Endocrine System

ENDOCRINE SYSTEM Ma. Victoria J. Recinto, BSN, RN, USRN Pediatric Intensive Care Nurse University of the Philippines-Manila Philippine General Hospital

PANCREAS Located posterior to the stomach Influences CHO metabolism Indirectly influences CHON & fat metabolism Produces insulin & glucagon

PANCREAS Exocrine gland Endocrine gland Acinar cells Islets of Langerhans Pancreatic juices  cells  cells Glucagon Insulin (Hypergly) (Hypogly) (aids in digestion) Pass in pancreatic duct

DIAGNOSTIC STUDIES: Glucose tolerance test Aids in dx of DM: if glucose levels peak at higher than N at 1-2hrs after glucose IV or po & slower than N to return to fasting levels Will take 3-5 hrs, pt is given glucose IV or po & multiple blood samples

DIAGNOSTIC STUDIES: Glucose tolerance test- pt. prep Before the test: Diet with adequate CHO (3 days) No alcohol, coffee & smoking (36 hrs) Fast (10-16 hrs) Withhold AM insulin or OHA (for DM pt) Avoid strenuous exercise (8 hrs, & after the test)

DIAGNOSTIC STUDIES: Glycosylated Hgb A Blood glucose bound to Hgb Reflects how well blood glucose levels have been controlled for the past 3-4 mos.  levels: hyperglycemia in DM pt N (DM pt)= ≤7.5% N (without DM)=4-6% Fasting not needed

Diabetes Mellitus Chronic disorder Impaired CHO, CHON & fat metabolism r/t insulin deficiency Cx: CAD, cardiomyopathy, HTN, CVA, PVD, infection, retinopathy, nephropathy, neuropathy

Diabetes Mellitus Macronutrient Anabolism Catabolism CHO Glucose Glycogen CHON Amino acid Nitrogen Fats Fatty acids Free fatty acids: Cholesterol & Ketones

Diabetes Mellitus Hyperglycemia Osmotic diuresis Polyuria Glycosuria Cellular dehydration Cellular starvation Stimulate thirst center Stimulate satiety center Hypothalamus Polydipsia Polyphagia

Type 1 Diabetes Mellitus Insulin-dependent/Juvenile Onset Nearly absolute deficiency of insulin If insulin is not given  fat metabolism  ketonemia (acidosis) DKA Incidence rate: 10% of gen. pop. Predisposing Factors Children, non-obese Cause: Unknown 90%: hereditary, total destruction of  cells Viruses Toxicity to CCl4 Drugs: Furosemide (Lasix) & Pentamide HCl (Pentam)

Type 1 Diabetes Mellitus S/Sx 3P’s + glycosuria Wt loss, A/N/V Blurred vision  susceptibility to infection  wound healing

Type 1 Diabetes Mellitus Tx Diet Exercise Insulin tx WOF Cx: DKA

Nursing Interventions: Diet The total no. of calories is individualized based on pt’s wt & other existing health problems Follows the food exchange from the American Diabetic Association (Food Guide Pyramid) Depending on the pt’s needs, lifestyle, cultural & socioeconomic status

Nursing Interventions: Exercise Benefits  blood glucose & cholesterol  cardiovascular risks  circulation & muscle tone  wt Monitor CBG before, during & after exercise (deferred if >250 mg/dL & (+) urine ketones) If taking insulin, eat a 15-g CHO snack (a fruit exchange) or complex CHO with CHON before mod. exercise

Insulin Therapy Used when diet & wt control have failed to maintain blood glucose levels Sources Animal: Pork/Beef- rarely used r/t anaphylaxis Human: e.g. Humulin R- less allergic reaction Artificial compounds ASA, alcohol, warfarin, OHA,  -blockers, TCA, MAOI, tetracycline  severe hypogly Steroids, thizide diuretics, thyroid agents, OCP & estrogen  severe hypergly Illness, infection & stress  blood glucose &  insulin needs

Insulin Therapy Types Consistency Peak Regular acting: Humulin R Clear 2-4 hrs Intermediate-acting: NPH (Humulin H) Cloudy 8-16 hrs Long-acting: Ultralente (Humulin U) Cloudy 16-24 hrs

Insulin Therapy Type Onset Peak (hrs) Duration (hrs) Rapid-acting: Lispro (Humalog) 15 min ½-1 ½ 4-5 Insulin aspart (Novolog) 5-10 min 1-3 3-5 Short-acting: Regular (Humulin R, Novolin R) ½-1 hr 2-4 5-7 Intermediate-acting: NPH (Humulin N, Novolin N) 1-2 hrs 6-14 24 Lente (Humulin L, Novolin L) 1-3 hrs 6-14 24

Insulin Therapy Type Onset Peak (hrs) Duration (hrs) Long-acting: Ultralente (Humulin U) 6 hrs 18-24 36 Insulin glargine (Lantus) - - 24 Premixed: 70% NPH/30% regular (Humulin 70/30) ½-1 hr 2-12 18-24 50% NPH/50% regular (Humulin 50/50) ½ hr 3-5 24 75% Lipro Protamine/25% Lispro 10-15 mins 1-6 24

Nursing Interventions: Storing Insulin Avoid exposure to extremes in T, should not be frozen or kept in direct sunlight or hot car Administer at room T (esp. if vial will be used up in a mo., otherwise should be refrigerated) to prevent lipodystrophy Store prefilled syringes (stable for 1 wk), keep the syringes flat or with needle in upright position to avoid clogging of the needle

Nursing Interventions: Administering Insulin 1ml TB syringe= 100 units Use G27 or 29 needle, ½ in long Gently roll vial between palms, don’t shake not to create bubbles, mix well Inject air to insulin vial before aspirating Aspirate clear 1 st before cloudy to prevent contamination & to promote proper calibration Administer mixed dose of insulin within 5-15 mins to maximize its tx effect

Nursing Interventions: Administering Insulin Administer at either 45-90  angle depending on the pt’s tissue deposit Don’t aspirate syringe after injection Rotate injection sites Main sites: abdomen (even & rapid absorption), posterior arms, anterior thighs, hips Do not use same site more than once in 2-3 wks Injections should be 1.5 in apart within the anatomical area Avoid heat, massage & exercise at the injected area   absorption  hypogly Avoid injection into scar tissue   absorption

Nursing Interventions: Administering Insulin WOF Cx and provide tx Local allergic reaction esp. during early stages of tx Avoid using alcohol for skin prep Antihistamine 1 hr before injection Lipodystrophy Use human insulin, rotate injection sites Insulin resistance Use pure insulin

Nursing Interventions: Administering Insulin WOF Cx and provide tx Dawn phenomenon: develops bet. 5 & 8 am (prebreakfast hypergly), r/t nocturnal release of growth hormone Give intermediate-acting insulin at 10 pm Somogyi phenomenon: hypogly at 2-3 am with rebound hypergly at 7 am  intermediate-acting insulin or  bedtime snack Insulin waning- progressive hypergly from bedtime to morning  evening dose of intermediate-acting insulin

Diabetic Ketoacidosis Gluconeogenesis CHON breakdown Fat breakdown (-) N2 balance FFA ketones Tissue wasting Atherosclerosis Ketoacidosis Cachexia HTN DKA MI CVA

Diabetic Ketoacidosis Acute Cx of IDDM r/t severe hypergly  CNS depression with coma Precipitating factors: stress, hypergly, infection, missed or  insulin dose

Diabetic Ketoacidosis: S/Sx 3Ps + 1 g CBG: 300-800 mg/dL A/N/V Wt. loss, dehydration Acetone breath (fruity odor) Kussmauls’ respiration: rapid, shallow breathing  LOC  coma  FBS, BUN, crea, Hct, ABG: metabolic acidosis

Nursing Interventions: Diabetic Ketoacidosis Assist in mech. vent. Administer as ordered Rapid IVF: 0.9NaCl followed by 0.45NaCl (to counter DHN), then D5 0.45 NaCl when CBG= 250-300 mg/dL (WOF  ICP r/t cerebral edema) Regular Insulin: only given IV, prime the IV tubing then discard the 1 st 50 cc solution or given with albumin to prevent sticking to the IV tubing NaHCO3, K+ supplements (WOF for hypoK esp. within the 1 st hr of tx) Antibiotics

Type 2 Diabetes Mellitus Non-insulin dependent/Adult or Maturity Onset Resistant to action of insulin Insulin is enough to stabilize fat & CHON but not CHO Incidence rate: 90% of gen. pop. Predisposing Factors >40 y/o 90%: Obese (lack of insulin receptor binding sites)

Type 2 Diabetes Mellitus S/Sx Asymptomatic at first then: 3 P’s + glycosuria Tx Oral Hypoglycemic agents Diet Exercise WOF Cx: Hyper Osmolar Non-Ketotic Coma (HONKC)

Oral Hypoglycemic Agents Action: stimulates pancreas to secrete insulin Sulfonylureas 1 st gen. Chlorpropamide (Diabinese) Tolbutamide (Orinase) Tolazamide (Tolinase) 2 nd gen. Glucotrol (Glipizide) Glyburide (Diabeta, Micronase) Biguanide: Metformin (Glucophage) OHA should not be taken with Aluminum hydroxide, alcohol, ASA, OCP, sulfonamide, MAOI  severe hypogly Steroids, thiazide diuretics & estrogen  severe hypergly

Hyper Osmolar Non-Ketotic Coma Slow onset of severe hypergly (CBG=600-1,200 mg/dL) Hyperosmotic  severe DHN Non-Ketotic  (-) ketones in urine & blood, no acidosis HA, irritability, agitation, sz,  LOC  Coma Tx: same as in DKA except NaHCO3 & insulin

Nursing Interventions: DM Monitor VS, I/O, CBG Monitor for peak action of insulin Monitor for S/Sx of hypo (or hypergly) T-remors, tachycardia I-rritability R-estlessness E-xcessive hunger, weakness D-epression, diaphoresis

Nursing Interventions: DM During mild (CBG<60 mg/dl) to moderate hypogly (CBG<40 mg/dl) : give 10-15 g fast-acting simple sugar (check CBG after 15 mins. then give a regular meal or food with CHON & CHO e.g. milk & cheese within 1 hr Commercially prepared glucose tab. 6-10 Life Savers or hard candy 4 tsp of sugar 4 sugar cubes 1 tbs honey or syrup ½ cup fruit juice or regular softdrink 8 oz low-fat milk 6 saltin crackers 3 graham crackers

Nursing Interventions: DM During severe hypogly (CBG<20 mg/dl): give glucagon SQ or IM up to a 2 nd dose after 10 mins. if pt is still unconscious, or 25-50 cc D50W IV

Nursing Interventions: DM Provide diabetic diet: alternative food products & not to skip meals Encourage exercise after meals Encourage annual eye & kidney exam

Nursing Interventions: DM Meticulous Skin & Foot care (r/t peripheral neuropathy) Inspect feet & between toes OD, keep it dry (no foot soaks) Wear well-fitting socks to keep feet warm, Change socks OD Don’t wear same pair of shoes 2 days in a row Don’t wear open-toed shoes or with a strap across toes

Nursing Interventions: DM Meticulous Skin & Foot care (r/t peripheral neuropathy) Check shoes for cracks/tears/foreign objects before wearing Don’t walk barefooted Cut toenails straight, smooth nails with an emery board Apply lanolin lotion but not in between toes Avoid restrictive garments, leg crossing, heating pads, hot water & baths

Nursing Interventions: DM Monitor for U/A: ketones/glucose (since Tape-test method & Clinistix may cause inaccurate results), 2 nd voided urine is most accurate Assist in surgical wound debridement, BKA, AKA

Nursing Interventions: DM WOF Cx Atheroslerosis, HTN, MI, CVA Microangiopathy Eyes: Retinopathy, premature cataract, retinal detachment, blindness Kidneys: Nephropathy, Recurrent pyelonephritis, ARF Peripheral neuropathy  PVD, sexual impotence Shock r/t DKA & HONKC Gangrene formation

Endocrine System

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Endocrine System