SCHOOL OF NURSING

NCM 116: MEDICAL SURGICAL NURSING

MODULE 2: CARE OF CLIENTS WITH ENDOCRINE DISORDERS
Transcribed by: Crisanta Grace Oponda Section: BSN 301 – 2nd Semester (S.Y 2022-2023)

TOPIC  (+) stimulation

SUB-TOPIC
SUB-SUB-TOPIC
 posterior pituitary gland releases ADH
 ADH goes to nephron (kidney)
 vasopressin receptor
CARE OF CLIENTS WITH ENDOCRINE DISORDERS SIADH – Water retention
DI - polyuria

SYNDROME OF INAPPROPRIATE ANTI-DIURETIC

HORMONE (SIADH)
 Condition of hyper functioning of the posterior pituitary gland in which
excess ADH is released, but not in response to the body’s need for it
 Causes include trauma, stroke, malignancies (often in the lungs or
pancreas), medications, and stress
 The syndrome results in increased intravascular volume, water
intoxication, and delutional hyponatremia
ENDOCRINE GLAND – HYPER AND HYPO SECRETION  May cause cerebral edema and the client is at risk for seizures
 Stimulating hormone – anterior part ASSESSMENT
 The rest – posterior part a. Signs of fluid overload
o Oxytocin, ADH b. Changes in level of consciousness and mental status changes
DISORDERS OF ANTERIOR PITUITARY GLAND c. Weight gain without edema
d. Hypertension
 Growth hormone
e. Tachycardia
o Gigantism – hypersecretion of growth hormone in children
f. Anorexia, nausea, and vomiting
o Acromegaly – increase growth hormone in adults
g. Hyponatremia
 They are at risk for fracture
h. Low urinary output and concentrated urine
o Dwarfism – decrease growth hormone
 Prolactin
SIGNS AND SYMPTOMS
o Galactorrhea – increase prolactin a. Increase BP
b. Edema – restriction of fluid is need
 Adrenocorticotrophic hormone (ACTH)
c. Dilutional hyponatremia
o Secondary cushing’s disease – increase ACTH
d. Decrease urine output (concentrated urine)
o Secondary addison’s disease – decrease ACTH
e. Increase specific gravity
 Thyroid stimulating hormone (TSH)
a. Normal: 1.010-1.025
o Hyperthyroidism
f. Weight gain – monitoring of weight daily is required with same time
o Hypothyroidism
and same type of clothing
 Gonadotrophins (TSH & LH)
o Decrease - failure to develop secondary sex characteristics INTERVENTIONS
o Increase - precocious? Puberty a. Monitor VS, cardiac, and neurological status
b. Provide a safe environment, particularly for the client with changes in
 Melanocyte stimulating hormone
o Increase - hyperpigmentation – external tan LOC or mental status
o Decrease - albinism c. Monitor for signs of increased ICP
d. Implement seizures precautions
DISORDER OF POSTERIOR PITUITARY GLAND
e. Elevate the head of the bed a maximum of 10 degrees to promote
 Syndrome of inappropriate antidiuretic hormone (SIADH)
venous return and decrease baroreceptor-induced ADH release
o DECREASE ADH = diabetes insipidus
f. Monitor I&O and obtain daily weight
 Hyperpituitarism
g. Monitor fluid and electrolyte balance
o Hyperfunction of anterior pituitary gland
h. Monitor serum and urine osmolality
 Hypopituitarism i. Restrict fluid intake as prescribed
o Hypofunction of anterior pituitary gland j. Administer IV fluids (usually normal saline or hypertonic saline) as
 Simmond’s disease prescribed, monitor fluids carefully because of the risk for fluid volume
o Absence of pituitary hormone overload
 Sheehan’s syndrome k. Loop diuretics may be prescribed to promote diuresis but only if serum
o Postpartum pituitary necrosis sodium is at least 125mEq/L (125mmol/L), potassium replacement may
DISORDERS OF THYROID GLAND be necessary if loop diuretics are prescribed
 Goiter l. Vasopressin antagonists may be prescribed to decrease the renal
 Hyperthyroidism response of ADH
 Hypothyroidism m. DOC: ADH antagonist
 Exophthalmos – protrusion of one or both eye o Demeclocycline & tolvactan
 Dermopath – disease of the skin

ANTIDIURETIC HORMONE (ADH)

 helps blood vessels constrict and helps the kidneys control the amount
of water and salt in the body. This helps control blood pressure and the
amount of urine that is made.
 If sobrang daming ADH kukunin lahat ng h20 to blood vessels

 From the hypothalamus DIABETES INSIPIDUS (DI)

 osmoreceptors (need stimulation) (angiotensin 2 & decrease BP
 Hyposecretion of ADH by the posterior pituitary gland caused by
 increase plasma osmolality – movement of H20 (low H2O & high
stroke, trauma, or surgery or it may be idiopathic
solutes)
 Kidney tubules fail to reabsorb water
 SCHOOL OF NURSING
NCM 116: MEDICAL SURGICAL NURSING
MODULE 2: CARE OF CLIENTS WITH ENDOCRINE DISORDERS
Transcribed by: Crisanta Grace Oponda Section: BSN 301 – 2nd Semester (S.Y 2022-2023)

 In central diabetes insipidus there is decreased ADH production HYPERTHYROIDISM

 In nephrogenic diabetes insipidus, ADH production is adequate but the
kidneys do not respond appropriately to the ADH  Hyperthyroid state resulting from hypersecretion of thyroid hormones
(T3 and T4)
ASSESSMENT
 Characterized by an increased rate of body metabolism.
a. Excretion of large amounts of dilute urine
 A common cause is Graves’ disease, also known as toxic diffuse goiter.
b. Polydipsia
c. Dehydration (decreased skin turgor and dry mucous membrane)  Clinical manifestations are referred to as thyrotoxicosis.
d. Inability to concentrate urine  The T3 and T4 are usually elevated and the TSH levels is low.
e. Low urinary specific gravity: normal is 1.003-1.030 (1.005-1.030)
f. Fatigue
g. Muscle pain and weakness
h. Headache
i. Postural hypotension that may progress to vascular collapse without
rehydration
j. Tachycardia
SIGNS AND SYMPTOMS
a. Polyuria e. increase urine output  Hypothalamus sends signal to P.G
b. Dehydration f. low specific gravity  Release of TSH
c. Hypernatremia – low h2o & high solutes g. weight loss  TSH travels to thyroid gland (follicular cells)
d. Diluted urine output h. low BP – high HR  Goes into the cell sa may receptor
INTERVENTIONS  (+) production of thyroid gland but need muna ng iodine and enzyme
a. Monitor VS, neurological, and cardiovascular status (thyroglobin)
b. Provide a safe environment, particularly for the client with postural  Pag nagjoin together (iodinated thyroglobin)
hypotension  Babalik ulit sa gland then relase of T3 & T4 hormone
c. Monitor electrolyte values and for signs and symptoms of dehydration  T4 mas madaming iodine & mas madaming number
d. Maintain client intake of adequate fluids; IV hypotonic saline may be
prescribed to replace urinary losses  Heart – increase B1 adrenergic receptor which controls heart rate
e. Monitor I&O, weight, serum osmolality, and specific gravity of urine for (increase HR) -> increase SU – increase CO
excessive urine output, weight loss, and low urinary specific gravity  Bones – balances osteoplast and osteoblast
f. Instruct the client to avoid foods or liquids that produce diuresis  CNS – increase sympathetic response
g. Vasopressin or desmopressin acetate may be prescribed; these are  GI – GI motility and increase HCL acid
used when ADH deficiency is severe or chronic  Skin – maintains cutaneous blood flow, sebaceous secretion,
h. Instruct the client in the administration of medications as prescribed; responsible for estrogen and progesterone levels, and normal skeletal
desmopressin acetate may be administered by subcutaneous injection, muscle contraction
intravenously, intranasally, or orally; watch for signs of water
intoxication indicating over treatment  Low ATP – body’s coping mechanism to have energy production
i. Instruct the client to wear a MedicAlert bracelet through eating (glycolysis and breaking down of fats)
j. Give synthetic ADH / hormone replacement therapy PRIMARY – HAPPENS INSIDE THE BODY
k. DIC: pitressin  Grave’s Disease
DIAGNOSTIC TEST o Primary cause
Stimulation test o Autoimmune
 In the client with suspected underactivity of an endocrine gland, a o Forms TSH (receptor) antibodies – stimulates the thyroid
stimulus may be provided to determine whether the gland is capable of gland to relaseT3 & T4
normal hormone production  Toxic adenoma
 Measured amounts of selected hormones or substances are o 1 nodules
administered to stimulate the target gland to produce its hormone  Toxic multinodular goiter
 Hormone levels produced by the target gland are measured o Nodules do the stimulation
 Failure of the hormone level to increase with stimulation indicates SECONDARY – THERE’S A DISEASE THAT CAUSES HT
hypofunction  Trauma
Suppression test  Tumor in pituitary gland – commands PG to relase TSH
 It is used when hormone levels are high or in the upper range of  Tumor in uterus
normal o B-HCG (pregnant & H.mole) – siya mismo nagsstimulate
 Agents that normally induce a suppressed response are administered kahit pinipigil ng PG
to determine whether normal negative feedback is intact CLINICAL MANIFESTATION
 Failure of hormone production to be suppressed during standardized a. Increase HR
testing indicates hyperfunction b. Weight loss (skinny patient)
c. Increase osteoclast (risk for fracture)
d. Increase SNS
e. Anxiety
f. Insomnia
g. Irritable
h. Lid lag - upper eyelid is higher than normal with the globe in downgaze.
i. Increase GI motility (diarrhea)
j. Decrease Blood volume
k. At risk for hypovolemia
l. Tremors: hypersecretion of muscle contraction
m. Diaphoresis
n. Oily skin
o. Exophthalmos – nagkakaroon ng water sa eyeballs
p. Heat intolerance
 SCHOOL OF NURSING
NCM 116: MEDICAL SURGICAL NURSING
MODULE 2: CARE OF CLIENTS WITH ENDOCRINE DISORDERS
Transcribed by: Crisanta Grace Oponda Section: BSN 301 – 2nd Semester (S.Y 2022-2023)

THYROID FUNCTION TEST o Mix with juice or water since it has metallic taste
1. Thyroid-stimulation hormone assay o Give straw to avoid staining of teeth
2. Radioactive Iodine Uptake (RAIU) o Weight gain is the indication that the medication is effective
o Patient teaching: radioactive dose is small and harmless d. Inderal (propranolol) – drug of choice for increase BP
o Contraindicated in pregnant e. Dexamethasone – to inhibit action of thyroid hormone
o Sea foods may elevate the result
o Drugs that may elevate the result: barbiturates, estrogen, THYROID STORM
lithium, phenothiazines  This acute and life-threatening occurs in a client with uncontrollable
o Drugs that may decrease results: lugol’s solution, saturated hyperthyroidism
solution of potassium iodine (SSKI),  It can be caused by manipulation of the thyroid gland during surgery
o Collect 24-hour urine specimen after oral tracer dose given and the release of thyroid hormone into the bloodstream; it also can
o Thyroid scanned after 24-hours occur from severe infection and stress
T4 T3 Radioactive Free TSH  Antithyroid medications, beta blockers, glucocorticoids, and iodides
uptake Iodine thyroxine may be administered to the client before thyroid surgery to prevent its
Uptake index occurrence.
Hyperthyroid Increased Increased Increased Increased Decreased
(Graves)  Complication of super high T3 & T4
High TBG Increased Decreased N N N  Life threatening condition d/t uncontrollable hyperthyroidism
Hypothyroid Decreased Decreased Decreased Decreased Increased o Surgery
Low TBG Decreased Increased N N N o Stress
o Severe infection
3. Thyroid Scan ASSESSMENT
o Radioactive iodine taken orally; dose is harmless a. Elevated Temperature (Fever)
o Scanning done after 24 hours b. Tachycardia
o Avoid iodine containing foods, dyes, medications c. Systolic Hypertension
o Cold Nodules: Cancer d. Nausea, vomiting, and diarrhea
o Hot Nodules: Benign e. Agitation, tremors, anxiety
o Ultrasound – No special preparation f. Irritability, agitation. Restlessness, confusion, and seizures as the
condition progresses
g. Delirium and coma
INTERVENTIONS
a. Maintain a patent airway and adequate ventilation
b. Administer antithyroid medications, iodides, propranolol, and
glucocorticoids as prescribed
c. Monitor vital signs
d. Monitor continually for cardiac dysrhythmias
e. Administer nonsalicylate antipyretics as prescribed (salicylates increase
free thyroid hormone levels)
f. Use a cooling blanket to decrease temperature as prescribed
4. Imaging
g. Gove beta blockers for dysrhythmia
 Magnetic Resonance Imaging SIGNS AND SYMPTOMS
o
Test cannot be done in clients with metal implants (e.g. a. High fever
pacemakers, arthroplasties, skull plates) b. Systolic hypertension
o Assess for allergy to contrast media c. N/B & Diarrhea
 Computed Tomography d. Agitated
o If contrast medium is used, note for allergy history e. Anxiety
INTERVENTIONS f. Tremors
a. Provide adequate test g. Delirium
b. Administer sedatives as prescribed h. Coma GCS 3
c. Provide a cool and quiet environment i. If uncontrollable, it might lead to death
d. Obtain weight daily PRIORITY
e. Provide a high-calorie diet  Airway
f. Avoid the administration of stimulants
 Cooling blanket/TSB
g. Administer antithyroid medications, such as methimazole or
THYROIDECTOMY
propylthiouracil that block thyroid synthesis as prescribed
a. Surgery is the intervention if medication is not effective
h. Administer iodine preparations that inhibit the release of thyroid
hormone as prescribed
i. Administer propranolol for tachycardia as prescribed
j. Prepare the client for radioactive iodine therapy, as prescribed, to
destroy thyroid cells
k. Prepare the client for subtotal thyroidectomy if prescribed
l. Elevate the head of the bed of a client experiencing exophthalmos; in
addition, instruct on low-salt diet, administer artificial tears, encourage  Removal of the thyroid gland
the use of dark glasses, and tape eyelids closed at night if necessary  Performed when persistent hyperthyroidism exists
m. Allow the client to express concerns about body image changes  Subtotal thyroidectomy, removal of a portion of the thyroid gland, is
MEDICATIONS the preferred surgical intervention
a. Antithyroid medications  Total thyroidectomy – risk for hypothyroidism
o Propylthiouracil (PTU) – inhibits T3 & T4 PRE-OPERATIVE INTERVENTION
o Tapazole – contraindicated in 1st trimester a. Obtain VS and weight
o Should give with empty stomach b. Assess electrolyte levels
b. Lugol’s solution – pre-op c. Assess for hyperglycemia
c. SSKI – saturated solution of potassium iodine
 SCHOOL OF NURSING
NCM 116: MEDICAL SURGICAL NURSING
MODULE 2: CARE OF CLIENTS WITH ENDOCRINE DISORDERS
Transcribed by: Crisanta Grace Oponda Section: BSN 301 – 2nd Semester (S.Y 2022-2023)

d. Instruct the client on how to perform coughing and deep breathing 4. Protruding tongue
exercises and how to support the neck in the postoperative period 5. Protruding umbilicus
when coughing and moving 6. Poor brain development
e. Administer anti-thyroid medications, iodine, propranolol, and 7. Prolonged neonatal jaundice
glucocorticoids as prescribed to prevent the occurrence of thyroid INTERVENTIONS
storm a. Monitor vs, including HR and rhythm
f. SSKL b. Administer thyroid replacement; levothyroxine sodium is most
POST-OPERATIVE INTERVENTIONS commonly prescribed
a. Monitor for respiratory distress c. Instruct the client about thyroid replacement therapy and about the
b. Have a tracheostomy set, oxygen, and suction at the bedside clinical manifestation of both hypothyroidism and hyperthyroidism
c. Limit client talking, and assess level of hoarseness related to underreplacement and overreplacement of the hormone
d. Avoid neck flexion and stress on the suture lines d. Instruct the client in a low calorie, low cholesterol, low saturated fat
e. Monitor for laryngeal nerve damage, as evidenced by airway diet; discuss a daily exercise program such as walking
obstruction, dysphonia, high-pitched voice, stridor, dysphagia, and e. Assess the client for constipation; provide roughage and fluids to
restlessness prevent constipation
f. Monitor for signs of hypocalcemia and tetany, which can be caused by f. Provide a warm environment for the client
trauma to the parathyroid gland g. Avoid sedatives and opioid analgesics because of increased sensitivity
g. Prepare to administer calcium gluconate as prescribed for tetany to these medications; may precipitate myxedema coma
h. Monitor for thyroid storm h. Monitor for overdose of thyroid medications, characterized by
i. Position in semi fowlers to promote lung expansion, atelectasis, and tachycardia, chest pain, restlessness, nervousness, and insomnia
prevent aspiration i. Instruct the client to report episodes of chest pain or other signs of
j. IF BLEEDING PUT SOAKED DRESSING AT THE BACK OF THE NECK overdose immediately
NURSING MANAGEMENT j. DOC - Levothryroxine
b. Provide non-stimulating and cool environment
c. Administer sedative as ordered to sleep MYXEDEMA COMA
d. Obtain weight daily  This rare but serious disorder results from persistently low thyroid
e. High calorie intake diet production
f. If (+) exophthalmos, wear shades for protection  Coma can be precipitated by acute illness, rapid withdrawal of thyroid
o Position semi-fowlers to facilitate drainage medications, anesthesia and surgery, hypothermia, or the use of
o Give artificial tears to avoid corneal ulceration sedatives and opioid analgesics
o Tapalan ang eyes every night  Life threatening complication
g. Low salt diet
ASSESSMENT
a. Hypotension
HYPOTHYROIDISM b. Bradycardia
 Hypothyroid state resulting from hyposecretion of thyroid hormones c. Hypothermia
and characterized by a decreased rate of body metabolism d. Hyponatremia
 The T4 is low and TSH is elevated e. Hypoglycemia
 In primary hypothyroidism, the source of dysfunction is the thyroid f. Generalized Edema
gland and the thyroid cannot produce the necessary amount of g. Respiratory Failure
hormones. In secondary hypothyroidism, the thyroid is not being h. Coma
stimulated by the pituitary to produce hormones. INTERVENTIONS
 Ow ATP = hypometabolism a. Maintain a patent airway.
 Low T3 & T4 but elevated TSH b. Institute aspiration precautions
CAUSES c. Administer IV fluids (normal or hypertonic saline) as prescribed
a. Low iodine intake d. Administer levothyroxine sodium intravenously as prescribed
b. Low T3 & T4 e. Administer glucose intravenously as prescribed
c. Hashimoto’s disease – small thyroid gland = low T3 & T4 f. Administer corticosteroids as prescribed
d. Central hypothyroidism g. Assess the client’s temperature hourly
o Injury/tumor at hypothalamus decrease production of T3 & h. Monitor blood pressure frequently
T4 i. Keep the client warm
e. Congenital hypothyroidism j. Monitor the changes in mental status
f. Maternal mediated destruction k. Monitor electrolyte and glucose levels
g. Thyroid agenesis HYPOTHYROIDISM HYPERTHYROIDISM
h. Iodine deficiency Lethary and fatigue Personality changes such as
irritability, agitation, and mood
i. Goister: low ATP
swings
SIGNS AND SYMPTOMS Weakness, muscle aches, and Nervousness and fine tremors of the
a. Cold intolerance (low body temp) k. brittle nails paresthesia hands
b. Weight gain l. Hair loss of outer eyebrow – queen anne’s sign Intolerance to colds Heat intolerance
c. Decrease appetite m. decrease sweating and oil production Weight gain Weight loss
d. Decrease HR – bradycardia Dry skin and hair loss or body hair Smooth, soft skin and hair
e. Decrease bone growth and maturation = short stature Bradycardia Palpitations, cardiac dysrhythmias
f. Decrease SNS activity such as tachycardia and atrial
g. (+) depression, fatigue, lethargy, memory loss fibrillation
h. Decrease tendon reflex n. dysrhythmias Constipation Diarrhea
i. Constipation o. (+) HPN Generalized puffiness and edema Protruding eyeballs (exophthalmos)
j. Dry skin p. Increase lipids (LDL, VLDL, triglyceride, cholesterol) around the eyes and face may be present
7 P’S OF HYPOTHYROIDISM (myxedema)
1. Pot belly Forgetfulness and loss of memory Diaphoresis
2. Pale looking Menstrual disturbances Hypertension
3. Puffy face Goiter may or may not be present Enlarged thyroid gland (goiter)
 SCHOOL OF NURSING
NCM 116: MEDICAL SURGICAL NURSING
MODULE 2: CARE OF CLIENTS WITH ENDOCRINE DISORDERS
Transcribed by: Crisanta Grace Oponda Section: BSN 301 – 2nd Semester (S.Y 2022-2023)

PARATHYROID HORMONE o hyperparathyroidism

o when elevated in conjunction with serum calcium levels, this
 Regulates serum calcium levels
is the most specific test for hyperparathyroidism
 Chief cells: regulates the PTH
 Triggers:
NURSING CONSIDERATION
o Decrease calcium levels a. Monitor VS, particulary blood pressure
o Vit D synthesis b. Monitor for cardiac dysrhythmias
o Phosphate levels c. Monitor IO, and signs of renal stones
d. Monitor for skeletal pain, move the client slowly and carefully
 Affected:
e. Encourage fluid intake
o Bone
f. Administer furosemide as prescribed to lower calcium levels
 Osteoblast – formation
g. Administer normal saline IV as prescribed to maintain hydration
 Osteoclast – destruction resorption
h. Administer phosphates, which interfere with the calcium reabsorption
 PTH
as prescribed
 Osteoblast
i. Administer calcitonin as prescribed to decrease skeletal calcium release
 Osteoclast
and increase renal excretion of calcium
 Calcium break out
j. Administer IV or oral bisphosphonates to inhibit bone resorption
o Kidneys
k. Monitor calcium and phosphorus levels
 PTH
l. Prepare the client for parathyroidectomy as prescribed
 Nephron
m. Encourage a high fiber, moderate calcium diet
 Activates alpha-I hydroxylase
n. Emphasize the importance of exercise program and avoiding prolonged
 Activated Vit D
inactivity
 GIT
 Thru vit D absorbs calcium
 Increase calcium
PHOSPHATE TRASHING HORMONE
 High phosphate in urine; low phosphate in blood
 High calcium in blood; low phosphate in blood

HYPERPARATHYROIDISM
 Hypercalcemia (increase phosphate)
 Blood has free calcium (phosphate + Calcium) phosphate -> ionized
calcium
 Secondary cause of CKD -> hyperphospholemia
 Primary hypersecretion of PTH
 Caused by hypersecretion or parathyroid hormone (PTH) by
parathyroid gland
ASSESSMENT SIGNS AND SYMPTOMS
a. Hypercalcemia and hypophosphatemia  Bones
b. Fatigue and muscle weakness o Too much calcium absorption
c. Skeletal pain and tenderness o Demineralizes
d. Bone deformities that result in pathological fractures o Decrease bone density
e. Anorexia, nausea, vomiting, and epigastric pain o Fracture (bone pain, immobility)
f. Weight loss  Stones
g. Constipation o Increase calcium
h. Hypertension o Calcium turns to stones
i. Cardiac dysrhythmias o nephrolithiasis
j. Renal stone  Groans (GI)
DIAGNOSTICS o Increase calcium
 Total serum calcium o Reduce motility
o Venous blood is extracted o Constipation – increase fiber (abd. Pain, N/V)
o Hyperparathyroidism  Throans (tubules in kidney)
o hypoparathyroidism o Nabblock ang water absorption sa kidney dahil sa mga
 Qualitative urinary calcium (sulkowitch test) nagccrystallized na calcium sa mga V2 receptors
o Collect urine specimen o Might cause polyuria or oliguria
o Fine white precipitate should form when sulkowitch reagent  Psychiatric overtones
is added to urine specimen o Nabblock ng calcium ang sodium channels
o Absent or decreased precipitate indicates low serum o Decrease firing
calcium and hypoparathyroidism o Slow motor movements (decrease DTR, fatigue, depression,
 Quantitative urinary calcium (calcium deprivation test and coma)
o Collect 24-hour urine specimen PARATHYROIDECTOMY
o Hyperparathyroidism  Removal of one or more of the parathyroid gland
o hypoparathyroidism  Endoscopic radio-guided parathyroidectomy with autotransplantation
 Serum phosphorus levels is the most common procedure
o Collect venous specimen  Parathyroid tissue is transplanted in the forearm or near the
o Hyperparathyroidism sternocleidomastoid muscle, allowing PTH secretion to continue
o hypoparathyroidism PRE-OP INTERVENTIONS
 Serum alkaline phosphatase a. Monitor electrolytes, calcium, phosphate, nd magnesium levels
o Hyperparathyroidism b. Ensure the calcium levels are decreased to near normal levels
o hypoparathyroidism c. Inform the client that talking may be painful for the first to two day
 parathormone (PTH) radioimmunoassay after surgery
o collect venous blood specimen
 SCHOOL OF NURSING
NCM 116: MEDICAL SURGICAL NURSING
MODULE 2: CARE OF CLIENTS WITH ENDOCRINE DISORDERS
Transcribed by: Crisanta Grace Oponda Section: BSN 301 – 2nd Semester (S.Y 2022-2023)

POST-OP INTERVENTION c. Initiate seizure precautions

a. Monitor for respiratory distress d. Place a tracheostomy set, oxygen, and suction equipment at the
b. Place tracheostomy set, oxygen, and suctioning equipment at the bed bedside
side e. Prepare to administer calcium gluconate intravenously for
c. Monitor vital signs hypocalcemia
d. Position to semi fowler’s f. Provide a high calcium and low phosphorus diet
e. Assess neck dressing for bleeding g. Instruct the client in the administration of calcium supplements as
f. Monitor for hypocalcemic crisis, as evidenced by tingling and twitching prescribed
in the extremities and face h. Instruct the client in the administration of vitamin D supplements as
g. Assess for positive trousseau’s sign and chvostek’s sign, which indicates prescribed, vitamin D enhances the absorption of calcium from the GI
tetany tract
h. Monitor for changes in voice pattern and hoarseness i. Instruct the client in the use of thiazide diuretics if prescribed, to
i. Monitor for laryngeal nerve damage protect the kidney if vitamin D is also taken
j. Instruct the client in the administration of calcium and vitamin D j. Instruct the client in the administration of phosphate binders as
supplements as prescribed prescribed to promote the excretion of phosphate through the GI tract
SIGNS OF TETANY k. Instruct the client to wear a MedicAlert bracelet
a. Cardiac dysrhythmias SIGNS AND SYMPTOMS
b. Carpopedal spasm b. Bronchospasm
c. Dysphagia c. Laryngospasm
d. Muscle and abdominal cramps d. Arrhythmias
e. Numbness and tingling of the face and extremities e. Seizures
f. Positive chvostek’s sign f. Delirium
g. Positive trousseau’s sign g. Increase deep tendon reflex
h. Visual disturbances (photophobia) h. Compression of nerves
i. Wheezing and dyspnea (bronchospasm, laryngospasm) PRIORITY
j. Seizures a. Airway
OVERT TETANY b. Safety
a. Tetany is a symptom that involves involuntary muscle contractions and c. Prepare tracheostomy set
overly stimulated peripheral nerves. It's caused by electrolyte d. O2 supply
imbalances — most often low blood calcium levels. e. Suction
NURSING MANAGEMENT
HYPOPARATHYROIDISM a. DOC: Calcium Gluconate – IV
a. Condition caused by hyposecretion of parathyroid hormone by the b. DIET: high in calcium, low in phosphate
parathyroid gland c. Advised to take calcium supplements
b. Can occur following thyroidectomy because of removal of parathyroid d. Thiazide diuretic
tissue e. Phosphate binders
c. No absorption of calcium at all f. Sunlight exposure preferable 6AM to 8AM
d. Low PTH secretion HYPERPARATHYROIDISM HYPOPARATHYROIDISM
Skinny Fat
ASSESSMENT
Cold tolerance Heat tolerance
a.Hypocalcemia and hyperphosphatemia
b.Numbness and tingling in the face
c.Muscle cramps and cramps in the abdomen or in the extremities CUSHING’S SYNDROME/ DISEASE
d.Positive Trousseau’s sign and chvostek’s sign CUSHING SYNDROME
e.Signs of overt tetany, such as bronchospasm, laryngospasm, carpopedal
 A metabolic disorder resulting from the chronic and excessive
spasm, dysphagia, photophobia, cardiac dysrhythmia, seizure production of cortisol by the adrenal cortex or from the administration
f. Hypotension
of glucocorticoids in large doses for several weeks or longer (exogenous
g. Anxiety, irritability, depression
or iatrogenic)
CAUSES  ACTH secreting tumors (most often of the lung, pancreas, or
e. No parathyroid gland gastrointestinal GI tract) can cause Cushing’s syndrome
f. Surgically removed
CUSHING DISEASE
g. Decrease calcium, decrease phosphate
 Is a metabolic disorder characterized by abnormally increased secretion
h. phosphate in urine, decrease calcium (no absorption)
(endogenous) of cortisol, caused by increased amounts of ACTH
i. alpha 1 hydroxylase
secreted by the pituitary gland
j. vitamin D
CORTISOL PATHWAY
 Hypothalamus
 Activates CRH (Corticotrophin releasing hormone)
 Pituitary gland
 ACTH increase
 Adrenal gland
 Cortisol release in blood
 Activate SNS response – increase activity and sensitivity
 Nor, Epi -> B1 adrenergic receptor -> increase HR, SV, CO, BP ->
secondary HPN
Pulseless V-tach is shockable because there is no cardiac output while the V-tach
with pulse is not, since it has still cardiac output

INTERVENTION
a. Monitor VS
b. Monitor for signs of hypocalcemia and tetany
 SCHOOL OF NURSING
NCM 116: MEDICAL SURGICAL NURSING
MODULE 2: CARE OF CLIENTS WITH ENDOCRINE DISORDERS
Transcribed by: Crisanta Grace Oponda Section: BSN 301 – 2nd Semester (S.Y 2022-2023)

o Requires lifelong replacement of glucocorticoids and

possibly of mineralocorticoids if significant hyposecretion
occurs, the condition is fatal if left untreated
 Hyposecretion of adrenal cortex hormone such as Aldosterone ACTH,
Cortisol ACTH, Androgen ACTH
 Secondary adrenal insufficiency is caused by hyposecretion of ACTH
from the anterior pituitary gland, mineralocorticoids release is spared
 Loss of glucocorticoids in Addison’s disease leads to decreased vascular
tone, decreased vascular response to the catecholamines epinephrine
and norepinephrine, and decreased gluconeogenesis
Truncal obesity – redistribution of fat from peripheral to central  In addison’s disease, loss of the mineralocorticoids aldosterone leads to
CLINICAL MANIFESTATION dehydration, hypotension, hyponatremia, and hyperkalemia
a. Moon face  No capacity for stress response
b. Irritable  Patient with this kind of disease are like time bomb
c. Pimple prone  Very rare condition
d. Hirsutism CAUSE
e. Gynecomastia a. Autoimmune
f. Buffalo humps b. Infection (TB/HIV – common)
g. Has decreased collagen production c. Metastasis (lungs and liver)
h. Central or local obesity o 90% damage
i. Stretch marks or striae d. Drugs
j. Hyperglycemic o Ketoconazole
k. Atrophy in peripheral muscle o Rifampicin
l. Sodium and water retention DOC – Glucocorticoids/steroids
a. Losing potassium as well INTERVENTION
m. Hyperpigmentation
a. Monitor VS, particularly hypotension, weight loss, and I&O
n. Bronze appearance
b. Monitor white blood cells (WBC) count; blood glucose; and potassium,
sodium, and calcium levels
c. Administer glucocorticoids and/or mineralocorticoid medications as
prescribed
d. Observe for Addisonian crisis caused by stress, trauma, infection, or
surgery
CLIENT EDUCATION
a. Need for lifelong glucocorticoid replacement and possibly lifelong
mineralocorticoid replacement
b. Corticosteroid replacement will need to be increased during times of
stress
c. Avoid individuals with an infection
d. Avoid strenuous exercise and stressful situations
e. Avoid over the counter medications
f. Diet should be high in protein and carbohydrates; clients taking
glucocorticoids should be prescribed calcium and vitamin D
supplements to protect against corticoid-induced osteoporosis; some
Steroids can increase glucose
client taking mineralocorticoids may be prescribed a diet high in
NURSING INTERVENTION
sodium
a. Monitor VS, particularly blood pressure
g. Reports sign and symptoms of complications, such as
b. Monitor I&O, weight daily
underreplacement and overreplacement of corticosteroid hormone
c. Monitor lab values, particularly WBC count and serum glucose, sodium,
“In Addison’s, you add sone”
potassium, and calcium levels
d. Prepare the client for radiation as prescribed if the condition results
INCREASE STRESS = acute crisis (trauma, infection)
from a pituitary adenoma
 Stress is a brain threat
e. Clients requiring lifelong glucocorticoids replacement following
 Stress response = to decrease glucose level in brain
adrenalectomy should obtain instructions from their HCPs about
increasing their glucocorticoid during times of stress
f. Assess for and protect against postoperative thrombus formation; ADDISONIAN CRISIS
cushing’s syndrome predisposes to thromboemboli  a life-threatening situation that results in low blood pressure, low
g. Allow the client to discuss feelings related to body appearance blood levels of sugar and high blood levels of potassium. It requires
h. Instruct the client about the need to wear a MedicAlert bracelet immediate medical care. Other autoimmune diseases.
i. Decrease cortisol  A life threatening disorder caused by acute adrenal insufficiency
j. Adrenalectomy  Precipitated by stress, infection, trauma, surgery, or abrupt withdrawal
k. Serum glucose level monitoring of exogenous corticosteroid use
CUSHING SYNDROME CUSHING DISEASE  Can cause HYPONATREMIA, HYPERCALCEMIA, HYPERKALEMIA,
Long term use of corticosteroids When physical manifestation appears HYPOGLYCEMIA, & SHOCK
ASSESSMENT
ADDISON’S DISEASE  Severe headache
ADRENAL CORTEX INSUFFICIENCY (ADDISON’S DISEASE)  Severe abdominal, leg, and lower back pain
 Primary adrenal insufficiency  Generalized weakness
o Hyposecretion of adrenal cortex hormones (glucocorticoids,  Irritability and confusion
mineralocorticoids, and androgen); autoimmune destruction  Severe hypotension
is a common cause  Shock
 SCHOOL OF NURSING
NCM 116: MEDICAL SURGICAL NURSING
MODULE 2: CARE OF CLIENTS WITH ENDOCRINE DISORDERS
Transcribed by: Crisanta Grace Oponda Section: BSN 301 – 2nd Semester (S.Y 2022-2023)

INTERVENTION  Life-long glucocorticoid and mineralocorticoid replacement is necessary

a. Prepare to administer glucocorticoids IV as prescribed with bilateral adrenalectomy
b. Administer IV fluids as prescribed to replace fluids and restore  Temporary glucocorticoid replacement, usually up to 2 years, is
electrolyte imbalance necessary after a unilateral adrenalectomy
c. Following resolution of the crisis, administer glucocorticoids and  Catecholamine levels drop as a result of surgery, which can result in
mineralocorticoids orally as prescribed cardiovascular collapse, hypotension, and shock, and the client needs
d. Monitor VS, particularly BP to be monitored closely
e. Monitor neurological status, noting irritability and confusion  Hemorrhage also can occur because of the high vascularity of the
f. Monitor I&O adrenal gland
g. Monitor lab values, particularly sodium, potassium, and blood glucose PRE-OP INTERVENTION
levels a. Monitor electrolyte levels and correct electrolyte imbalances
h. Protect the client form infection b. Assess for dysrhythmias
i. Maintain bed rest and provide a quiet environment c. Monitor for hyperglycemia
ADDISON’S DISEASE CUSHING’S SYNDROME AND d. Protect the client from infection
CUSHING’S DISEASE e. Administer glucocorticoids as prescribed
Lethargy, fatigue, and muscle Generalized muscle wasting and POST-OP INTERVENTION
weakness weakness
a. Monitor VS
Gastrointestinal disturbances Moon face, buffalo hump
b. Monitor I&O, if the UO is lower than 30ml/hr, notify the HCP, because
Weight loss Truncal obesity with thin extremities,
this may result in acute kidney injury and indicate impending shock
supraclavicular fat pads, weight gain
c. Monitor weight daily
Menstrual changes in women; Hirsutism (masculine characteristics
impotence in men in female) d. Monitor electrolyte and serum glucose level
Hypoglycemia, hyponatremia Hyperglycemia, hypernatremia e. Monitor for signs of hemorrhage and shock, particularly during the first
Hyperkalemia, hypercalcemia Hypokalemia, hypocalcemia 24 to 48-hours
Hypotension Hypertension f. Monitor for manifestations of adrenal insufficiency
Hyperpigmentation of skin (bronzed) Fragile skin that bruises easily g. Assess the dressing for drainage
and primary disease Reddish-purple striae on the h. Monitor for paralytic ileus
abdomen and upper thighs i. Administer IV fluids as prescribed to maintain blood volume
j. Administer glucocorticoids and mineralocorticoids as prescribed
k. Administer pain medication as prescribed
l. Provide pulmonary intervention to prevent atelectasis (coughing and
PHEOCHROMOCYTOMA deep breathing, incentive spirometry, splinting of incision)
a. Catecholamine-producing tumor usually found in the adrenal medulla,
m. Instruct the client in the importance of hormone replacement therapy
but extra-adrenal locations include the chest, bladder, abdomen, and
following surgery
brain; typically a benign tumor but can be malignant
n. Instruct the client regarding signs and symptoms of complications such
b. Excessive amounts of epinephrine and norepinephrine are secreted
as underreplacement and overreplcament of hormones.
c. Diagnostic test includes a 24-hour urine collection for VMA
CLINICAL MANIFESTATION
d. Surgical removal of the adrenal gland is the primary treatment
h. Hypertensive crisis
e. Sympathetic treatment is initiated if surgical removal is not possible
i. Arrhythmias
f. The complications associated with pheochromocytoma include
j. Palpitations
hypertensive crisis; hypertensive retinopathy and nephropathy, cardiac
k.
enlargement, and dysrhythmias; heart failure; myocardial infarction;
l. Diaphoresis
increased platelet aggregation; and stroke
m. Chest pain
g. Death can occur from shock, stroke, renal failure, dysrhythmias, or
n. Heat intolerance
dissecting aortic aneurysm
o. Weight loss
ASSESSMENT
p. Tremors
 Paroxysmal or sustained hypertension q. Hyperglycemia
 severe headaches
TREATMENT
 Palpitations
 Anticipate administration of beta blockers
 Flushing and profuse diaphoresis
 Monitor serum glucose level
 Pain in the chest or abdomen with nausea and vomiting
 Provide non stressful environment
 Het intolerance
 High calorie diet
 Weight loss
 Connect to cardiac monitor
 Tremors
 Monitor for atelectasis
 Hyperglycemia
SURGERY
INTERVENTION
 Adrenalectomy
a.Monitor VS, particularly BP and HR
o Complication: hemorrhage
b.Monitor for hypertensive crisis; monitor for complications that can
 Lifetime steroids
occur with hypertensive crisis, such as stroke, cardiac dysrhythmias,
and myocardial infarction
c. Instruct the client not to smoke, drink caffeine-containing beverages, or DIABETES MELLITUS
change position suddenly  Is a chronic disorder of carbohydrate, fat, and protein metabolism
d. Prepare to administer a-adrenergic blocking agents and b-adrenergic  It is due to inadequate insulin or increased resistance to insulin
blocking agents as prescribed to control hypertension. Alpha  The cause of DM is unknown
adrenergic blocking agents are started 7 to 10 days before beta  Impaired glucose metabolism
adrenergic blocking agents  “mellitus” or honey
e. Monitor serum glucose levels DI – polyuria leads to dehydration
f. Promote rest and a non-stressful environment DM – polyuria d/t decrease osmolality
g. Provide a diet high in calories, vitamins, and minerals PREDISPOSING FACTORS
h. Prepare the client for adrenalectomy  Stress
ADRENALECTOMY  Heredity
 Surgical removal of an adrenal gland
 SCHOOL OF NURSING
NCM 116: MEDICAL SURGICAL NURSING
MODULE 2: CARE OF CLIENTS WITH ENDOCRINE DISORDERS
Transcribed by: Crisanta Grace Oponda Section: BSN 301 – 2nd Semester (S.Y 2022-2023)

 Obesity  1st degree relative – another risk factor aside

o Major risk factor for DM type 2 from obesity
o adipose tissues are resistant to insulin
 Viral infections
 Autoimmune disorders
 Women, who are multigravida with large babies

TYPE I DIABETES MELLITUS

 Also called “insulin dependent DM” (IDDM)
 Juvenile – onset
 Brittle or unstable DM
 Onset is before 30 years of age
 Absolute deficiency of insulin is due to absence of islet of Langerhans in
the pancreas
 The client is thin. This is due to inability of the body to obtain glucose
from carbohydrate. Therefore is increased production of ketones,
resulting in ketoacidosis
 The client is prone to Diabetic Ketoacidosis (DKA). In the absence of
insulin, fats are metabolized. There is increased production of ketones,
resulting in ketoacidosis

COLLABORATIVE MANAGEMENT
 Diet (3)  Kidneys have maximum amount of substance being absorbed,
 Insulin (always a component of management of IDDM) (1) the excess would be in urine
 Exercise and activity (2)  Cell hunger
Compliance is a must
HBA1C – GLYCOSYLATED HEMOGLOBIN
 The hemoglobin A1c (glycated hemoglobin, glycosylated
TYPE II DIABETES MELLITUS
hemoglobin, HbA1c, or A1c) test is used to evaluate a person's
 Also called as “Non-insulin dependent DM” (NIDDM)
 Maturity or non-juvenile onset level of glucose control.
 Ketosis resistant DM  Normal: less than 6
 Onset is after age 30 years  Assess glucose control and compliance
 With relative lack of insulin or resistance is the action of insulin, usually COLLABORATIVE MANAGEMENT
insulin is sufficient to stabilize fat and protein metabolism but not to  Diet (1)
deal with carbohydrate metabolism  Oral hypoglycemic agent (3)
 The client is obese  Activity and exercise (2)
 The client is prone to hyperglycemic hyperosmolar non-ketotic coma Calories restriction
(HHNC). This is extreme hyperglycemia without acidosis SFF 6 times a day
 Metabolic syndrome Best diet: calorie restriction
 High yield: 3 or more of the ff: ORAL HYPOGLYCEMIC AGENTS (OHA) OR INJECTIBLE HYPOGLYCEMIC
o FBS - >126 mg/dl AGENTS (IHA)
 NPO for 10 to 12 hours (8PM – 6 to 8AM)  If hypoglycemia is uncontrolled
 VENOUS BLOOD EXTRACTION  Insulin. In case stress, surgery, infections, and pregnancy. These
o Triglycerides - >150mg/dl conditions trigger stress responses and stimulate secretion of
o HDL – F: <50mg/dl; M: <40mg/dl epinephrine, norepinephrine and glucocorticoids. These hormones
o BP - >130/80 cause hyperglycemia
o BMI – F: >35; M - >40  A deficiency in insulin results in hyperglycemia
 SCHOOL OF NURSING
NCM 116: MEDICAL SURGICAL NURSING
MODULE 2: CARE OF CLIENTS WITH ENDOCRINE DISORDERS
Transcribed by: Crisanta Grace Oponda Section: BSN 301 – 2nd Semester (S.Y 2022-2023)

CLINICAL MANIFESTATIONS  Glucocorticoids, thiazide diuretics, and estrogen increase blood

 Polyuria, Polydipsia, Polyphagia (3 Ps) – more common type in Type I glucose levels (hyperglycemia)
DM)  Sulfonylureas should not be taken with alcohol. To prevent dusulfiram-
 Weight loss – more common in Type I DM like reactions
 Blurred vision  Inderal (propranolol) and other beta-adrenergic blockers may cause
 Slow wound healing hypoglycemia
 Infections: pyorrhea (periodontal infections), UTI, vasculitis, cellulitis,  Sulfonylureas may cause cardiac dysrhythmias
furuncles, carbuncles, vaginal infection  Sulfonylureas may cause GI symptoms. Hypoglycemia may occur
 Weakness and paresthesia SULFONYLUREAS MEDICATIONS
 Signs of inadequate circulation to the feet  Dymelor (acetohexamide)
 Signs of accelerated atherosclerosis (renal, cerebral, cardiac,  Diabenese (chlorpropramide)
peripheral)  Amaryl (glimepiride)
 Macrovascular complications include coronary artery disease,  Glucotrol (glipizide)
cardiomyopathy, hypertension, cerebrovascular disease, peripheral  Diabeta, Micronase (glyburide)
vascular diseases and infection  Tolinase (tolazamide)
 Microvascular complications include retinopathy, nephropathy and  Orinase (tolbutamide)
neuropathy NON-SULFONYLUREAS
COLLABORATIVE MANAGEMENT  Alpha glucosidase inhibitors
Diet  Precise (acarbose)
 Low calorie diet, especially if the client is obese  Glyset (miglitol)
 The diet should consist of:  Biguanide
o 20% protein  Metformin (Glucophage)
o 30% fats  Meglitinide
o 50% carbohydrates – complex carbs – matagal magturn as  Starlix (nateglinide)
glucose  Prandin (repaglinide)
 High fiber diet, especially vegetables  Thiozolidinediones
 Complex carbohydrates like rice, bread, pasta, root crops are preferred  Actos (pioglitazone)
Activity and Exercise – the benefits of regular pattern of exercise are as follows:  Avandia (rosiglitazone)
 Exercises increases glucose uptake by the cells. Therefore, it lowers INSULIN
blood glucose levels  Indicated in Type I DM
 Exercise lowers insulin requirements  Indicated in Type II DM when diet and weight control are ineffective to
 Exercise helps achieve desirable body weight maintain blood glucose levels
 Exercise helps maintain normal serum lipids. This reduces vascular risks  Regular insulin is type only insulin that can be administered
 Instruct the client on dietary adjustments when exercising intravenously in the emergency treatment of diabetic ketoacidosis
 Instruct client to monitor blood glucose before, during and after the  Aspirin, alcohol, oral anticoagulants, oral hypoglycemic drugs, beta
exercise period adrenergic blockers
 Tricyclic antidepressants, tetracycline, and MAOIs increase the
 Initially, the client who requires insulin should be instructed to eat 15g hypoglycemic effects of insulin causing glucocorticoids, thiazide
carbohydrates snack (a fruit exchange or a snack of complex diuretics, throid agents, oral contraceptives, and estrogen may cause
carbohydrate with a protein) before engaging in moderate exercise to hyperglycemia
prevent hypoglycemia  Illness, infection, and stress can elevate blood glucose levels and the
 If blood glucose level is greater than 250mg/dl and urinary ketones are need for insulin. Insulin should not be withheld during illness,
present (DM Type I), the client is instructed not to exercise until blood infection, and stress because hyperglycemia and ketoacidosis can
glucose is normal and urinary ketones are absent result
 It might cause atherosclerosis in:  The peak of action time of insulin is important because of the
o Coronaries possibility of hypoglycemic reactions occurring that time. The common
o Brain – CVA types of insulin are as follows:
o Pedal o Onset – fee
 Tingling, numbness, non-sensation, foot ulcer o Peak – decreases glucose, hypoglycemia
(end stage) o Duration – how long and until when
ORAL HYPOGLYCEMIC AGENTS INSULIN ONSET PEAK DURATION
 Indicated only in Type II DM HUMALOG (lispro) 15 MINS 30 MINS 4-5 HOURS
TYPES OF OHA NOVOLOG (insulin aspart) 5-10 MINS 3-5 HOURS
1. Sulfonylureas REGULAR (Humulin) ½ - 1 HOUR 2-4 HOURS 4 – 7 HOURS
a. Stimulates islet of Langerhans to secrete insulin R NOVOLIN R
b. Gliplizide, tolazamide – most common NPH 6 HOURS 8 - 10 12 HOURS
2. Biguanides HUMULIN N; NOBOLIN N HOURS
LENTE 1 – 3 HOURS 6 – 14 24 HOURS
a. Decrease hepatic formation of glucoe in liver HUMULIN L; NOVOLIN L HOURS
b. Metformin ULTRALENTE 6 HOURS 18 – 24 24 HOURS
3. Alpha glucosidase inhibitors HUMULIN U HOURS
a. Block glucose absorption in intestines INSULIN GLARGINE 6 HOURS 18 – 24 24 HOURS
b. Acarbose (LANTUS) HOURS
HUMULIN 70/30 ½ - 1 HOUR 2 – 12 18 – 24
4. Thiazolidiedion (70% NPH / 30% REGULAR) HOURS HOURS
a. Increase sensitivity in insulin receptor sites HUMULIN 50/50 ½ HOUR 3–5 24 HOURS
b. Bioglitazone (50% NPH / 50% REGULAR) HOURS
DRUG INTERACTIONS AND CONTRAINDICATIONS LISPRO/PROTAMINE 75/25 10 – 15 MINS 5 HOURS 24 HOURS
(75% LISPRO / 25%
 Aspirin, alcohol, sulfonamides, contraceptives and monoamine
PROTAMINE)
oxidase inhibitors (MAOI’s) increase the hypoglycemic effect, causing a
decrease in blood glucose levels (hypoglycemia)
 SCHOOL OF NURSING
NCM 116: MEDICAL SURGICAL NURSING
MODULE 2: CARE OF CLIENTS WITH ENDOCRINE DISORDERS
Transcribed by: Crisanta Grace Oponda Section: BSN 301 – 2nd Semester (S.Y 2022-2023)

INSULIN PUMP AND SKIN SENSOR COMPLICATIONS OF INSULIN THERAPY

 For patients with DM Type I 1. LOCAL ALLERGIC REACTIONS
 Needle change every 2-3 days a. Redness, swelling, tenderness and induration or a wheal at
 Pump last for 3 days the site of injection may occur 1 to 2 hours after
NURSING INTERVENTION administration
1. The main route of insulin injection is subcutaneous b. Instruct the client to avoid the use of alcohol to cleans the
2. The main areas for insulin are the abdomen, arms (posterior surface), skin before injection
thighs (anterior surface), and buttocks i. PNSS can do or just take a bath
a. Let the needle stay for about 1-2 secs for better absorption c. Administer anti histamine one hour before injection as
3. Administer insulin at 90⁰L. most insulin syringes have needle gauge 27 prescribed by the physician
to 29 that is about ½ inch long. 2. INSULIN LIPODYSTROPHY
4. Do not massage injection site to prevent rapid absorption a. Instruct the client to avoid injecting insulin into affected
5. Injections should be ½ inch apart within the anatomical area sites
6. To prevent lipodystrophy (hard fatty masses in the subcutaneous b. Instruct the client about the importance of rotating insulin
layer): injection site
a. Systematic rotation of the site pf injection. Reuse one site c. Instruct the client to inject insulin at room temperature
after at least 2 to 3 weeks d. Loss of SQ sites and injection sites having dimples
b. Administer insulin at room temperature. Cold insulin causes 3. INSULIN RESISTANCE
lipodystrophy a. The client receiving insulin develops i9mmune antibodies
Lipodystrophy inhibits insulin absorption that bind with the insulin, thereby decreasing the insulin
7. Gently roll vial in between the palms to redistribute insulin particles. available for use in the body
Do not shake the vial; bubble make it difficult to aspirate exact amount b. This condition may be managed by administering a purer
insulin preparation
4. DAWN PHENOMENON
a. Treatment is administering immediate – acting insulin (NPH)
at 10PM to control early morning hyperglycemia
b. Hyperglycemia upon wakening due to release of cortisol
5. SOMOGYI PHENOMENON
a. By 7AM, in response to the counter regulatory hormones,
the blood glucose rebounds to hyperglycemic range
(rebound hyperglycemia)
b. Treatment for Somogyi phenomenon includes decreasing
the evening (pre-dinner or bedtime) dose of immediate –
acting insulin, or increasing the bedtime snack
c. Normal blood glucose level during bedtime
d. Hyperglycemia takes place during 2-3AM
6. INSULIN WANING
a. Treatment includes increasing the evening (pre-dinner or
bedtime) dose of intermediate or long acting insulin before
the evening meal if one is not already prescribed

Storing insulin:
8. Prefilled insulin syringes should be kept in the refrigerator. These will
be potent for 7 days (1 week). The syringes should be kept flat or with
the needle in an upright position to prevent clogging of the needle
9. Is a vial of insulin will be used up to 30 days, it may be kept at room
temperature. Otherwise, the vial should be refrigerated
10. Avoid exposing insulin to extreme temperature
11. Insulin should not be frozen or kept in direct sunlight or a hot car
Regular insulin may be mixed with any other type of insulin
12. Insulin zinc suspensions (intermediate - acting) may be mixed only with
each other and regular insulin; not with other types of insulin
To mix insulin, the following nursing actions are done:
13. Introduce air into the vial of intermediate – acting insulin (e.g. NPH). Do
not aspirate or draw up the insulin yet
14. Introduce air into the vial of regular insulin, and draw up the insulin
15. Draw up the intermediate-acting insulin (NPH)
16. Administer a mixed dose of insulin within 5 to 15 mins of preparation
17. Avoid exposing insulin to extremes in temperature
18. Monitor client for complications of insulin therapy
Exercise potentiates insulin
Stress increase blood glucose levels