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Endocrine System
 

Endocrine System

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    Endocrine System Endocrine System Presentation Transcript

    • 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