COMPETENCY APPRAISAL II
IV FLOW RATES COMPLICATIONS:
FORMULA = total volume (ml) X drop factor
(gtts/ml) time (mins)
Drop factors according to: unit = gtts/ml
 macroset : 10, 15, 20
 microset: 60 (universal)
Examples of IV Fluids:
0.45 saline solution = hypotonic solution
0.9 sodium chloride = isotonic solution
Ex. given:
1 liter = 1000 ml 8 hours = 480 minutes DF:
15 gtts/ml
Solution: 1000 ml X 15 gtts/ml =
480 mins
= 2.08 X 15 = 31.25 or 31 gtts.min
TOTAL PARENTERAL NUTRITION
 Patient is not allowed to eat orally;
alternative will be the TPN.
 TPN contains carbohydrates in the form of
sugar, particularly dextrose. Contains
water, contains protein and fats, which is
the macronutrients needed by a person.
Also contains essential vitamins such as
minerals or trace elements
 TPN is mostly given in central than
peripheral.
ROUTE:
Parenteral: given via intravenous route.
It can be given central or peripheral
line.
Central line used for neck veins
Peripheral used veins in hands or
line extremities
TPN is given in central line
 TPN is rich in dextrose, a carbohydrate
source for patient so expect
hyperglycemia.
 To prevent it, TPN is diluted in a lot of
blood via central line for it is abundant in
blood.
 It is more in correcting nutritional loss.
Peripheral line- is prone in phlebitis or
inflammation of smaller veins.
 If seen, it is to prevent nutritional loss.
1. INFECTION
 There is incision, the entry point
 TPN is rich in glucose and bacteria will
love and thrive in glucose.
Nursing Responsibilities:
 Check site if there is presence of
inflammation.
 Check if patient has elevated body
temperature
2. HYPERGLYCEMIA
 TPN is gradually given or introduced in the
body. Example: for today patient is given 1
liter of TPN then if patient tolerated 1 liter
of TPN, we can give 2 liters, and if
tolerated we can give 4 liters. For the
reason of it is rich in glucose, pancreas
need to produce more insulin in the body
to avoid hyperglycemia.
 If you abruptly infuse TPN, pancreas will
be overwhelmed. It cannot produce
enough insulin, causing patient to have
hyperglycemia.
3. HYPOGLYCEMIA
 If given gradually, the body will adapt to
the hyperglycemic state or high glucose
state, causing pancreas to constantly
producing insulin.
 In the case if the bag is empty, pancreas
will not be able to adjust abruptly
maintaining high levels of insulin causing
now the patient to have hypoglycemia.
 When the patient with TPN will have
hypoglycemia, nurse will give IV Solution
that is rich in glucose which is Dextrose.
 The higher percentage higher glucose
content.
4. AIR EMBOLISM
• Happens when we remove the catheter,
there is a chance air can enter in the vein.
 COMPETENCY APPRAISAL II
PNEUMOTHORAX Vesicular Vesicles or Alveoli in Base
of the lungs.
 Too much air is accumulated in the lungs. URINARY CATHETER
 too much air-filled lungs, the flow of air will
not be heard in the airways of the patient.  The patient should not be in pain when
Often in case of pneumothorax, the lungs being inserted a catheter
will collapse and there will be atelectasis.  If the insertion is painful, it is in the wrong
 If lungs are collapsed, there will be absent place.
of sounds in the area.  Painful = the catheter is in the urethra
 Decrease in fremitus during palpation  Deflate the balloon by
aspirating the fluid
5 Percussion Sounds
 advance and reinflate.
Resonance  Mostly air
 One of the associated problems in
 Normal sound
inserting catheter is Urethral Injury.
 Landmark for urinary meatus in female
Dullness  Fluids
should be the CLITORIS, urinary meatus
 Usually in Liver, because
it is a vascular organ rich is below the clitoris.
in blood. POSITION
Female  Supine with knees flexed
Hyper  Excessive air in the
resonance  Feet is 2 ft apart
lungs.
 Pneumothorax  Hips is slightly externally rotated

Tympanitic  Gas filled Male  Supine and thighs should be

Ex. Stomach or abdomen or slightly abducted (outward)
intestine. ADDUCT - inward

Flatness  Bones SIZES

In Auscultation  The greater the number, the wider the
RALES  Fluids lumen.
/CRACKLES Ex: Pneumonia  unit of catheter is measured in French (fr)
RONCHI  obstruction in airway Adult French 14-16, in some cases 18.

FREMITUS - are VIBRATIONS Children French 8-10

LUBRICATION of catheter
 Tactile – when palpated
Female 1-2 inches
 Increase in fremitus indicates
Male 6-7 inches
consolidation or mass in lungs
(pulmonary mass)
GUIDE IN INSERTION:
Vocal – when auscultated 1. If the urine flows, that will indicate that you
are in the bladder. You need to advance
AUSCULTATION of the LUNGS
further for 2 INCHES to make sure that the tip
 Ask patient to sit up straight is in the bladder.
 Place the stethoscope directly to the client’s 2. If in the right site: Inflate the balloon with
skin sterile water,
 Ask the client to breathe slowly  Adult: 5 ml
 Diaphragm - for high pitched sounds, lung  Pedia: 3 ml
sounds. COMPLICATION: in Indwelling Catheter
 Bell - is for low pitched, for heart sounds.
1. Catheter Associated Urinary Tract
NORMAL Breath Sounds Infection (CAUTI)
Tubular/  Tubals  number 1 problem, very high risk.
Bronchial  Trachea  To prevent: In insertion of catheter, you
need to use aseptic technique (sterile).
Bronchovesicular  Scapular The urine in the bladder is considered
 Back sterile.
 In ideal set up, you need to have clean
gloves then sterile gloves. When inserting
 COMPETENCY APPRAISAL II
catheter, cleaning of the perineum is the
first task and when cleaning ideally you
need to use clean gloves. When inserting
catheter, that’s when sterile gloves are
used.
URINE COLLECTION
 In urine collection, the first voided urine
should be discarded because our premise
is the last voided urine is residual in the
previous urination.
 The last voided urine should be collected
because it is still part in the collection time.
 Ideally, the urine is preserved by putting it
in the refrigerator or putting it in ice.
MODALITIES OF NURSING CARE
 The GOAL of the Modalities of Nursing
Care should give benefit to the patient and
to the hospital.
1. FUCTIONAL NURSING - task oriented.
 Each nurse will have a specific task in the
hospital. One nurse will do the medication,
the other nurse will do vital signs, and
another nurse will do the ambulation. Each
nurse will have task.
 Ideally speaking, in Functional Nursing
you are only focused on one tasked.
Expertise will be heightened and task is
faster.
 Ideally speaking it is used when there are
many patients and nurses are only few
because even though nurses are few, they
are expert of their task making it easier
and faster to be done and can still
accommodates the patients.
 Problem: There are aspects of caring that
the nurses cannot provide such as
providing emotional support to the patient.
2. CASE METHOD or TOTAL CARE - there is
only one nurse who will do everything for
your patient. The nurse will provide all the
needs of the patient.
 Similar in private nurse.
 One nurse is assigned to one patient or a
group of patient and will be responsible in
all aspects of care during per shift.
 Ideally speaking it is used when there are
more nurses than patients. Example: ICU
Department where patients are highly
unstable.
3. PRIMARY NURSING - almost similar to Case
Method.
 Keywords: consistent, individualized,
comprehensive.
 There would be one nurse responsible to
plan for everything for the entire day of the
patient. The NCP will be used for 24 hours
but not necessarily mean that nurse will be
on duty for 24 hours, the incoming nurse
will carry out the NCP made by primary
nurse.
 The advantage of primary nursing is that
only one nurse will create the NCP of the
patient for 24 hours or seven days, plan of
care will be consistent and highly
individualized and also comprehensive.
4. TEAM NURSING - there is collaboration.
 The delivery of the nursing care to the
clients is led by a professional nurse. It is
composed of RNs and NAs.
 Registered nurse as a leader and Nursing
Assistants.
 Team leader will assign the responsibilities
of the RNs and NAs. It is like functional
nursing but the only difference is there is a
LEADER.
 The leader will supervise and acts as
manager in the department, commonly
seen in the hospital.
 However, when the nurse assigned for
that task is not available, other nurses
need to supply the task.
 The heart of team nursing is TEAM
CONFERENCE. Communication in what
you did during your shift and what you will
need to endorse for the incoming shift.
5. CASE MANAGEMENT
 In case management, the important
keyword would be case managers utilize
critical pathways. Critical Pathways are
documents that track the progress of the
client towards healthcare, Known in critical
paths and action plans.
 There will be a case manager and will
involve a multidisciplinary team. It also
involves the other members of the
healthcare team but their leader is still a
Registered Nurse.
 The RN (leader) will be the one giving the
task to the other members of the
healthcare team.
 Not used in the hospital setting anymore.

LEADERSHIP STYLE
1. AUTHORITARIAN
 members do not have any input, only the
leader makes the decision for the
organization.
 Not a good leadership style.
 COMPETENCY APPRAISAL II
 In emergency cases, it is the used
leadership style because of the emergent
situation leaders do not have to ask the
opinion of the members.
 Self-motivation and self-satisfaction fail in
this type of leadership.
2. LAISSEZ-FAIRE
 the members make the decision for the
organization.
 Leader gives up his leadership role often
called as “lazy” leader.
 Members should be experts and can
already come up with own decisions and
plans for the organization.
 The only problem in this type of leadership
is leader almost has no participation and
members are already experts causing
ideas and plans not to match and no one
gives in to other ideas.
 Members cannot come up in unanimous or
consensus decision making within the
organization. Not a good leadership style.
3. PARTICIPATIVE
 also known as Democratic leadership.
 The leader and members who makes the
decision.
 Ideal leadership style for nurses.
 If non-emergency cases, it should be
authocratic style used.
 It gives self-motivation and self-
satisfaction to the members, in the
organization members should be satisfied
and happy with the treatment.
4. SITUATIONAL
 leadership style depends or will be based
on the situation it presents.
 It is believed that leader should have fluid
leadership style, which one should be able
to adapt and fit to the leadership style
according to situation.
 There is no fixed leadership style.
KAWASAKI DISEASE
 Very common in Asia, most especially in
Japan where most cases happened.
 Usually affects males than females
 Usually affects less than 5 years old.
 Formerly known as mucocutaneous lymph
nodes syndrome and infantile polyarteritis
nodosa.
 Kawasaki Disease is an autoimmune
disorder where origin is unknown.
 Characterized by systemic inflammation.
 Often involves blood vessels that is why it
is called vasculitis (inflammation of
vessels).
 Most affected blood vessel is will be the
coronary arteries.
Antigen-Antibody Complex
 It may have started because of an
infectious process or sometimes genetics.
 Remember when there is infection, the
antigen which is the foreign body. If there
is antigen in the body or enters the body,
the body will create now an antibody. In
some cases, antigen-antibody complex
happens, where antibody fails to kill the
antigen instead antibody and antigen
combines with each other.
 Since antigen and antibody has combined,
it will become now a bigger molecule that
the body will have the difficulty to clear out
the complex. So instead of taking it out on
the body, it will deposit in the blood
vessels.
Inflammation
 The increased antigen-antibody complex
that’s being deposited in the blood vessels
creates now the inflammation.
 Since there is inflammation, there is
warmth, blood vessels are expected to
dilate.
Aneurysm Formation
 Overdilation of blood vessels.
 In inflammation, the blood vessels are
dilated and the problem in dilation is it will
weaken the wall of the blood vessel to
become over dilated causing Aneurysm.
 The problem in Aneurysm is it can rupture
causing massive bleeding.
 In Kawasaki Disease, if the coronary
artery ruptures it will develop myocardial
infarction.
Platelet Accumulation and Formation Of
Thrombi/Obstruction
 If vessels keep on dilating, it will cause
micro bleeding.
 If there is bleeding, platelets will be
activated.
 Once platelets will be accumulated and
formulation of clots happen, it could create
an obstruction in the vessel causing
decrease of blood flow that leads
possibilities of Myocardial Infarction or
coronary artery disease.
 COMPETENCY APPRAISAL II
peel off
commonly in
the hands and
3 Phases of Clinical Manifestations of feet
Kawasaki Disease
Thrombocytosis
PHASE DURATION MANIFESTATION
Convalescen 6–8 Disappearance of
Acute Phase 1–2 High fever t Phase weeks clinical symptoms
weeks of  up to 38C or -recovery after and continues until
illness more phase illness ESR returns to
 not responsive (stable) onset normal.
to antipyretics
Erythrocyte
Conjunctival Sedimentation
erythema Rate (ESR) a
 redness of marker of
conjunctiva inflammation.

Mucosal changes ESR is elevated

 dry lips when there is
 tongue is super inflammation and
red is expected in the
(strawberry first 2 phases of
tongue) Kawasaki
Disease.
Cervical
lymphadenopathy Criteria for Diagnosis of Kawasaki Disease
 enlargement of
lymph nodes Fever of 5-day duration associated with at least
up to 1.5 cm. four of the following changes:

Hands and feet  Bilateral nonsuppurative conjunctivitis

swelling  One or more changes of the mucous
 related to membranes of the upper respiratory tract,
inflammation including pharyngeal injection, dry fissured
lips, injected lips, and “strawberry tongue”
Rashes (pathogmnemonic of Kawasaki Disease)
 Polymorphus  One or more changes of the extremities,
(appearance including peripheral erythema, peripheral
is varied,
edema, periungual desquamation, and
there is
generalized desquamation
macular and
popular,  Polymorphous rash, primarily truncal
there is flat (chest area)
and  Posterior cervical lymphadenopathy
elevated) greater than 1.5 cm in diameter.
Subacute Until 4 Gradual resolution  You can also diagnose Kawasaki Disease
Phase weeks of of fever (if without meeting the 4 criteria when there
-most illness untreated) and is fever with 5 day duration, 2D Echo
dangerous other symptoms result of heart failure, and 3 of the 5
phase of  however, changes.
Kawasaki platelet levels
Disease. will increase TREATMENT of Kawasaki Disease
and clot
formation also  Mainstay therapy: Intravenous
increases Immunoglobulin
causing more  should not receive routine immunizations
chances of while taking IVIG
obstruction and  Aspirin: anti-inflammatory (acute phase)
high risk for MI.
 antithrombotic (subacute –convalescent
phase) – higher dose
Skin
desquamation  NSAIDs for pain management usually
 skin fall off or Ibuprofen for fast relief.
 COMPETENCY APPRAISAL II
Nursing Interventions for Kawasaki Disease
1. Observe for signs of Heart Failure and
Myocarditis
2. Administer Ibuprofen for pain and itchiness
(low level of pain) – joint stiffness or pain
3. Non constrictive clothing – especially if their
edema
4. Lip balm – fever causes dry lips it is to prevent
cracking
5. Increase hydration (oral,IV) – fever increase
fluid losses causing dehydration
6. Diet: soft, non-irritating food – in as much as
possible, mouth can be tendered due to
inflammation. You cannot give juices to
patient; it is an irritant.
7. Encourage to continue brushing teeth – use
soft bristles.
BACTERIAL CONJUNCTIVITIS
 It is simply called as sore eyes.
 It can be transmitted through contact of
secretions.
VULVAR HEMATOMA
 HEMATOMA - internal bleeding,
accumulated bleeding.
 Usually, woman who experiences perineal
hematoma if they have fast/quick delivery
because of the force or underwent
episiotomy. In episiotomy, the bleeding is
not moved out or excavate because of the
suture or subsequently who have
episiorraphy.
 Hematoma will be reabsorbed by the body
in 3 to 4 days.
Manifestations
 Severe pain complaint in the area or
heavy pressure in between their legs.
Management
 Apply cold packs to stop the bleeding for
constriction and to stop enlargement of
hematoma.
 If not responsive to cold packs: Incision
 Hematoma will be incised to excavate
bleeding or drain accumulated blood and
identify the blood vessel that is bleeding.
 When blood vessel is identified, it will be
ligated or sutured or cauterized. But in OB,
it is sutured. Once flattened, you will
suture it again.
ANATOMY AND PHYSIOLOGY OF ENDOCRINE
SYSTEM
PITUITARY GLAND - master gland, most of the
hormones are being stored or being secreted
2 PARTS OF PITUITARY GLAND
1. POSTERIOR - storage for hormones
a. Oxytocin - responsible for uterine
contractions, facilitates excretion of breast
milk.
b. Antidiuretic Hormones - facilitates or
regulates urination. Inhibits urination esp if
there is imbalances.
2. ANTERIOR - GTPALF
- they are being secreted thus
produced by the Pituitary
gland.
a. Growth Hormone - facilitates growth of
muscles and structures
 If decrease = decreased growth causing
DWARFISM.
 If increase = increased in growth
depending on the epiphyseal plate
(responsible for vertical growth; height)
 If still open = still allows height/vertical
growth causing GIGANTISM
 If already close = allows growth
horizontally, growth in extremities (hands
and legs) causing ACROMEGALY.
b. Thyroid Stimulating Hormone -
 Thyroid gland produces thyroid hormones
but to produce such hormones, thyroid
gland needs TSH.
c.Prolactin - responsible for production of
breast milk.
 There is an abnormality in Prolactin, a
condition where too much production of
breast milk causing emission in breast
buds, wetting of nipples.
d. Adrenocorticotropic Hormone / ACTH -
steroids
i. Glucocorticoids - glucose control
ii. Mineralocorticoids - salt absorption;
commonly related to fluid balance.
iii. Androgen - sex hormones
 COMPETENCY APPRAISAL II
e. Luteinizing Hormone - responsible for
ovulation of women.
f. Follicle Stimulating Hormone / FSH
DID YOU KNOW?
In some cases of tumor in the Pituitary gland,
the tumor STIMULATES.
Therefore, there will be increase of all
hormones, so one of the options include
removal of the pituitary gland because increase
level of hormones is not good for the body.
HYPOPHYSECTOMY
 The removal of the pituitary gland,
“ectomy” means removal.
 In medical term, pituitary gland is called
hypophysis.
 Before, cranium is being opened during
Hypophysectomy to access the pituitary
gland.
In time with the help of technology,
TRANSPHENOIDAL APPROACH OR SURGERY
is used.
 The probe is inserted in the nose of the
patient containing the Endoscope and
access the pituitary gland via the sphenoid
bone.
 If for example, the pituitary gland is not
evacuated or removed or impossible to
access by the transsphenoidal approach,
CRANIOTOMY is performed.
MUSTACHE DRESSING - dressing used after
transsphenoidal procedure in the incision site.
 Possible problem is obstruction in airway
through the nose making patient breath in
the mouth.
CONSIDERATIONS TO WATCH IN
HYPOPHYSECTOMY
NURSING RESPONSIBILITY IN: MOUTH
BREATHING
 Inform patient preoperatively that in
transsphenoidal approach, the dressing
will cover the nose of the patient and will
breathe through the mouth.
 Advising patient to increase hydration =
the effects of mouth breathing can lead to
dry mouth, since patient will do mouth
breathing for a couple of days
 If presence of cracked lips is found, lip
balms can be used.
INCREASED OF INTRACRANIAL PRESSURE
 Another important consideration
postoperatively is to watch out for since it
can still be cranial surgery.
Altered LOC - Earliest sign of increased ICP, due
to pressure in the parenchyma.
 Patient will be restless, to lethargic or
stuporous, then coma.
 Headache, projectile vomiting, vital signs
including hypertension, bradycardia, and
bradypnea which are vital signs
associated with increased ICP but is
considered late signs.
LEAKAGE OF CEREBROSPINAL FLUID
 Observe for leakage of Cerebrospinal
fluid. Watch out for signs of Rhinorrhea.
 Ask patient if he/she feels something is
dripping in his/her nose. If the patients feel
so, the nurse should try catching the fluid
in a tissue the sample of postnasal drip.
The sample will be tested if it is CSF.
 Halo sign will be seen if CSF is leaking,
the appearance of halo sign is the center
is clear and the surroundings are also
clear. If this happened to the tissue
collected, this indicated CSF leakage.
If there is CSF leakage, it is just self-limiting.
 Monitor continuously
 Watch out for signs of ICP.
 Inform physician about the tissue sample,
the halo sign.
 Instruct bed rest.
NURSING CONSIDERATION IN
HYPOPHYSECTOMY
1. Monitor the patient’s neurologic status hourly
for the first 24 hours and then every 4 hours.
 Watch out for signs of increased ICP
2. Monitor fluid balance, especially for output
greater than intake.
 Intake should be almost equal to the
output.
 Since parathyroid gland is removed,
Diabetes Insipidus can be a complication
where antidiuretic hormones are
 COMPETENCY APPRAISAL II
decreased and cause continuous
urination.
3. Encourage the patient to perform deep
breathing exercises
 Since it is a postoperative patient, it is to
prevent pulmonary complications
4. Instruct the patient not to cough, blow nose, or
sneeze.
 These are activities that can increase the
ICP.
 Coughing exercises are not allowed, it
could increase ICP and sutures can be
damaged in the incision site.
5. Instruct the patient to use dental floss and oral
mouth rinses rather than tooth brushing until
the surgeon gives permission.
 Accordingly, tooth brushing can increase
ICP and at the same time can add further
insult to the incision site.
 Tooth brushing can be withheld for at least
two weeks or until surgeon gives
permission.
6. Instruct the patient to avoid bending at the
waist to prevent increasing intracranial
pressure.
 Bending in the waist level can increased
ICP. When picking up things on the floor,
they should bend their knees.
7. Monitor the nasal drip pad for the type and
amount of drainage.
 To find out if there is a CSF leakage.
 Watch out for Halo sign
 Color of CSF is clear.
8. Teach the patient methods to avoid
constipation and subsequent “straining”
 One of the maneuvers that may increase
the ICP is Valsalva maneuver which is
equivalent to straining.
 To avoid constipation, increase intake of
fiber and fluids.
9. Teach the patient self-administration of the
prescribed hormone.
 All hormone levels will decrease because
of the removal of pituitary gland.
THE GOAL OF THESE INTERVENTIONS IS TO
PREVENT INCREASE OF INTRACRANIAL
PRESSURE.
TYPES OF DIABETES INSIPIDUS:
1. CENTRAL problem is in the brain, specifically
in the pituitary gland or in the brain in general.
 This can happen as a result from head
trauma, typical reason why central DI
happens.
2. NEPHROGENIC - the problem is in the
kidneys. The kidneys do not recognize the
ADH. This may happen as a result from kidney
injury or renal failure
 The ADH level is normal.
3. DIPSOGENIC - The problem is in the
hypothalamus.
 The thirst center of the body is located in
the hypothalamus, there is a defect in the
hypothalamus therefore increases craving
towards drinking. Patient drinks water too
much and as a response of the body the
patient will urinate too much.
4. GESTATIONAL - affected patients are
pregnant.
Laboratory Diagnosis:
Test: Fluid Deprivation Test = hallmark finding:
inability to increase specific gravity and osmolality
of urine.
 The patient will be deprived from fluids;
usually the patient is in NPO for 8 to 12
hours or in the basis of the patient’s weight
if the weight loss is in 3 to 5% already.
Stop Fluid Deprivation Test When:
 Hypotension and Tachycardia is present =
when the patient is fluid deprived it
develops hypotension and if hypotension
is present, heart rate will increase to
compensate. It can lead to Hypovolemic
shock that is life threatening.
 Excess weight loss = if weight loss is
about 10%, leading the patient to
dehydration already.
Pharmacologic Management: Synthetic ADH
1. DESMOPRESSIN = given more than
vasopressin.
 COMPETENCY APPRAISAL II
 Safest because there is no cardiotoxic
effect.
2. VASOPRESSIN = perceives vasoconstrictive
effect, there is an effect in the cardiac function
of the patient.
 You cannot give it to patient with coronary
artery disease where coronary arteries are
constricted. When giving Vasopressin to
patients with CAD, you are putting patient
risk to Myocardial Infarction.
3. THIAZIDE DIURETICS = In Nephrogenic
cause DI, you don’t give synthetic ADH.
 Thiazide diuretics facilitates movement of
sodium instead of urine being diluted, it
will have sodium and potassium and will
make urine concentrated hence correcting
the nephrogenic diabetes insipidus.
 High risk for developing dehydration.
Action of mechanism wise.
NURSING RESPONSIBILITIES:
 Monitor I and O.
 For patients with Diabetes Insipidus, there is
no need to restrict their fluid intake.
Restriction of fluids has nothing to do with DI.
SIAD = Syndrome of Inappropriate Antidiuretic
Hormone
 Increase Antidiuretic Hormone = there is
inability to execute urination and dilute urine
 there is fluid retention: more water compares
to sodium
 dilutional hyponatremia: sodium levels are
normal but water high in level there is still
dilution. There is problem in the fluids in the
body.
Hyponatremia the problem is low on sodium level
while Dilutional hyponatremia the problem is high
in fluid level.
Most often SIAD is not endocrine problem; it is a
result of pulmonary cancer. It is an extrapulmonary
manifestation, it starts with lung mass or
pulmonary cancer then eventually develop to
manifestations of SIAD.
 In the phase of lung cancer, the lung cancer
will release antidiuretic hormones that’s why
our ADH is high in levels.
Management:
SIAD is self-limiting. The goal is to prevent
congestion.
 Fluids are retained in the body thus what
you need to do is restrict fluid to avoid
congested heart failure and pleural
effusion.
Medication
Diuretics = furosemide/loop diuretics (Lasix)
because it is the most fast acting among all
diuretics.
 The problem is it decreases all the
electrolyte levels (sodium, potassium, and
calcium).
 The problem in SIAD is it has dilutional
hyponatremia, if given furosemide it will
lead to hyponatremia because it will
decrease the sodium level of the patient.
To counteract the decrease of sodium levels of the
patient, Sodium Chloride or NSS (NaCl) IV fluid is
given.
 Isotonic: 0.9% sodium content, equal with
body plasma
 Hypotonic: Less than 0.9% sodium content
 Hypertonic: If the patient manifest
hyponatremia. More than 0.9% sodium
content.
HYPOTHYROIDISM
 Thyroid glands have many functions in our
body. It is responsible for your cellular
metabolism (use of oxygen by the cells).
 For adults the most common cause:
Hashimoto Disease (autoimmune thyroiditis)
= the immune system attacks the thyroid
glands of the patient.
Manifestations of Hypothyroidism:
 Impaired memory
 Diminished perspiration
 Cold intolerance – the thyroid hormones is
responsible to fatty acid formation, when
you have hypothyroidism, your fat content
is low.
 Bradycardia – slow pulse enlarges heart
(cardiomegaly). The patient has
bradycardia as an attempt the heart
pumps faster causing muscles
hypertrophy.
 Constipation - slow peristaltic activity
 Increase in weight – related to slow
metabolism, thyroid hormone is
responsible for the cellular metabolism. If
you have hypothyroidism, your cellular
metabolism is slow. Nutrients is not use
immediately, there is a tendency that the
nutrients will stay in the body leading to
weight gain.
 Menorrhagia - Increase in
menses/bleeding.
 COMPETENCY APPRAISAL II
CLASSIFICATIONS of hypothyroidism:
1. Primary: Thyroid dysfunction = the problem
is in the thyroid ex: Hashimoto Disease
2. Secondary: Pituitary Disorder= the problem
is in the pituitary gland, which produces the
TSH to order Thyroid glands to release thyroid
hormones which is the T3 (Triiodothyronine)
and T4 (Tetraiodothyronine).
 In pituitary disorder, hypothyroidism
happens because there is lessen of TSH
formation because pituitary gland is
damage.
3. Tertiary: Hypothalamus Disorder = defect in
the thyroid formation because before it creates
TSH, the hypothalamus creates thyroid
stimulating releasing factor/hormone.
 Hypothalamus releases thyroid stimulating
releasing factor (TSRF) then in the
pituitary gland producing the thyroid
stimulating hormone (TSH) then if TSH is
produced, the thyroid glands will now
produce thyroid hormones which is the T 3
and T4.
MYXEDEME COMA: severe form of
hypothyroidism
 Patient is comatose
 Life-threatening due to severe
bradycardia.
 Severe bradycardia leads to poor cardiac
output making cerebral flow decrease
causing alteration of LOC.
Management:
Goal for Hypothyroidism: supply the lacking
hormone.
 Give synthetic levothyroxine – drug of
choice of hypothyroidism.
Complication:
 Sometimes it causes fatty deposits in the
coronary blood vessel or
ATEROSCLEROSIS. Blood flow in the
heart decreases, developing ischemic
heart disease. One of the possibilities of
mortality is due to cardiac problem
Nursing management in cold intolerance:
1. Warm environment by advice to wear
sweater, use thick clothes, blanket.
2. Monitor time to time cardiac functioning ECG
monitoring
3. Monitor for any signs ACS or MI
4. Engage them more in activities because they
are low in energy and develop activity
intolerance so include Activity of Daily Living
with different group activities.
5. For constipation advise more fluids and fiber.
HYPERTHYROIDISM
 Most common cause is Grave’s disease
 most common in female
 age group is 20 to 40 years old
Physical Examination:
 Exophthalmos – protruding of eyeballs.
 Multinodular goiter
 Toxic adenoma – tumor
Manifestations are MOSTLY Increase:
 Metabolic rate is fast
 Insomnia
 Restless
 Exophthalmos
 Heat intolerance – ask if naka aircon,
madali bang mainitan?
 Tachycardia
 Palpitations
 Weight loss
 Muscle wasting
 Oligomenorrhea
Management: Inhibit production of thyroid
hormones
 Radioactive iodine – destroy parts of
thyroid gland to inhibit excessive production
of thyroid hormones.
- More effective
- Contraindication: pregnancy and
breastfeeding
Restriction: breastfeeding should be stop for
more than 6 weeks to start radioactive iodine.
If dealing with reproductive age and considering
hyperthyroidism, include pregnancy test to make
sure no problem in radiation use.
Thyroid gland productions should be stabilized first
before radioactive iodine.
Management Complication: Hypothyroidism.
 To counterattack, start thyroid hormone
replace in 4 to 18 weeks from the time
nagstop ang radiation therapy.
 Antithyroid medications (Thionamides) =
inhibits production of thyroid glands but it has
lesser effects.
 COMPETENCY APPRAISAL II
 Remind to take in empty stomach, 30
minutes before eating.
- Propylthiouracil= 1st trimester pregnant
but hepatotoxic
- Methimazole= have teratogenic effect,
used in 2nd to 3rd trimester pregnant to
breastfeeding era
- Sodium Iodide = supress thyroid
hormone, not main therapy
- Potassium Iodide = supress thyroid
hormone, not main therapy
- Saturated solution of potassium iodide
(SSKI) = also known as the Lugols
solution, supress thyroid hormone, not
main therapy a
- Iodide decreases the vascularity of thyroid
gland for less bleeding when
thyroidectomy.
Measure thyroid hormone level to assure success
of radiation therapy.
 Measure FT4 or freet4, because it is more
reliable than TSH.
 It is measure 3 to 6 weeks after the
initiation of radioactive iodine. Follow up is
1 to 2 months until normal levels indicating
radioactive therapy is effective.
 TSH can be measured if you reached the
normal levels of thyroid glands. Once FT4
is normal, TSH can be measure for around
6 to 12 months to lifetime.
Complication:
 Tachycardia leads to heart failure to slow
down heart rate beta blockers are used or
given to patient with hyperthyroidism in an
attempt to decrease heart rate.
THYROID STORM = severe form of
hyperthyroidism
 increase manifestations
 Extreme tachycardia = more than 130
 Body temperature = 38.5
 Alteration in LOC
 Cardiovascular manifestation:
- Chest pain
- Palpitation
 Diarrhea
 Weight loss
Qualification for Surgery:
 Pregnant women allergic to antithyroid
medications
 Large goiters = most often multinodular
 Unable to take antithyroid agents
Before surgery, normalize thyroid hormone levels
perform surgery 4 to 6 weeks after normalized
thyroid hormone.
Nursing Management Post Thyroidectomy
1. Monitor for signs of bleeding in post
thyroidectomy.
 Assess in the posterior neck or in the
lateral side.
 If there is bleeding there will be edema, if
there is edema obstruction can happen. In
the bedside, tracheostomy should be
present.
Complications:
 Damage to recurrent laryngeal nerve, you
will know if it is damage if voice is hoarse or
loss of voice.
 Monitor hoarness of voice or loss of voice.
Irreversable.
 Parathyroid gland can be damaged or
accidentally removed during thyroidectomy
causing parathyroid hormone (which brings
calcium to the blood) to decrease causing
calcium levels in the blood to decrease
leading to hypocalcemia which has a
possibility for the patient to develop Tetany.
 They will have seizure episodes.
 What to do: give IV Calcium Gluconate
HYPERPARATHYROIDISM
 The problem in hyperparathyroidism is high
levels of calcium in blood and too much
calcium in the blood is high risk for developing
stones, particularly kidney stones.
 Calcium = sources of stones
 Parathyroid Hormone is responsible for
bringing calcium from the bone to the
blood.
 99% calcium in the bone and 1% in the
blood.
 If hyperparathyroidism happens, calcium in the
bone decreases and becomes weaker and
high risk for fracture.
Primary hyperparathyroidism high parathyroid
hormone
 If parathyroid hormones levels are high,
calcium levels in the blood will increase.
 The main problem is patient develops
Nephrolithiasis or kidney stones.
Management
 Once patient is symptomatic, parathyroid
gland is removed.
 COMPETENCY APPRAISAL II
 No manifestation in hyperparathyroidism
except for kidney stones or fracture, that’s
the time surgery, is needed to remove
parathyroid glands.
 If not so symptomatic, management includes
prevention of stone formation.
 Advice to increase fluid intake to remove
calcium deposits inside
 Medication: Diuretics: Loop diuretic or
Potassium Sparing diuretics
 Thiazide diuretics SHOULD NOT be given
because it only excretes sodium and
potassium but not calcium.
Diet: No restriction.
For Porous Bones:
 Bed rest as much as possible.
 Studies says that bed rest increases
calcium excretion and decrease calcium
formation thus stabilizes normal
physiology, calcium now deposits in the
bone and somehow provides strength to
the patient.
 When in activity:
 Avoid high risk for falls or injury
environment.
 Things should be well-organized.
 Room should be well-lit
QUESTIONS
Question: The nurse is caring for a client
scheduled for a transsphenoidal hypophysectomy.
The preoperative teaching instructions should
include which most important statement?
a) "Deep breathing and coughing will be
needed after surgery.”
b) “You will receive spinal anesthesia.”
c) “Brushing your teeth will not be permitted
for at least 2 weeks following surgery.”
d) “Your hair will need to be shaved.”
RATIONALE: Anesthsia used in transsphenoidal
hypophysectomy is general anesthesia. Hair is not
necessarily shaved unless if transsphenoidal
approach is not possible and craniotomy is used.
Question: A nurse is caring for a client after
hypophysectomy. The nurse notices clear nasal
drainage from the client's nostril. The initial nursing
action would be to:
a) Lower the head of the bed.
b) Continue to observe the drainage.
c) Test the drainage for glucose.
d) Obtain a culture of the drainage.
RATIONALE: Obtaining culture is not necessary
because we do not suspect infection. Lowering of
bed causes aspiration, proper position is Semi
Fowlers. Halo sign or test for glucose because
CSF is rich in glucose.
Initial nursing action = confirm if drainage is CSF.
Question: The nurse is admitting a client to the
neurological intensive care unit who is
postoperative transsphenoidal hypophysectomy.
Which data would warrant immediate intervention?
a) The client’s vital signs are T 97.6, P 88, R
20, and BP 130/80.
b) The client is alert to name but is unable to
tell the nurse the location.
c) The client has an output of 2500 mL since
surgery and an intake of 1000 mL.
d) The client has a 3-cm amount of dark-red
drainage on the turban dressing.
RATIONALE: Dark red drainage is typical in
immediate post operation, Vital signs are normal or
derangement and in hypophysectomy,
complication is Diabetes Insipidus which manifest
hypotension and more output than intake.
Question: The client is admitted to the medical
unit with a diagnosis of rule out diabetes insipidus
(DI). Which instructions should the nurse teach
regarding a fluid deprivation test?
a) The client will be asked to drink 100 mL of
fluid as rapidly as possible and then will
not be allowed fluid for 24 hours.
b) The client will be NPO, and vital signs and
weights will be done hourly until the end of
the test.
c) The client will be given an injection of
antidiuretic hormone, and urine output will
be measured for four (4) to six (6) hours.
RATIONALE: Put patient on NPO for 8 to 12 or
weight loss about 3 to 5%
Question: The client is diagnosed with diabetes
insipidus. Which laboratory value should be
monitored by the nurse?
a) Serum calcium
b) Urine white blood cells
c) Urine glucose.
d) Serum sodium.
RATIONALE: In DI, patient urinates more than
normal, so there is potential dehydration. Sodium
will tell that patient manifest dehydration.
Question: A nurse is monitoring a client receiving
desmopressin acetate (DDAVP) for adverse
effects to the medication. Which of the following
indicates the presence of an adverse effect?
 COMPETENCY APPRAISAL II
a) Increased urination
b) Insomnia
c) Drowsiness
d) Weight loss
RATIONALE: DDAVP is a synthetic antidiuretic
hormone, the fluids will retain. If fluid is retain there
is a possibility of water intoxication where there is
excessive fluid retention. The brain is filled with
water; there will be an increased in ICP as
manifested by drowsiness. When you give
DDAVP, there will be decreased urination and
weight gain.
Question: Vasopressin (Pitressin) is prescribed for
a client with diabetes insipidus. A nurse is
particularly cautious in monitoring the client
receiving this medication if the client has which of
the following preexisting conditions?
a) Pheochromocytoma
b) Endometriosis
c) Coronary artery disease
d) Depression
RATIONALE: Vasopressin causes
vasoconstriction.
Question: The nurse is admitting a client
diagnosed with syndrome of inappropriate
antidiuretic hormone (SIADH). Which clinical
manifestations should be reported to the
healthcare provider?Serum sodium of 112 mEq/L
and a headache.
a) Serum potassium of 5.0 mEq/L and a
heightened awareness.
b) Serum calcium of 10 mg/dL and tented
tissue turgor.
c) Serum magnesium of 1.2 mg/dL and large
urinary output.
RATIONALE: SIAD fluids are retained. There will
be dilutional hyponatremia.
Normal level of sodium : 135 to 145 meq/l
Normal level of potassium : 3.5 to 5.0 meq/l
Normal level of calcium : 8.5 to 10 mg/dl
Normal level of serum magnesium : 1.5 to 2.5
mg/dl
Patient with SIAD does not have large urinary
output.
Question: A client’s exophthalmos continues in
spite of thyroidectomy for Grave’s Disease. The
nurse teaches her how to reduce discomfort and
prevent corneal ulceration. The nurse recognizes
that the client understands the teaching when she
says: “I should:
a) Elevate the head of my bed at night
b) Avoid moving my extra-ocular muscles
c) Avoid using a sleeping mask at night
d) Avoid excessive blinking
RATIONALE: Patient should blink from time to
time to partially cover eyes and free from injury.
Patient should move extra ocular muscles to
exercise. Sleeping mask can cause injury to the
eye of the patient especially during night.
Question: Which nursing intervention should be
included in the plan of care for the client diagnosed
with hyperthyroidism?
a) Increase the amount of fiber in the diet.
b) Encourage a low-calorie, low-protein diet.
c) Decrease the client’s fluid intake to 1000
mL day.
d) Provide six (6) small, well-balanced meals
a day.
RATIONALE: Fast metabolism. Increase
frequency of feeding. Do not decrease fluid intake
but instead increase because they are risk for
constipation. High protein and high calorie diet.
Question: The 68-year-old client diagnosed with
hyperthyroidism is being treated with radioactive
iodine therapy. Which interventions should the
nurse discuss with the client?
a) Explain that it will take up to a month for
symptoms of hyperthyroidism to subside.
b) Teach that the iodine therapy will have to
be tapered slowly over 1 week.
c) Discuss that the client will have to be
hospitalized during the radioactive
therapy.
d) Inform the client that after therapy the
client will not have to take any medication.
RATIONALE: Patient will still have antithyroid
supplement. Patients do not have to be admitted in
the hospital but need to be isolated to avoid
radiation exposure to others. Radioactive are
bodily fluids. No sharing of utensils. Gradual
effects will be seen,
Question: During the first 24 hours after thyroid
surgery, the nurse should include in her care:
a) Checking the back and sides of the
operative dressing
b) Supporting the head during mild range of
motion exercise
c) Encouraging the client to ventilate her
feelings about the surgery
d) Advising the client that she can resume
her normal activities immediately
 COMPETENCY APPRAISAL II
RATIONALE: Complication of thyroidectomy is
bleeding. Patient should be at bed rest for at least
24 hours.
Question: When a post-thyroidectomy client
returns from surgery the nurse assesses her for
unilateral injury of the laryngeal nerve every 30 to
60 minutes by:
a) bserving for signs of tetany
a) Checking her throat for swelling
b) Asking her to state her name out loud
c) Palpating the side of her neck for blood
seepage
RATIONALE: Laryngeal nerve injury
complications include hoarseness of voice.
Question: The client diagnosed with
hypothyroidism is prescribed the thyroid hormone
levothyroxine (Synthroid). Which assessment data
indicate the medication has been effective?
a) The client has a three (3)-pound weight
gain.
b) The client has a decreased pulse rate.
c) The client’s temperature is within normal
limits
d) The client denies any diaphoresis
RATIONALE: Levothyroxine gear towards
hyperthyroidism.
Question: A nurse is completing an assessment
on a client who is being admitted for a diagnostic
workup for primary hyperparathyroidism. Which
client complaint would be characteristic of this
disorder?
a) Diarrhea
b) Polyuria
c) Polyphagia
d) Weight gain
RATIONALE: Primary hyperparathyroidism has
increase calcium in the blood. Parathyroid
hormone is increase, hypercalcemia is
manifestations. Risk fir kidney stones, in attempt of
the body to excrete stones is by urinating.
Question: When assessing a client with a
parathyroid hormone deficiency, the nurse would
expect abnormal serum levels of which
substances?
a) Sodium and chloride
b) Potassium and glucose
c) Urea and uric acid.
d) Calcium and phosphorous
RATIONALE: Calcium is decrease. Generally,
calcium and phosphorous has inverse relationship.
But there are books that says both are elevated.
Signs of Hypocalcemia:
1. Chvostek = taps cheeks then it will have spams.
2. Trousseau = when taking BP they elevate their
arms involuntarily.
Question: The client has developed iatrogenic
Cushing’s disease. Which is a scientific rationale
for the development of this problem?
a) The client has an autoimmune problem
that causes the destruction of the adrenal
cortex.
b) The client has been taking steroid
medications for an extended period for
another disease process.
c) The client has a pituitary gland tumor that
causes the adrenal glands to produce too
much cortisol.
d) The client has developed an adrenal gland
problem for which the health-care provider
does not have an explanation.
RATIONALE:
Question: The client diagnosed with Cushing’s
disease has undergone a unilateral
adrenalectomy. Which discharge instructions
should the nurse teach?
a) Instruct the client to take the
glucocorticosteroid and
mineralcorticosteroid medications as
prescribed.
b) Teach the client regarding sexual
functioning and androgen replacement
therapy.
c) Explain the signs and symptoms of
infection and when to call the health-care
provider.
d) Demonstrate turn, cough, and deep-
breathing exercises that the client should
perform every 2 hours.
Question: Which signs and symptoms occurring in
a client 48 hours postadrenalectomy indicate that
glucocorticoid dosage needs to be increased?
a) Marked weakness, anorexia, nausea, or
vomiting.
b) Severe dyspnea, tachycardia,
apprehension
c) Paresthesias, numbness and tingling in
the extremities, muscle spasms
d) Orthostatic hypotension, depressed
reflexes, slow mentation.
Question: A nurse is preparing to provide
instructions to a client with Addison's disease
regarding diet therapy. The nurse knows that
 COMPETENCY APPRAISAL II
which of the following diets most likely would be
prescribed for this client?

a) High-fat intake
b) Low-protein intake
c) Normal sodium intake
d) Low-carbohydrate intake

Question: A nurse is performing an admission

assessment on a client admitted with a diagnosis
of pheochromocytoma. The nurse assesses for the
major symptom associated with
pheochromocytoma when the nurse:

a) Obtains the client's weight

b) Takes the client's blood pressure
c) Tests the client's urine for glucose
d) Palpates the skin for its temperature

Question: A nurse collects urine specimens for

catecholamine testing from a client with suspected
pheochromocytoma. The results of the
catecholamine test are reported as 20 mcg/100 mL
urine. The nurse analyzes these results as:

a) Normal
b) Insignificant and unrelated to
pheochromocytoma
c) Lower than normal, ruling out
pheochromocytoma
d) Higher than normal, indicating
pheochromocytoma

Question: A nurse is performing an assessment

on a client with pheochromocytoma. Which of the
following assessment data would indicate a
potential complication associated with this
disorder?

a) A coagulation time of 5 minutes

b) A blood urea nitrogen level of 20 mg/dL
c) A urinary output of 50 mL per hour
d) A heart rate that is 90 beats/min and
irregular
 COMPETENCY APPRAISAL II
DIABETES Type 2 MOST common
Diabetes classification; 95%
3 Ps of Diabetes: - Lifestyle mediated
- Adequate production of
1. Polyuria – increased urination
- insulin but (problem) have
2. Polydipsia – increased thirst insulin resistance or
3. Polyphagia – increased eating; NOT decreased sensitivity of
considered as classic symptom of cells to the insulin, because
diabetes the insulin produced is not
being used.
3 Classic Symptoms (these 3 should be present + - The factor that decreases
RBS value para masabi na have diabetes): the sensitivity of cells to
insulin is fats/high fat
1. Polyuria
content. So, it's more
 Because of the high glucose, the body will associated with obesity.
try to move out the excessive glucose in - We still give insulin but do
the body However, it will only happen if not expect it to be as
there is polyuria and if the blood glucose effective as compared to
level is at 180 mg/dL (osmotic diuresis). type 1.
 Along with the excessive glucose is the - We usually give oral
increase of fluids, that is why polyuria is hypoglycemic agents
present. (OHA) (e.g. metformin).
 Since there is polyuria, patient becomes - Onset: more than 30 years
dehydrated so it will send a signal to the old (in books); 20 years old
and above (in practical)
brain to activate the thirst temper (?) then
there will be polydipsia Latent - Combination of types 1 & 2
Autoimmune - Autoimmune (cause [type
2. Polydipsia Diabetes of 1]);
3. Weight loss Adults - Adults (onset [type 2])
(LADA) - Nakikita ito as slow onset of
types 1 or 2 diabetes in a
PRODUCED BY PANCREAS AS PART OF THE patient with autoimmune
ENDOCRINE FUNCTION: disorder.
- Keywords: slow onset +
 Beta cell is a type of cell in the pancreas autoimmune disorder
that produces insulin.
 Alpha cell produces glucagon. Gestational - Happens during pregnancy
Diabetes - It's the fault of human
placental lactogen (HPL)
(a placental
6 TYPES OF DIABETES hormone/diabetogenic
hormone that decreases
Type 1 Common classification; 5- the sensitivity to insulin)
Diabetes 10% (??) kaya nagkakaroon ng
diabetes during pregnancy.
- Autoimmune related (rare)
- Pancreas is not capable of - 2nd to 3rd trimesters of
producing insulin. pregnancy.
- Insulin production is either
absent or minimal by the - Screening for gestational
pancreas. diabetes starts at 24
- Give/administer insulin weeks AOG.
- Patient is thin
- Onset: younger population
Risk factors:
(less than 30 years old)
- Age (more than 30)
- Baby is large for gestational
age (LGA)

Diabetes
associated
with other
conditions
or
syndromes
 COMPETENCY APPRAISAL II
Prediabetes Warning sign that patient will be HYPOGLYCEMIA
diabetic
another potential problem with diabetes lalo na
So, know what is normal and kapag minamanage na ito
diabetic rate (RBS is 111 or not
- Blood glucose of < 70 mg/dL
umabot sa 200).
Manifestations of Hypoglycemia
Normal glucose level is 70-110
mg/dL. Adrenergic Sympathetic response
Sign/Symptom Expect mild hypoglycemia
(sympathetic or stress
CRITERIA FOR DIAGNOSIS: response)
If you have hypoglycemia,
 Classic symptoms of diabetes and casual epinephrine & norepinephrine
plasma glucose concentration ≥ 200 mg/dL hormones will be activated
- "Causal" = not fasting or random blood because of stress.
sugar (RBS)
- RBS is more than 200. Cerebral Expect moderate and severe
Sign/Symptom hypoglycemia
 Fasting plasma glucose: ≥ 126 mg/dL
- If not RBS, use fasting plasma glucose.
- This is the ideal for determination or TYPES OF HYPOGLYCEMIA
diagnosing diabetes. Mild Hypoglycemia:
- Check blood sugar level of patient if they
did fast for 8 hours  Sweating
- RBS is more than 126 to consider as  Tremor
diabetes.  Tachycardia
 Palpitation
 Two-hour postload glucose ≥ 200 mg/dL  Nervousness
during OGTT  Hunger
- Oral Glucose Tolerance Test (OGTT)
- In OGTT, give 75 grams of anhydrous Moderate Hypoglycemia:
glucose then mixed with water, and let the
patient drink it.  Inability to concentrate
- After 2 hours, measure the patient's  Headache
glucose level.  Lightheadedness
- After measuring, if more than 200 mg/dL,  Confusion
patient is diagnosed for diabetes.  Memory lapses
 Hemoglobin A1c ≥ 6.5%  Numbness of the lips and tongue
 Slurred speech
 Impaired coordination
SYMPTOMS:  Emotional change
1. Fatigue and weakness – can also be seen in  Irrational or combative behavior
hypoglycemia  Double vision
2. Sudden vision changes  Drowsiness
3. Tingling or numbness in hands or feet –
Severe Hypoglycemia:
diabetes can also lead to peripheral
neuropathy  Disoriented behavior
4. Dry skin – a good indicator if the patient has  Seizures
hypoglycemia or hyperglycemia  Difficulty arousing from sleep
- Expect flushed dry skin (hyperglycemia)
 Loss of consciousness
- Cool, moist skin (hypoglycemia)
- Consider hypoglycemia in an
5. Skin lesions or wounds that are slow to heal
unconscious patient
6. Recurrent infections
- Hyper- and hypoglycemia both present
as loss of consciousness. Pero, bakit
hypoglycemia ang iisipin talaga?
Because if we give sugar to the patient
then he is hypoglycemic, at least na-
reverse ang problem. If ever
hyperglycemic ang patient, not delikado
 COMPETENCY APPRAISAL II
ang sugar for him. That's why, it's better
to treat the patient as hypoglycemia
rather than hyperglycemia.
Management of Hypoglycemia:
 15 to 20 g of a fast-acting concentrated
source of carbohydrate
- We give juice or candy (fast-acting
concentrated source of carbohydrate) if the
patient is conscious.
- We can give unsweetened juice because it
still has carbohydrate content that may
reverse hypoglycemia.
 Glucagon injection 1mg SQ or IM
- Give this to the unconscious patient.
- Glucagon is a prescribed medication that
necessitates doctor's order to purchase by
patient.
- If known diabetic ang patient, have yan sila
storage of glucose kasi maaanticipate na
nito na pwede na magkaroon ng
hypoglycemia anytime.
 25 to 50 mL D50W IV
- To those patients na hindi pa pala
nadiagnose with diabetes then bigla nag
hypoglycemia, hindi talaga makakahanap
ng glucagon.
- Dalhin kaagad sa hospital if unconscious
ang patient sa bahay tapos walang
glucagon.
- Once the patient is in the hospital, we give
dextrose containing fluids.
- Dextrose is already the glucose.
- Since we give 50% glucose in water, it's
very high in terms of glucose content.
- Since it's being given IV, expect the
response will be rapid ang corruption ng
hypoglycemia.
DIABETIC KETOACIDOSIS
 Seen in patients with Type 1 Diabetes
 Diabetic means the patient is hyperglycemic at
this point.
 Since wala masyadong sugar sa type 1, hindi
nareregulate ang kanilang glucose content sa
blood. At the same time, yung kinakain nilang
glucose, hindi rin ito nadedeliver going to the
different cells kasi walang insulin (magdadala
ng glucose going to cells).
 Since in type 1, wala masyado or walang
insulin naproproduce, we'll expect na walang
narereceive na glucose ang cells.
 Kahit maraming glucose sa blood but the cells
are deprived of the glucose, simply because
there's no insulin.
 If for example, need ng additional glucose ang
patient, liver is the organ na maaactivate. So,
mag undergo ng glycogenolysis or the
breakdown of the glycogen, which is the
byproduct is the glucose.
 Diba nag breakdown na ang glycogen? In type
1 diabetes tapos nag glycogenolysis na,
walang marereceive na sugar ang cells kasi
the problem is hindi natratransport ang
glucose dahil walang insulin. So, mas dumami
ang glucose in the blood.
 After glycogenolysis, the body will undergo
gluconeogenesis. ("genesis" means formation
of glucose from a [neo] new source [new
source is fats]). So, the liver will break down
the fats into free fatty acids (FFA), which will
be the source of the glucose and ketones.
 Ketones are acidic by nature sa body. Kaya,
nagdedevelop ng ketoacidosis because of the
fat breakdown.
 Again, the only problem is insulin pero ang
iniisip ng body is hindi sapat ang glucose kaya
nagkaka glycogenolysis and gluconeogenesis.
- The glucose level of the patient will be
masyadong mataas.
- Kung masyadong mataas ang glucose
content sa blood, the kidneys = polyuria or
undergo again osmotic diuresis.
- If ihi nang ihi ang patient, dehydration na.
- Note: Monitor ABG results.
Management for DKA:
1. Increase fluid intake
2. Give 0.9 sodium chloride or PNSS (fast
drip; around 1-2 hours will consume 1
liter).
3. Do not give dextrose containing muna kasi
initially, the patient's glucose level is
already high, so not na mag add glucose.
4. Give potassium supplements
Signs of DKA:
1. Polyuria
2. Polyphagia
3. Polydipsia
4. Fruity breath odor or acetone breath –
most common sign; acetone breath is a
result of ketone bodies
5. Kussmaul respiration – this is an attempt
to correct acidosis, so rapid deep
breathing ito.
 COMPETENCY APPRAISAL II
Complications:
1. Local Allergic Reaction
- Redness, pain, itchy at the injection site
- Nawawala naman ito
2. Systemic Allergic Reaction
- Very rare
- Develop urticaria or anaphylactic reaction
3. Insulin Lipodystrophy
- Lipodystrophy means nasisira ang fats.
- It can also be lipoatrophy, which means
lumiliit ang injection site or fatty tissues.
- Pwede rin lipohypertrophy, lumalaki ang
fatty tissues.
- (Lipoatrophy) Noon, ginagamit ang animal
insulin kaso it can depress the fatty
tissues. So, ang ginagamit na now is
human insulin.
- (Lipohypertrophy) Fibrofatty means that if
we're using the same site, nagkakaroon
ng scar formation sa injection site or the
fatty area. That's why, it's not advisable on
the same site lamang mag iinject ang
insulin kasi hindi na ito maaabsorb. Dapat
mag rotate ang injection site to prevent
lipohypertrophy.
- Note: We give insulin subcutaneously.
4. Resistance to injected insulins
- Although it's a rare phenomenon pero if
this happens, we have to increase the
dosage of insulin or change the insulin
type.
- If not na effective ang mga short-acting
insulin, pwede naman ang long-acting.
5. Morning hyperglycemia
- Mahirap i-determine ang cause nito. Hindi
madaling sabihin na it's dawn
phenomenon or insulin waning.
- In terms of management of dawn
phenomenon & insulin waning, they're just
the same (give insulin/glucose at bedtime
for longer coverage).
Characteristics and Treatment of Morning
Hyperglycemia:
1. Insulin Waning - problem is insulin
- "Waning" means humihina na ang insulin.
- Progressive rise in blood glucose from
bedtime to morning. (- as a result of poor
insulin absorption)
- Treated by increasing evening (pre dinner
or bedtime) dose of intermediate- or long-
acting insulin, or instituting a dose of
insulin before the evening meal if one is
not already part of the treatment regimen.
2. Dawn Phenomenon - problem is glucose\
- Relatively normal blood glucose until
early morning hours when levels begin to
rise.
- Kaya ito tinatawag na "dawn", kasi at around
3am, the growth hormone is similar ang
structure with the glucose. So, sumasabay
din and tumataas ang glucose level. Kaya at
3am onwards, pwedeng magkaroon ng
hyperglycemia ang patient as related to
growth hormone.
- Treated by changing time of injection of
evening intermediate-acting insulin from
dinnertime to bedtime.
- Instead of dinnertime ito binibigay, bedtime
ibibigay para greater ang duration ng insulin
at maprevent ang hyperglycemia at around
3am.
3. Somogyi Effect
- Normal or elevated blood glucose at
bedtime, early morning hypoglycemia, and a
subsequent increased blood glucose caused
by the production of counterregulatory
hormones.
- Nagkakaroon ng hypoglycemia at 3am
- While the patient's sleeping, glucagon will be
released. Paggising niya, hyperglycemic na
siya.
- Treated by decreasing evening (pre dinner or
bedtime) dose of intermediate-acting insulin,
or increasing bedtime snack.
STORAGE:
 Avoid extremes of temperature
- Di dapat maexpose to direct sunlight
- Dapat refrigerated lang. Not i-freeze.
- Administering the medication should be at
room temperature para hindi
uncomfortable kapag mag inject na.
- Store opened vials sa freezer. Unopened
vials, refrigerator.
 Cloudy insulin: through mixing
- Roll it between your palms or invert gently
para mag mix thoroughly.
 Flocculated insulin: do not use
- "Flocculated" means that the side of the
insulin bottle ay parang may mga frosting
na.
- Once have frosting/flocculated, it already
means sira na ang insulin. Kaya, discard
it/hindi na magagamit.
- Lifespan of insulin is only good for 1
month.
MIXING:
 Regular insulin be drawn up first.
- Usually, minimix ang regular insulin and
NPH.
- By appearances, regular insulin looks clear.
NPH is cloudy.
- According to American Diabetes Association
(ADA – premiere foundations pagdating sa
 COMPETENCY APPRAISAL II
diabetes), they recommend regular insulin
muna talaga ang gagamitin.
- If inuna i-aspirate ang NPH kaysa sa regular
insulin, pwedeng macontaminate ng NPH
ang regular insulin. So, mahihirapan ka na
mag differentiate kung yung vial is NPH or
regular insulin kasi same na sila cloudy
appearing.
- Kahit mag inject ka ng regular insulin sa
NPH, it won't change the appearance of
NPH.
- This pic depicts the suggested sites for
- Mahirap i-detect ang HHS kasi initially, it only
presents with polyuria and polydipsia.
- Malalaman na nag HHS na ang patient if
once nagkaroon na ng neurologic
manifestations.
- More common sa older adults kaya medyo
challenging ang pagbibigay ng fluids sa mga
patients na yan. Dapat i-hydrate sila nang
mabilisan but we also have to consider na
pwede magkaroon ng heart failure, kaya
monitor from time to time. That's why, it's
very challenging sa HHS.

TABLEEEE

The 3 Ultimate Complications of Diabetes:

(assess (in order): retinopathy, nephropathy, and
neuropathy)

1. Eyes
2. Kidneys
3. Nerves

injection of the insulin.

- Abdomen, anterior thigh, posterior upper
arm, and hip.

HYPERGLYCEMIC HYPEROSMOLAR
SYNDROME (HHS)

- Since have naman adequate insulin pero

ang cells lang have problem, hindi
maghahanap ang body ng alternative source
for glucose. That's why, hindi nagkakaroon
ng gluconeogenesis when it comes to type 2
diabetes. So, hindi na need i-breakdown ang
fats para lamang magkaroon ng adequate
glucose.
- The problem sa HHS is mataas ang glucose,
at the same time, hyperosmolar.
- Sodium determines the (hyper)osmolality of
the blood. So, expect the patient to have
increased sodium then decreased fluid
volume.
- Basically, the problem sa HHS is still
dehydration.
- The same lang ang management ng DKA
and HHS.
- We still give insulin to correct the
hyperglycemia.

Manifestations:

(- mataas ang sodium, mababa ang fluid.)

1. Hypotension
2. Profound dehydration
3. Tachycardia
4. Variable neurologic signs & symptoms