1C)
- Blood test reflects average blood level
- Period of 2-3 months
- Normal values: 4-6% (consistent near normal
blood glucose concentration); less than 7%
C. Testing for Ketones
- Byproducts of fat breakdown
- Accumulated at blood/urine
- Deficiency of insulin (most common in type 1
diabetes)
- Ketonuria (presence of ketones in urine) leads
to Risk for DKA (type 1)
Responding to Self-Monitoring of Blood Glucose Methods of Insulin Delivery
Results:
1. Insulin Pens.
1. Patients are asked to keep a record or logbook of
2. Jet Injectors
blood glucose levels
3. Insulin Pumps
2. When to test:
B. Oral Antidiabetic Agents (for type 2 DM, nutrition
- at the peak action time of the medication to
+ exercise)
evaluate the need for dosage adjustments
▪ Sulfonylureas (stimulates beta cells in pancreas
- before meals to evaluate basal insulin and
to produce insulin)
determine bolus insulin doses
▪ Non-Sulfonylurea Insulin Secretagogues
- 2 hours after meals to evaluate bolus doses of (stimulates beta cells in pancreas to produce
regular or rapid-acting insulin insulin BUT ONLY TAKEN AFTER MEALS)
▪ Biguanides (inhibits production of glucose in liver;
- with type 2: daily before and 2 hours after the
decrease cholesterol)
largest meal of the day until stabilized
▪ Alpha-Glucosidase Inhibitors (helps delay
- patients who take insulin at bedtime or who absorption of complex carbohydrates; TAKEN
use an insulin infusion pump: test at 3 AM once WITH FIRST BITE OF FOOD)
a week ▪ Thiazolidinediones or glitazones (stimulates
insulin receptor sites to lower blood glucose; helps
- if the patient is unwilling or cannot afford to improve action of insulin)
test frequently: once or twice a day (before meal)
Preparations:
4. Pharmacologic Therapy
(Time Course; Agent; Onset; Peak; Duration)
A. Insulin Therapy
PAGKAKASUNOD SUNOD NYAN ETONG TIME
- type 1 DM: needed insulin for life COURSE KINEME SA SS GAWAN MO TABLE
- type 2 DM: maybe necessary to control glucose
level
Note: Insulin may be increased (depending on the
doctors order)
Complications of Insulin Therapy:
1. Local Allergic Reactions
2. Systemic Allergic Reactions (rare)
3. Insulin Lipodystrophy (lipodystrophy - loss of
subcutaneous fat)
4. Resistance to Injected Insulin
5. Morning Hyperglycemia
Notes:
Notes:
Rapid acting (EAT NO MORE THAN 5-15 MINS AFTER
Lypoatrophy (small subcutaneous fats) INJECTION)
Lypohypertrophy (fibro fatty mass because of r Short acting (regular insulin – clear solution FOR ONLY
epeated injection of site) IV USE)
Intermediate acting (NPH insulin – white, cloudy in color;
TAKEN 30 MINS BEFORE MEALS)
Nursing interventions
Very long acting (peakless because it’s continuous;
1. Protect the patient from infection and injury related
absorbs very slow, CAN BE GIVEN OD AT THE SAME
to circulatory compromise and possible nerve
TIME OF THE DAY OR HS)
impairment
Oral Antidiabetic Agents ▪ Report wounds to the practitioner for
treatment
Sulfonylureas
▪ Apply lanolin to the feet and ankles
First-Generation Sulfonylureas ▪ Carefully dry the feet, especially between
the toes
✓ Acetohexamide (Dymelor) ▪ Encourage the use of cotton socks to
✓ Chlorpropamide (Diabinese) reduce moisture, and wear well-fitting
✓ Tolazamide (Tolinase) shoes
✓ Tolbutamide (Orinase) ▪ Have toenails clipped by a podiatrist
Second Generation Sulfonylureas (more potent) ▪ Teach the patient and family about good
skin care
✓ Glipizide (Glucotrol) ▪ Tell the patient to avoid heating pads and
✓ Glyburide (Micronase, Glynase, Dia-beta) to exercise caution when near open fires
✓ Glimepiride (Amaryl) because burns are more difficult to treat in
Side Effect: hypoglycemia; mild GI discomforts; weight diabetic patients
gain; allergic reactions ▪ Treat fluid loss caused by hyperglycemia
▪ Rapidly infuse I.V. isotonic (normal) or
Non-Sulfonylurea Insulin Secretagogues hypotonic (half-normal) saline solution
✓ Repaglinide (Prandin) ▪ When blood glucose level falls below 250
✓ Nateglinide (Starlix) mg/dl, administer I.V.
▪ dextrose 5% in water to prevent
SE: hypoglycemia hypoglycemia and cerebral edema
Biguanides ▪ Check urine output and ketone levels
hourly
✓ Metformin (Glucophage, Glucophage XL, ▪ Monitor potassium level, and replace
Fortamet) potassium as needed
✓ Metformin (Glucovance) 2. Help the patient maintain good nutritional habits
▪ Obtain a diet history, and note the impact
SE: hypoglycemia; lactic acidosis; GI disturbances
of lifestyle and culture on food intake
Alpha-Glucosidase Inhibitors ▪ Encourage the patient to follow the
American Diabetes Association’s
✓ Acarbose (Precose)
calculated diet plan; encourage the obese
✓ Miglitol (Glyset)
patient to lose weight
SE: hypoglycemia; GI discomforts (distention, ▪ Explain the importance of exercise and a
diarrhea, flatulence) balanced diet
3. Teach the patient and his family about the
Thiazolidinediones (or glitazones) disease, complications, and treatment
• Pioglitazone (Actos) ▪ Discuss blood glucose self-testing, skin
• Rosiglitazone (Avandia) care, and treatment of minor injuries;
discuss which injuries should be reported
SE: URTI; GI (diarrhea); headache; hypoglycemia to a practitioner
 ▪ Make sure the patient and his family know HYPERTHYROIDISM
the signs of hyperglycemia and
Excessive production of thyroid hormone resulting in a
hypoglycemia
hypermetabolic state
▪ Make sure the patient and family know
how to adjust insulin doses for changes in Severe hyperthyroidism can precipitate a thyroid storm or
diet, exercise, and stress level crisis, which is a life-threatening emergency; the crisis can
▪ Have the patient or a family member be triggered by minor trauma or stress
demonstrate the technique for drawing up
and administering insulin Hyperthyroidism can result from discontinuation or
▪ Teach the patient how to adjust doses if excessive use of antithyroid medication, tumors that
an insulin-infusion pump is used stimulate thyroid secretion, or deterioration of preexisting
▪ Educate the patient and his family about hyperthyroid state due to DKA, infection, toxemia, trauma,
care during illness; tell the patient to or excessive iodine intake
monitor blood glucose levels more Types:
frequently, to increase fluid intake, and
not to stop taking his antidiabetic without ▪ Graves’ disease
consulting with the practitioner ▪ Toxic nodular goiter
4. Provide care for a diabetic patient with peripheral
neuropathy
▪ Discuss causes of aching or burning
sensation in legs
▪ Provide foot cradles to prevent contact
with bed linens for a patient in severe pain
▪ Encourage exercise as tolerated, which
may help to relieve pain
5. Provide care for a diabetic patient with altered
bowel and bladder elimination related to
neuropathy by providing psychological support,
administering prescribed drugs such as
metoclopramide hydrochloride, and discussing
the signs of bladder infection with the patient and
family Diagnosis
6. Provide care for a diabetic patient with retinopathy
by encouraging independence, providing a safe ▪ Increased levels of thyroid hormones
environment, and eliciting the support of (triiodothyronine [T3] and thyroxine [T4])
community agencies ▪ Decreased thyroid-stimulating hormone (TSH)
7. Provide care for a patient with diabetes who has a level
sexual dysfunction related to neuropathy by ▪ Increased blood glucose level resulting from
impaired insulin secretion
encouraging expression of feelings; exploring
▪ Electrocardiography shows atrial fibrillation, P-
options such as a penile prosthesis; and
and T-wave alterations, and tachycardia
recommending professional counseling as
▪ thyroid scan shows increased uptake of
needed
radioactive iodine
Treatment room cool, establishing a calm environment, using
relaxation techniques, administering drugs as
▪ To reduce thyroid hormone levels (The principal
prescribed, identifying and treating precipitating
goal of treatment)
factors, and teaching the patient and family how to
o Antithyroid medications are generally used
prevent thyroid storm
for pretreating patients who are elderly or who
▪ If the patient has exophthalmos, administer
have cardiac disease before starting
eyedrops or ointment, and encourage the use of
radioactive iodine; methimazole and
sunglasses for comfort and to protect his eyes
propylthiouracil are slow-acting drugs that
▪ If the patient has diaphoresis
block thyroid synthesis and typically produce
o keep his skin dry with powders that contain
improvement after 2 to 4 weeks of therapy; A
cornstarch, and frequently change his bed
beta-adrenergic blocker such as propranolol
linens
may be used as an adjunct to control activity
▪ If the patient underwent a thyroidectomy
of the sympathetic nervous system
o keep him in Fowler’s position to promote
o Surgery (subtotal thyroidectomy) is reserved
venous return from the head
for patients with a very large gland, or who
o assess for signs of respiratory distress and
can’t undergo other treatments, or who have
vocal changes
thyroid cancer; before surgery, the patient
o keep a tracheotomy tray at the bedside;
receives antithyroid medication to reduce
monitor him for signs of hemorrhage;
hormone levels and saturated solution of
assess for hypocalcemia (such as tingling
potassium iodide to decrease surgical
and numbness of the extremities, muscle
complications
twitching, laryngeal spasm, and positive
o Radioactive iodine therapy also is the
Chvostek’s and Trousseau’s signs), which
standard for treating hyper thyroidism; dosing
may occur if parathyroid glands are
is based on the patient’s symptoms; it’s
damaged
contraindicated during pregnancy or
o assess for signs of thyroid storm (such as
breastfeeding, and many patients who receive
tachycardia, hyperkinesis, fever, vomiting,
radioactive iodine become euthyroid or
and hypertension)
hypothyroid, requiring levothyroxine treatment
o and keep calcium gluconate available for
▪ Prevent thyroid storm (The second goal of
emergency I.V. administration
treatment)
o Antipyretic (only as prescribed and to seek HYPOTHYROIDISM
care for infection)
▪ Hypothyroidism is the diminished production of
o Fluids replacement (Fluids are replaced as
thyroid hormone, leading to thyroid insufficiency
needed to prevent the condition from
▪ Primary hypothyroidism is caused by thyroid
worsening)
gland dysfunction
Nursing interventions ▪ Secondary hypothyroidism, from insufficient
secretion of TSH by the pituitary gland
▪ Maintain normal fluid and electrolyte balance to
▪ Hypothyroidism occurs as myxedema in adults, as
prevent arrhythmias
juvenile hypothyroidism in young children, or as
▪ Tell the patient to avoid caffeine, which can stimulate
congenital hypothyroidism
the sympathetic nervous system
▪ Thyroid insufficiency causes decreased
▪ Provide a high-calorie, high-protein diet through
consciousness, hypometabolism, hypothermia,
several small, well-balanced meals
and hypoventilation
▪ Ensure adequate hydration
▪ Unrecognized and untreated congenital
▪ Conserve the patient’s energy to help decrease
hypothyroidism — cretinism — can result in
metabolism needs
mental and physical retardation
▪ Prevent thyroid crisis by using a cooling mat to
achieve normal temperature, keeping the patient’s
 ▪ Hypothyroidism may be caused by worsening of a ▪ Monitor fluid intake and output, and weigh the
preexisting hypothyroid condition; insufficient patient daily to check for fluid retention
thyroid hormone replacement therapy for ▪ If the patient has hypothermia, increase body
hyperthyroidism; pituitary gland dysfunction due to temperature gradually by using warm blankets or
infection, surgery, trauma, or tumor; autoimmune increasing the room temperature
disease; iodine deficiency; and drugs (such as ▪ Encourage coughing and deep breathing, and
lithium and amiodarone) administer oxygen as prescribed
▪ Ask the patient and his family to demonstrate their
Signs and symptoms
understanding of the medication schedule
▪ VS: bradycardia, decreased respiratory rate with ▪ Give the patient and his family opportunities to ask
shallow inspirations, hypotension, and about the disease and its treatment
hypothermia ▪ Provide supportive care for a patient in myxedema
▪ Hoarseness, impaired hearing, myxedema coma; maintain a patent airway, monitor vital signs
(nonpitting edema), and a puffy face, hands, and closely, and administer oxygen and I.V. fluid
tongue may result from swelling replacement until the patient begins to recover
▪ Crackles may stem from pleural effusion from the coma
▪ Other: intolerance to cold; dry, coarse skin;
lethargy, stupor, coma; menstrual irregularities;
fatigue; alopecia; and brittle nails
Diagnosis
▪ serum TSH, T3 , and T4 , and free T4 levels; T3
resin uptake test; and radioisotope thyroid uptake
test
▪ blood glucose level, plasma osmolality, a
decreased TSH level (with a pituitary or
hypothalamic defect) or an increased TSH level
(with a thyroid defect), and hyponatremia
Treatment
▪ primary treatment: lifelong replacement of the
deficient hormone; synthetic levothyroxine sodium
is the preferred thyroid hormone replacement and
typically relieves symptoms in 2 to 3 days
▪ myxedema coma: immediate I.V. administration of
a corticosteroid, glucose, and levothyroxine
sodium can reverse this life-threatening condition
Nursing interventions
▪ Administer replacement therapy as prescribed
▪ Avoid sedating the patient, which may further
decrease respirations
▪ Recognize that slower metabolism may slow drug
absorption and excretion
▪ Provide frequent skin care to prevent breakdown
and decrease the risk of infection
▪ Administer fluids as prescribed; correct
imbalances without causing fluid overload