11.1mmol/L
Causes of Morning Hyperglycemia
1.
Dawn Phenomenon-
characterized by a relatively normal blood glucose level when blood
glucose level begins to rise. The
phenomenon is thought to result from nocturnal surges in growth hormone
secretion that create a greater need for insulin in the early morning hours in
patient with Type 1
2.
Somogyi Effect- normal
or elevated blood glucose at bedtime, a decrease at 2-3 am to hypocglycemic
levels and subsequent increase caused by the production of counter regulatory
hormones
Medications
A. OHA (Oral
Hypoglycemic Agents)
1. Sulfonylureas
-
Directly stimulating the pancreas to secrete insulin. These agents improve insulin action at the
cellular level. The common side effects
are GI symptoms and dermatologic reactions
Ex. 1st generation: Acetohexamide,
chlorpropamide, tolazamide, tolbutamide
2nd generation: glipizide, glyburide, glimeperide
2. Biguanides
- produces its antidiabetioc
effects by facilitating insulin’s action on peripheral receptor sites. Have no effect on pancreatic beta
cells. Biguamides used with
sulfonylurea may enhance the glucose lowering effect more than either
medication used alone.
Ex.
Metformin, glucophage
3. Apha
Glucosidase Inhibitors
they work by delaying the absorption of glucose in the
intestinal system resulting in a lower postprandial blood glucose level.
Ex.
Acarbose
4. Thiazolidineones
-
they are indicated for patients with Type 2 diabetes who take insulin
injections and whose blood glucose control is inadequate. Enhance insulin action at the receptor sites
without increasing insulin secretions from beta cells. Women should be informed can cause
resumption of ovulation in peri-menopausal, anovulatory women.
Ex. Pioglitazone
Rosiglitazone
5. Meglitinides
- lowers the blood
glucose level by stimulating insulin release from beta cells.
Ex. Repaglinide
Nateglinide
. Insulin
1. Rapid-Acting: Clear
Insulin
-
Regular
-
Humulin-R
-
Semilente
-
Crystalline zinc
-
Actrapid
-
Onset: 30 mins- 1 hr.
-
Peak: 2-4 hrs.
-
Duration: 6-8 hrs.
2. Intermediate-Acting: cloudy
-
NPH
-
Humulin-N
-
Lente
-
Monotard
-
Onset: 1-2 hrs
-
Peak: 6-8 hrs.
-
Duration: 18-24 hrs.
- Long-Acting:
cloudy
-
PZI
-
Ultralente
-
Onset: 3-4 hrs.
-
Peak: 16-20 hrs.
-
Duration: 30-36 hrs.
Health Teaching
1.
Foot care: daily
cleanse feet in warm, soapy water; rinse and dry carefully; inspect, don’t
break blisters; trim nails to follow natural curve of toe; always wear breathable shoes such as
leather; no crossing of the legs; no cream between toes; inspect visually
daily NCLEX
2.
Injection techniques (intra site rotation)
3.
Dietary management
4.
Quit smoking
Stress management (stress increases blood sugar)
PITUITARY GLAND: HORMONES PRODUCED AND FUNCTIONS
- controlled primarily by the hypothalamus; termed “master
gland” as it directly affects the function of other endocrine glands
Anterior Lobe
- Adrenocorticotropic
hormone (ACTH)- concerned with growth and secretory activity of adrenal
cortex, which produces steroids
- Thyrotropic
hormone (TSH) – for growth and secretory activity of thyroid; controls
release rate of thyroxine, which controls rate of most chemical reaction in
the body; target is thyroid gland
- Somatotropic
hormones (STH or GH)- promote
growth of body tissue
- Gonadotropic
hormones and estrogen secretion; follicle stimulating hormone (FSH)- stimulate development of ovarian
follicles; semeniferous tubules and sperm maturation
- Luteinizing
hormone (LH)- works with FSH in final maturation of follicles; promotes
ovulation and progesterone secretion
- Prolactin- for milk production
- Melanocyte
stimulating hormone (MSH)- produces the characteristic skin darkening
Posterior Lobe
- Vasopressin
(ADH)- influnces water absorption by kidney
- Oxytocin-influences
the menstrual cycle, labor and lactation
Disorders of Anterior Pituitary
1. Acromegaly- hypersecretion of GH that occurs in
adulthood; commonly associated with benign pituitary tumors
Manifestations:
a. Enlargement of external extremeties (e.g. nose, jaw,
hands, feet)
NCLEX - assessment question “ are you buying
larger size shoes”
One of the earliest manifestation is increase in shoe size
b. Protrusion of the jaw and orbital ridges
c. Coarse features
d. Visual problems,
blindness
e. Hyperglycemia,
insulin resistance
f. Hypercalcemia
Treatment
a. Irradiation of
pituitary
b. Transphenoidal
hypophysectomy: removal of pituitary
gland
1. Assess for signs of
increased cranial pressure- signs of adrenal insufficiency,
hypothyroidism and temporary diabetes insipidus
2. Elevate head of bed 30 degrees
1.
Avoid coughing, sneezing, blowing nose
2.
Check for CSF in nasal packing
c. Bromocriptine
(Parlodel) with surgery or radiation
Nursing Interventions
a.. Provide
emotional support
b.
Directed toward symptomatic care
2. Gigantism-
hypersecretion of GH that occurs in childhood
Manifestations:
a. Proportional
overgrowth in all body tissue
b. Overgrowth of
long bones: height in childhood may reach 8 or 9 feet
c. Teaching and
nursing responsibilities same with acromegaly
3. Dwarfism- hyposecretion of GH during childhood
Manifestations:
a.
Retarded symmetrical physical growth
b.
Premature body aging processes
c.
Slow intellectual development
Treatment
1. Removal of the
causative factor (for ex. Tumors)
2.
Human growth hormone injections (HGH)
Nursing Responsibilities- same with acromegaly
Disorders of Posterior Pituitary
1. Diabetes Insipidus- hyposecretion of ADH, due to a tumor
or damage of the posterior lobe of the pituitary; may be idiopathic; may be
genetic; very common following neurosurgery or head trauma
Manifestations
a. Polyuria
b. Polydipsia
c. Hypernatremia
d. Weight loss
e. Dehydration/dry
skin
Treatment
a. Desmopressin
acetate (DDAVP) nasal spray
b. Vasopressin
tannate (Pitressin Tannate) in Oil (IM for chronic severe cases)
c. Lypressin
(diapid) nasal spray
Nursing Interventions
1. Maintain adequate
fluids
2. Avoid foods with
diuretic-type action
3. Monitor intake
and output: report any changes; can sometimes have 800mL output per hour
4. Daily weights
5. Specific gravity
(should be greater that 1.004)
2. Syndrome of
Inappropriate Antidiuretic Hormone (SIADH)- inappropriate, continued release of antidiuretic hormone
resulting in water intoxication; caused by neoplastic tumors, respiratory
disorders, drugs
Manifetstions
a. Mental
confusion/irritability
b. Lethargy/seizures
c. Dilutional
hyponatremia
d. Weight gain
e. Anorexia, nausea
and vomiting
f. Weakness
Treatment
a. Fluid restriction
(less than 500 mL/24 hrs) with hypertonic solutions to treat the hyponatremia
2. Strict intake and
output
3. Treat underlying
cause (surgery, radiation, chemotherapy)
4. diuretics
5. Daily weight
Adrenal Gland
Disorders of Adrenal Cortex
- Addison’s
disease- hyposecretion of adrenal cortex hormones, (insufficiency of
cortisol, aldosterone and androgen); discontinuing steroid medication
abruptly without weaning off them
Causes
1)
Autoimmune or idiopathic atrophy of the adrenal glands
2)
Surgical removal of Adrenal glands
3)
Infection ( Tuberculosis , Histoplasmosis)
4)
Decreased ACTH
Manifestations
a. Slow, insidious
onset
b. Malaise and
generalized weakness from increased potassium restriction
c. Hypotension,
hypovolemia from increased sodium excretion
d. Increase
pigmentation of the skin- “eternal tan”
e. Anorexia, nausea,
vomiting
f. Electrolyte
imbalance (hyponatremia, hyperkalemia)
g. Weight loss
h. Loss of libido
i. Hypoglycemia
j. Personality
changes
Treatment
a. Lifelong steroid
replacement; hydrocortisone (Florinef); complications of long-term steroid
therapy include osteoporosis
b. High protein,
high carbohydrate diet may increase sodium intake ( low potassium intake)
c. Monitor fluid and
electrolytes routinely
d. Decrease
emotional and physical stress
Nursing Interventions
a. Observe for Addisonian crisis (sudden extreme weakness; severe
abdominal, back and leg pain; hyperpyrexia; coma; death)
b. Observe for side effects of hormone replacement
c. Provide emotional support
d. Teaching (lifelong medications, prompt treatment of infection,
illness, stress management)
e. Monitor fluid and electrolyte balance regularly
NCLEX- Common Complication is Shock
CGFNS – Initial manifestation , Hypotension, Bronze skin.
2. Cushing’s Syndrome-
hypersecretion of the glucocorticoids; overdose of steroid medications
Manifestations
a. Central-type obesity, moon face, buffalo hump and obese trunk
with thin extremities
b. Mood swings
c. Malaise and muscular weakness (increase preotein catabolism)
d. Masculine characteristics in females (hirsutism)
e. Hypokalemia (may cause arrythmias)
f. Hyperglycemia (insulin resistant)
g. Hypertension (edema; may lead to CHF or CVAs)
h. Acne (striae on chest, abdomen, legs)
i. Amenorrhea
j. Osteoporosis; thin skin with ecchymosis
k. Increased susceptibility to infections
l. Peptic ulcer
Treatment
a. Adrenalectomy: unilateral or bilateral
b. Chemotherapy:
bromocriptine (Parlodel) ; mitotane (Lysodren), or aminoglutethimide
(Cytadren)
c. High-protein, low-carbohydrate, low sodium diet with potassium
supplement
Nursing Interventions
a. Protect from infection
b. Protect from accidents and falls due to osteoporosis
c. Client education concerning lifelong self-administration of
hormone suppression therapy
Steroid replacement (similar to
Cushing’s syndrome but in lesser effect)
Purpose:
a. anti-inflammatory and anti-allergic reaction
b. Enables one to tolerate high degree of stress
Indications:
a. Crisis (fro ex. Shock, bronchial obstruction)
b. Long-term therapy (for ex. Post-adrenalectomy, arthritis,
leukemia)
3. Aldosteronism (Conn’s syndrome)- hypersecretion of aldosterone
from adrenal cortex (usually due to tumor)
Manifestations:
a. Hypokalemia and hypernatremia
b. Hypertension from hypernatremia
c. Muscle weakness and cardiac problems related to hypokalemia
Treatment
a. Surgical removal of tumor/adrenal gland
b. Potassium replacement
c. Antihypertensive drugs: spinolactone (Aldactone)
Nursing Interventions
a. Provide quiet environment
b. Monitor BP and cardiac activity
c. Monitor potassium level
Disorders of Adrenal Medulla
1. Pheochromocytoma- hypersecretion of the hormones of adrenal
medulla (exact cause unknown)
Manifestations (sudden onset):
seen in young women and men
a. Hypertension (principal manifestation): very high crisis
b. Sudden attackes resemble manifestations of overstimulation of
sympathetic nervous system
-
Sweating
-
Apprehension
-
Palpitations
-
Nausea
-
Vomiting
-
Orthostatic hypotension
-
Headache
-
Tachycardia
c. Hyperglycemia
Treatment
a. Surgical excision of tumor or adrenal gland
b. Symptomatic if surgery not
feasible
Nursing Interventions:
a. Provide high-calorie, nutritious diet (avoid caffeine)
b. Preoperative: control
hypertension
Thryroid Gland
Disorders of Thyroid Gland
1. Myxedema: hyposecretion of throid hormone in adulthood; highest
incidence between ages 50 & 60; more often in women
Manifestations
a. Slow rate of metabolism
b. Personality changes (depression)
c. “Dull” appearance
d. Anorexia and constipation
e. Intolerance to cold
f. Decreased sweating
g. Hypersensitivity to barbiturates and narcotics
h. Generalized interstitial edema
i. Husky voice from swelling of vocal cords
j. Coarse, dry skin
k. Thin hair
l. Generalized weakness
m. Goiter
n. Weight gain
o. puffy appearance
(nonpitting)
p. Anemia
q. Increased cholesterol and lipids
r. Menstrual disorders in women
Treatment: drug therapy: Levothyroxine (Synthroid)
a. Thyroid replacement hormones should be taken on an empty stomach
b. Monitor heart rate: fewer than 100 beats per minute is desirable;
monitor for cardiac symptoms of angina at initiation of therapy
Nursing Interventions
a. Directed toward manifestations of decreased metabolism
-
provide warm environment
-
Low-calorie, low cholesterol, low saturated fat diet
-
Increase roughage
-
Moderate fluids
-
Avoid sedatives
-
Plan rest periods
-
Weigh client
b. Observe for overdosage manifestations of thyroid preparations
2. Cretinism- hyposecretion of thyroid hormones in the fetus or
neonate
-
diagnosed shortly after birth thru newborn screening
-
can lead to severe, irreversible mental retardation, if not
treated
-
requires lifelong hormone replacement therapy
3. Hyperthyroidism (Grave’s disease, diffuse toxic goiter)- hypersecretion of thyroid hormone; over
treatment of hypothyroidism
Manifestations
a. Increased rate of body metabolism
b. Personality changes
c. Enlargement of the thyroid gland
d. Exopthalmos (never goes away)
e. Cardiac dysrhytmia and hypertension
f. Increased appetite (but weight loss)
g. Diaerrhea
h. Diaphoresis and heat intolerance
i. Easy fatigability
j. Anxiety/insomnia
k. Nervous appearance
l. Amenorrhea
Treatment
a. Drug therapy
1. Methimazole
(Tapazole): blocks thyroid hormone production
2. Propylthiouracil
(Propyl-Thyracil): blocks thyroid hormone production
-
can cause agranulocytosis
-
client must have frequent CBCs performed
3. Iodides:
decrease vascularity; inhibit release of thyroid hormones
-
Lugol’s solution ( use is decreasing because this medication
is expensive and inactivates thyroid medications in the bowel)
-
Saturated solution of potassium iodide (SSKI); use prior to
thyroidectomy
4. Propanolol
(inderal); relief of tachycardia
b. Radioiodinetherapy: slowly destroys hyperfunctioning thyroid
tissue
c. Thyroidectomy: subtotal or total
Nursing Interventions:
a. Provide adequate rest
b. Provide cool, quiet environment
c. Provide high calorie (4000-5000 cal.day), high protein,
carbohydrate, vitamin diet without stimulants, extra fluids
d. Weigh client daily
e. Provide emotional support; activities
f. Provide eye protection: ophthalmic medicine; tape eyes at night;
decrease sodium and water
g. elevate head of bed
h. Be alert for complications
-
corneal abrasion
-
heart disease
-
Thyroid Storm (usually occurs after thyroid surgery)
Thyroidectomy- removal of the
thyroid gland, either total or partial
Nursing Interventions
a. Semi-Fowler’s position
b. Check dressing esp. back of neck
c. Observe for repiratory distress; tracheostomy tray, oxygen and
suction apparatus at bedside
d. Be alert for signs of hemorrhage
e. Talking limited, note any hoarseness; may indicate injury to
laryngeal nerve
f. Observe for signs of tetany: Chvostek’s sign and Trousseau’s sigh
(parathyroid glands may accidentally be removed)
g. Calcium gluconate IV at bedside
h. Observe for Thryoid Storm (life threatening)
-
Fever
-
Tachycardia
-
Delirium
-
Irritability
-
Important to assess temperature routinely
- gradually increase range of motion to
neck; support when sitting up
Parathyroid Gland
Disorders of Parathyroid Gland
1. Hypoparathyroidism-
hyposecretion of the parathyroid hormone; accidental removal during thyroid
surgery
Manifestations
a. Hypocalcemia
b. Acute: increased neuromuscular irritability tetany (positive
Chvostek and positive Trousseau)
c. Chronic:
-
Poor development of tooth enamel
-
Lethargic
-
Thin hair; brittle nails
-
Mental retardation
-
Circumoral paresthesia with numbness and tingling of fingers
Treatment
a. Acute: IV Calcium
Gluconate
b. Chronic:
-
oral calcium salts
-
Vitamin D and aluminum hydroxide gel (Amphojel)
-
High calcium, low phosphorous diet
Nursing Interventions
a. Provide quiet room, no stimulus
b.
Assess for increased signs of neuromuscular irritability
2. Hyperparathyroidism (causes are
tumor or renal disease)- hypersecretion of parathyroid hormone
Manifestations (causes loss of calcium
from the bones to the serum)
a.
Bone deformities (susceptible to fractures
b.
Calcium deposits in various body organs
c.
Hypercalcemia
d.
Gastric ulcers and GI disturbances
e.
Apathy, fatigue, weakness, depression
f.
Nausea, vomiting, anorexia
g.
Constipation, abdominal pain
h.
Joint and bone pain
i.
Polyuria
j.
Polydipsia
k.
Azotemia
l.
Hypertension
Treatment
a.
Subtotal surgical resection of parathyroid gland
b.
Hydration and diuretics- furosemide (Lasix) excretes excess calcium
c.
Plicamycin (Mithracin) or gallium nitrate (Ganite)
Nursing Interventions
a.
Force fluids
b.
Provide a low-calcium, low Vit. D diet
c.
Prevent constipation and fecal impaction
d.
Strain all urine
e.
Safety measures to prevent breaks
f.
Calcitonin; binds phosphate; in renal failure
PITUITARY GLAND: HORMONES PRODUCED AND FUNCTIONS
- controlled primarily by the hypothalamus; termed “master
gland” as it directly affects the function of other endocrine glands
Anterior Lobe
- Adrenocorticotropic
hormone (ACTH)- concerned with growth and secretory activity of adrenal
cortex, which produces steroids
- Thyrotropic
hormone (TSH) – for growth and secretory activity of thyroid; controls
release rate of thyroxine, which controls rate of most chemical reaction in
the body; target is thyroid gland
- Somatotropic
hormones (STH or GH)- promote
growth of body tissue
- Gonadotropic
hormones and estrogen secretion; follicle stimulating hormone (FSH)- stimulate development of ovarian
follicles; semeniferous tubules and sperm maturation
- Luteinizing
hormone (LH)- works with FSH in final maturation of follicles; promotes
ovulation and progesterone secretion
- Prolactin- for milk production
- Melanocyte
stimulating hormone (MSH)- produces the characteristic skin darkening
Posterior Lobe
- Vasopressin
(ADH)- influnces water absorption by kidney
- Oxytocin-influences
the menstrual cycle, labor and lactation
