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Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
Endocrine System
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  • 1. ENDOCRINE SYSTEM Ma. Victoria J. Recinto, BSN, RN, USRN Pediatric Intensive Care Nurse University of the Philippines-Manila Philippine General Hospital
  • 2. PANCREAS
    • Located posterior to the stomach
    • Influences CHO metabolism
    • Indirectly influences CHON & fat metabolism
    • Produces insulin & glucagon
  • 3. 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
  • 4. 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
  • 5. 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)
  • 6. 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
  • 7. Diabetes Mellitus
    • Chronic disorder
    • Impaired CHO, CHON & fat metabolism r/t insulin deficiency
    • Cx: CAD, cardiomyopathy, HTN, CVA, PVD, infection, retinopathy, nephropathy, neuropathy
  • 8. Diabetes Mellitus Macronutrient Anabolism Catabolism CHO Glucose Glycogen CHON Amino acid Nitrogen Fats Fatty acids Free fatty acids: Cholesterol & Ketones
  • 9. Diabetes Mellitus
    • Hyperglycemia
    • Osmotic diuresis
    • Polyuria Glycosuria
    • Cellular dehydration Cellular starvation
    • Stimulate thirst center Stimulate satiety center
    • Hypothalamus
    • Polydipsia Polyphagia
  • 10. 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)
  • 11. Type 1 Diabetes Mellitus
    • S/Sx
      • 3P’s + glycosuria
      • Wt loss, A/N/V
      • Blurred vision
      •  susceptibility to infection
      •  wound healing
  • 12. Type 1 Diabetes Mellitus
    • Tx
      • Diet
      • Exercise
      • Insulin tx
      • WOF Cx: DKA
  • 13. 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
  • 14. 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
  • 15. 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
  • 16. 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
  • 17. 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
  • 18. 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
  • 19. 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
  • 20. 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
  • 21. 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
  • 22. 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
  • 23. 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
  • 24. Diabetic Ketoacidosis
    • Gluconeogenesis
    • CHON breakdown Fat breakdown
    • (-) N2 balance FFA ketones
    • Tissue wasting Atherosclerosis Ketoacidosis
    • Cachexia HTN DKA
    • MI CVA
  • 25. Diabetic Ketoacidosis
    • Acute Cx of IDDM r/t severe hypergly  CNS depression with coma
    • Precipitating factors: stress, hypergly, infection, missed or  insulin dose
  • 26. 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
  • 27. 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
  • 28. 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)
  • 29. 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)
  • 30. 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
  • 31. 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
  • 32. 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
  • 33. 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
  • 34. 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
  • 35. Nursing Interventions: DM
    • Provide diabetic diet: alternative food products & not to skip meals
    • Encourage exercise after meals
    • Encourage annual eye & kidney exam
  • 36. 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
  • 37. 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
  • 38. 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
  • 39. 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

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