Endocrine System Disorder

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• Endocrine System Disorder

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Endocrine System

• The foundations of the endocrine system are the
  hormones and glands. As the body's chemical
  messengers, hormones transfer information and
  instructions from one set of cells to another.
• The major glands that make up the human endocrine
  system are t hypothalamus
• - pituitary
• - thyroid
• - parathyroids
• - adrenals pineal body
• - and the reproductive glands, which include
  the ovaries and testes.
• The pancreas is also part of this
  hormone-secreting system, it is also associated
  with the digestive system because it also
  produces and secretes digestive enzymes.

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Pancreas

• The pancreas is a glandular organ that secretes
  digestive enzymes (internal secretions) and
  hormones (external secretions). In humans, the
  pancreas is a yellowish organ about 7 inches
  (17.8 cm) long and 1.5 inches. (3.8 cm) wide.
• The pancreas lies beneath the stomach and is
  connected to the small intestine at the duodenum

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Pancreas - Functions

• The pancreas contains enzyme producing cells that
  secrete two hormones.
• The two hormones are insulin and glucagon.
  Insulin and glucagon are secreted directly into
  the bloodstream, and together, they regulate the
  level of glucose in the blood.
• Insulin lowers the blood sugar level and
  increases the amount of glycogen (stored
  carbohydrate) in the liver.
• Glucagon slowly increases the blood sugar level
  if it falls too low. If the insulin secreting
  cells do not work properly, diabetes occurs.

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Pancreas - Function

• The pancreas also helps neutralize chyme and
  helps break down proteins, fats and starch.
• Chyme is a thick semi-fluid mass of partly
  digested food that is passed from the stomach to
  the duodenum.
• If the pancreas is not working properly to
  neutralize chyme and break down proteins, fats
  and starch, starvation may occur.
• Conditions of the Pancreas
• Pancreatitis is a condition that affects the
  pancreas.

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Pancreas location anatomically
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Pancreas
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Endocrine Disorder

• Diabetes Millitus
• Diabetes Mellitus is a chronic multisystem
  disease related to abnormal insulin production,
  impaired insulin use, or both.
• Insulin is a hormone that helps the glucose get
  into the cells to give them energy. With Type 1
  diabetes, the body does not make insulin. With
  Type 2 diabetes, the more common type, the body
  does not make or use insulin well. Without enough
  insulin, the glucose stays in your blood.

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Diabetes Mellitus

• DM is a serious health problem throughout the
  world.
• Leading cause of end-stage renal disease.
• Adult blindness.
• Non-traumatic limb amputation.
• Major contributing Factor in
• Heart disease and stroke
• Decreased tissue perfusion in D.M. may lead to
  cardiovascular disease, hypertension, renal
  failure, blindness, and stroke

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Diabetes Mellitus

• Over time, having too much glucose in blood can
  cause serious damage to eyes (retinopathy),
  kidneys (nephropathy), and nerves (neuropathy).
• Diabetes can also cause
• - heart disease
• - stroke
• - amputation (need to remove a limb).
• - Pregnant women can also get diabetes,
  called
• gestational diabetes.

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Current Theories leading to its Etiology

• Genetic
• Autoimmune
• Viral
• Environmental factors (e.g. viral and stress).
• Two Most Common Types
• Type 1 IDDM, Juvenile Diabetes
• Type 2 NIDDM, Adult Onset DM
• Gestational, pre-diabetes, secondary diabetes

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Diagnostic tests

• Diagnostic criteria
• Two findings (separate days) of one of the
  following
• Symptoms of DM plus casual plasma
• glucose concentration of greater than 200
  
• mg/dL ( without regard to time since last
  
• meal).
• Fasting Blood Glucose greater than 126 mg/dL (8
  hour fasting).
• Two-hour glucose greater than 200 mg/dL with an
  oral glucose tolerance test (10 to 12 hr.
  fasting).

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DM Diagnostic Tests Nursing Intervention

• FBG or FBS ensure client has fasted for 8 hours
  prior to the blood draw. Antidiabetic
  (hypoglycemic agents) medications should be
  postponed until after the level is drawn.
• Pre-meal glucose The target is 90 130 mg/dL.
  Follow or ensure that the client follow the
  procedure for blood sample collection and use of
  glucose meter. Supplemental short-acting insulin
  maybe prescribed for elevated pre-meal glucose
  levels.

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DM Diagnostic Tests Nursing Intervention

• Oral Glucose Tolerance Test (OGTT) Instruct the
  client to consume a balanced diet for the three
  days prior to the test. Then instruct the client
  to fast for 10 12 hr. prior to the test.
• A FBS is drawn at start of the test. The
  client
• is then instructed to consume a specified
• amount of glucose. BG level or CBG level are
• drawn every 30 min. for 2 hr. Client must be
  
• assessed for hypoglycemia throughout the
• procedure

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DM Diagnostic Tests Nursing Intervention

• Glycosylated Hemonglobin (Hgb A1- C)
• - This is used to determine the long-term
• compliance of client to DM treatment
• regimen.
• The target is 4 to 6 Hgb A1-C. HgbA1-C is the
  best indicator of average blood glucose for past
  120 days. Assist for evaluating treatemtn
  effectiveness and compliance.

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Assessments Sign and Symptoms to look
forStart prioritizing
Type 1 Type 2
Polyuria, polydipsia, polyphagia Polyuria, polydipsia, polyphagia
Weight Loss Obesity
Fatigue Fatigue
Increase frequency of infections Increase frequency of infections
Rapid Onset Gradual Onset
Controlled by exogenous insulin Controlled by Oral hypoglycemic medications and insulin
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Sign and Symptoms by Glucose Alteration
Hypoglycemia ( equal or less than 50 mg/dL) Hyperglycemia (equal or more than 250 mg/dL)
Cool clammy skin Hot, dry skin
Diaphoresis (sweating) Absence of diaphoresis (absence of sweating)
Anxiety, irritability, confusion, blurred vision Alert to coma ( varies)
Hunger Nausea and vomiting, abdominal pain (with ketoacidosis)
General weakness, seizure ( severe hypoglycemia Rapid deep respiration (Kaussmals breathing) acetone/fruity odor due to ketones this is resulting from Diabetic ketoacidosis
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Blood Glucose monitors
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Glucose Continuum
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Normal Insulin Secretion
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Insulin Preparations
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Insulin Pen
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Insulin Pump
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Subcutaneous Injection Sites
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Type 1 DM (Insulin Dependent DM)

• Type 1 diabetes ( Juvenile Diabetes Mellitus)
• When the pancreas fails to produce enough
  insulin, type 1 diabetes (previously known as
  juvenile diabetes) occurs. Often occurs in people
  who are less than 40 years old.
• Symptoms include excessive
• - thirst, hunger, urination, and weight
  loss.
• In children and teens, the condition is usually
  an autoimmune disorder in which specific immune
  system cells and antibodies produced by the
  immune system attack and destroy the cells of the
  pancreas that produce insulin.

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Diabetes Millitus

• The disease can cause long-term complications
  including kidney problems, nerve damage,
  blindness, and early coronary heart disease and
  stroke.
• To control blood sugar levels and reduce the risk
  of developing diabetes complications, kids with
  this condition need regular injections of insulin

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Type I - DM

• Autoimmune disorder due to beta cell destruction
• Occurs in genetically susceptible individuals
  (islet cell antibodies)
• Typical onset is before the age of 30
• Can result in ketoacidosis (DKA).
  
  
  
  
  
  
  
  
  

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Pathophysiology

• Type 1 DM is auto-immune mediated disease. The
  bodys own T-Cell attack and destroy the
  pancreatic beta cells which are the source of
  insulin. In addition, autoantibodies to the islet
  cells cause a reduction of 80 to 90 of normal
  B cell before hyperglycemia and other
  manifestations occur.
• A genetic predisposition and exposure to virus
  may contribute to the pathogenesis of Type 1 DM.

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Pathophysiology

• Type 1 is associated with long preclinical
  period. Islet cell antibodies responsible for
  B-cell destruction are present for months to
  years before onset of symptoms.
• Manifestation develops when the persons pancreas
  can no longer produce sufficient amount of
  glucose to maintain normal glucose. Once this
  occur, the onset of symptoms is usually rapid.

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Type I - DM

• Clinical Characteristics
• serum glucose of 350 and above
• ketonuria in large amounts
• venous pH of 6.8 to 7.2
• serum bicarbonate below 15 mEq/dl
• 3 Ps
• Sudden weigh loss
• Without insulin, the cleint develops diabetic
  ketoacidosis (DKA), a life threatening condition
  resulting in metabolic acidosis.

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Prediabetes

• It is a condition in which individuals are at
  increased risk for developing diabetes.
• Blood glucose are high but not high enough to
  meet diagnostic criteria for DM.
• Impaired Fasting Glucose (IFG) or Impaired
  glucose tolerance (IGT).
• Most people with prediabetes are at increased
  risk for developing Type 2 DM, and if no
  preventive measures are taken, they will usually
  develop it within 10 years.

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DM- Type 1 Collaborative Care and Treatment

• The goal of DM management is to reduce symptoms
  and promote well-being, prevent acute
  complications of hyperglycemia, and prevent or
  delay the onset and progression of long term
  complications.
• Nutrition
• Drug therapy
• Exercise
• And self-monitoring of blood glucose are the
  tools used in management of DM.

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Drug Therapy

• The two major types of glucose lowering agents
  (GLAs) used in treatment of DM are insulin and
  oral hypoglycemic agents.
• Insulin exogenous insulin is needed when a
  client has inadequate insulin to meet specific
  metabolic needs.
• Type 1 requires insulin to survive.
• Type 2 requires insulin during period of severe
  stress such as illness or surgery.

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Insulin

• Insulin is prepared through the use of genetic
  engineer ( derived from common bacteria (e.g. E.
  Coli) or yeast cells using recombinant DNA
  technology.
• They differ in regards to onset, peak, and
  duration.
• Categorized as rapid acting, short-acting,
  intermediate-acting, and long acting.

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Drug Therapy Types of Insulin
Classification Example Clarity of Solution Characteristics
Rapid-Acting Insulin Humalog ( Lispro) Aspart (Novolog) Glulisine (Aapidra) Clear Onset less than 15 minutes. Peak 0.5 to 1.5 hr. Duration 2- 6 hr. Administer 5 to 15 min before meals
Short-Acting Insulin Regular (Humulin R, Novolin R, ReliOn R) Clear Onset 30 60 min. Peak 2 - 3 hr. Duration 3 10 hr. Administer 30 min before meals
Intermediate-Acting Insulin NPH ( Humulin N, Novolin N, ReliOn N) Cloudy Onset 2 - 4 hr. Peak 4 10 hr. Duration 10 - 18 hr.
Long Acting Insulin Glargine (Lantus) Detemir (Levemir) Clear Peak None Duration 24 hour acting
Combination Therapy NPH/Regular 70/30 (humulin 70/30, Novolin 70/30, ReliOn 70/30 NPH/Regular 50/50 Lispro protamine/lispro 50/50 (Humalog Mix Aspart protamine/aspart 70/30 (Novolog mix 70/30 Cloudy
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insulin pump
insulin pen
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Subcutaneous Injection Sites
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Self-administration of insulin

• Rotate injection sites
• Inject at a 90 angle (45 if thin). do not
  aspirate
• When missing rapid or short with long acting
  insulin draw up the shorter-acting insulin into
  the syringe first and than the longer-acting
  insulin (reduces the risk of introducing
  longer-acting insulin into shorter-acting insulin
  vial).
• Observe client perform self-administration and
  offer additional instruction as indicated.

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Nursing Related to Insulin Therapy

• Proper administration assessment of clients
  response to insulin therapy, and education of the
  client regarding administration of insulin , and
  adjustment to, and monitoring and reporting of
  side effects of insulin.
• Assess the client who is new to insulin and
  evaluate ability to manage this therapy safely.
  This include the ability to understand
  interaction of isulin, diet, and activity, and to
  be able to recognize and treat appropriately the
  sysmptoms of hypoglycemia.

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Nursing Related to Insulin Therapy

• The client and the caregiver must also be able to
  prepare and inject the insulin ( see Table 49-5
  Lewis et al., 2011 pg. 1226. Additional teaching
  or resources is needed if client or caregiver
  lacks the ability.
• Follow-up assessment of the client ( e.g.
  lipodystrophy, hypoglycemic episodes, and
  handling of hypoglycemic episodes).
• A review of the client record of urine and blood
  glucose test is also important overall glycemic
  control.

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Type II

• Often due to the development of resistance to
  endogenous insulin
• Individuals with a family disposition,
  individuals who are obese and over the age of 40
• obesity, physical inactivity, high triglycerides
  (gt250 mg/dl), and hypertension are the hallmark
  risk factors for the development of insulin
  resistance.

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Type II - DM

• Type 2 diabetes, the most common type, can start
  when the body doesn't use insulin as it should.
  If body can't keep up with the need for insulin,
  the individual may need to take pills
  (hypoglycemic agents).
• Some individuals need both insulin and pills.
  Along with meal planning and physical activity,
  diabetes pills help people with type 2 diabetes
  or gestational diabetes keep their blood glucose
  levels on target.
• Several kinds of pills are available. Each works
  in a different way. Many people take two or three
  kinds of pills.
• Some people take combination pills. Combination
  pills contain two kinds of diabetes medicine in
  one tablet. Some people take pills and insulin.

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Type II

• Clinical Characteristics (sign and symptoms)
• hyperglycemia
• plasma hyperosmolality
• dehydration
• changed mental status
• Treatment
• isotonic IV fluid replacement and careful
  monitoring of potassium and glucose levels
• intravenous insulin (not always necessary)

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signs symptoms of glucose alteration
hypoglycemia ( 50 mg/dL) hyperglycemia (gt250 mg/dL)
cool, clammy skin hot, dry skin
diaphoresis absence of diaphoresis
anxiety, irritability, confusion, blurred vision alert to coma (varies)
hunger nausea, vomiting, abdominal pain (with ketoacidosis)
general weakness, seizures (severe hypoglycemia) rapid deep respirations (acetone/fruity odor due to ketones)
slurred speech blurred vision
weight loss hunger
weakness lethargy
syncope confusion
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Oral Agents

• Sulfonylureas
• Biguinides
• Alpha-glucosidase inhibitors
• Thiazolidinediones
• Meglitindes

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oral anti-diabetic medications

• administer as prescribed
• avoid alcohol with sulfonylurea agents
  (disulfiram-like reaction)
• monitor renal function (biguanides)
• monitor liver function (thiazolidinediones and
  alpha-glucosidase inhibitors
• women of childbearing age may need to take
  additional contraception methods since the drugs
  reduce the blood levels of some oral
  contraceptives

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Sick Day Management

• Illness and or infection can raise blood glucose
• the bodys response to illness and stress is to
  produce glucose. any illness may result in
  hyperglycemia
• Patient teachings
• teach client to keep taking insulin or oral
  anti-diabetic agents
• monitor glucose more frequently (every 4 hours)
• watch for signs of hyperglycemia
• rest

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Exercise

• regular, non-strenuous exercise
• exercise after mealtime
• exercise with a partner or let someone know where
  the exercise will take place to ensure safety.
• a snack may be needed before or during exercise

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Diet
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Diabetic Diet

• Type 1 Diabetes Diet - Type 1 diabetes always
  requires insulin treatment, the main focus is to
  find a balance between the food intake and
  insulin.
• Type 2 Diabetic Diet - Type 2 diet focus on
  controlling weight in order to improve the body's
  ability to utilize insulin. In most cases Type 2
  diabetes can be controlled through proper diet
  and exercise alone.
• Gestational Diabetes Diet - unlike the Type 2
  diet, gestational diabetes diet focus on adequate
  energy and nutrients to support both the mothers
  body and growing baby while maintaining stable
  blood glucose levels for the pregnant mother.

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Diabetic Diet

• Healthy eating helps to reduce blood sugar. It is
  a critical part of managing diabetes, because
  controlling blood sugar can prevent the
  complications of diabetes.
• Wise food choices are a foundation of diabetes
  treatment.
• Diabetes experts suggest meal plans that are
  flexible and take lifestyle and other health
  needs into account.
• Healthy diabetic eating includes
• - Limiting sweets
• - Eating often
• - Being careful about when and how many
  carbohydrates is being
• eaten.
• Eating lots of whole-grain foods, fruits and
  vegetables
• Eating less fat
• Limiting your use of alcohol

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Diabetic Diet Goal

• The diet goal is to eat a balanced, portion
  controlled meal that will allow body to stay on
  an even keel throughout the day as the components
  of each meal hit the system.
• Eating every two to three hours is best, five or
  six small meals being recommended, and light
  exercise after each meal will help kick start the
  digestive system and prevent a spike in sugar
  levels.

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Diabetic Diet Sample Meal And Food

• One serving of protein (3 oz of chicken, lean
  beef or fish)
• One serving of bread (whole grain roll, tortilla
  or ½ cup pasta)
• One serving of dairy (cheese, milk or low-fat
  sour cream)
• One serving vegetables (fist sized portion or a
  small bowl of salad)
• One serving fruit (tennis ball sized or ½ cup
  sliced)
• Small amounts of unsaturated fats are needed, so
  add a little dressing or a pat of soft margarine.
  Avoid sweets consider the fruit your dessert!
• Foods that should be avoided include fatty red
  meat, organ meat, highly processed food, fried
  food, fast food, high cholesterol food and foods
  rich in saturated fat.

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Diabetic Diet

• Generally Type 2 diabetic patients need 1500-1800
  calorie diet per day to promote weight loss.
• Calories requirement may vary depending upon
  patients age, sex, activity level and body
  weight. 
• Half of total daily required calories should
  come from carbohydrates.
• One gram of carbohydrate is about 4 calories. A
  diabetic patient on a 1600 calorie diet should
  get half of these calories from carbohydrate. In
  other words it will be equal to 800 calories from
  carbohydrates, it means they need 200gms of
  carbohydrates everyday.

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Improving The Sensitivity For Insulin

• When glucose balance is improved, the sensitivity
  of all cells to the hormone insulin also
  improves.
• Very important because insulin is the hormone
  which opens the doors in all cells to allow
  glucose to enter, in order to supply fuel for the
  production of energy.
• Once this process is ineffective or out of
  balance diabetic symptoms, signs of diabetes, pre
  diabetes, or the cause of diabetes can occurs.

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Hypoglycemia

• check blood glucose levels
• treat with 15 g carbohydrates
• recheck blood glucose in 15 minutes
• if still low, give 15 more g of carbs
• recheck blood in 15 minutes
• if normal, take 7 g of protein (if next meal is
  more than an hour away)

?15 g of carbs (examples) 4 oz orange juice, 2
oz grape, 8 oz milk, glucose tablets ?7 g
protein (example) 1 oz string cheese fluid is
more readily absorbed (juice, non-diet drink,
skim milk
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NANDA nursing diagnosis

• risk for injury
• imbalanced nutrition
• risk for impaired skin integrity
• deficient knowledge
• self-care deficit
• ineffective coping

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• eye problems damage to blood vessels in the eyes
  (retinopathy), pressure in the eye (glaucoma),
  and clouding of the eye (cataract)
• tooth and gum problems (periodental disease)
  loss of teeth and bone
• blood vessel (vascular) disease leading to
  circulation problems, heart attack, or stroke
• problems with sexual function
• kidney disease (nephropathy)
• nerve problems (neuropathy), causing pain or loss
  of feeling in your feet and other parts of your
  body
• hight blood pressure (HTN), putting strain on
  your heart and blood vessels
• serious infections possibly leading to loss of
  toes, feet or limbs

Complications
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Diabetic retinopathy

• can cause blindness
• encourage yearly exams refer to opthalmologist.
• encourage management of glucose levels
• diet low fat, high in fruits, vegetables ad
  whole grains
• encourage a dietary consult

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Foot care for the diabetic clients

• inspect feet daily and wash with mild soap and
  warm water
• pat feet gently especially between the toes
• use mild foot powder on sweaty feet
• do not use commercial remedies for calluses or
  corns
• consult a podiatrist
• cut toenails even with rounded contour of toes
• cut toe nails after a bath or shower
• separate overlapping toes with cotton or lambs
  wool
• do not go out barefoot
• wear clean absorbent socks
• do not use water bottles or heating pads to warm
  feet. wear socks for warmth.

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complications
diabetic foot ulcer
diabetic retinopathy
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Diabetic Ketoacidosis DKA
Acute, life threatening condition characterized
by hyperglycemia (gt300 mg/dL) resulting in
breakdown of body fat for energy and an
accumulation of ketones on the blood and urine.
The onset is rapid, and the mortality rate of
DKA is 1 to 10
most common in individuals with type I diabetes
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Diabetic Ketoacidosis
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Diabetic Ketoacidosis
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Hyperglycemic-Hyperosmolar Nonketonic Syndrome
(HHNS)
Acute life-threatening condition characterized by
profound hyperglycemia (gt600 mg/dL), dehydration,
and absence of ketosis. the onset it generally
over several day, and the mortality rate of HHNS
is up to 15 or more
more common in older adult clients and in
individuals with untreated or diagnosed type II
diabetes
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Nursing management DKA/HHS

• Patient closely monitored
• Administration
• IV fluids
• Insulin therapy
• Electrolytes
• Assessment
• Renal status
• Cardiopulmonary status
• Level of consciousness
• Patient closely monitored
• Signs potassium imbalance
• Cardiac monitoring
• Vital signs

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laboratory analysis
Diagnostic Procedure DKA HHNS
serum glucose levels gt300 mg/dL gt600 mg/dL
serum electrolytes ? sodium ?potassium Na increased due to water loss K initially low due to diuresis, may increase due to acidosis increased secondary to dehydration
serum renal studies ? BUN ?Creatinine increased secondary to dehydration increased secondary to dehydration
ketone levels ? serum ?urine present present absent absent
serum pH (ABG) metabolic acidosis with respiratory compensation (Kussmaul respirations) absence of acidosis