Endocrine disorderso Julie Mann, NP

Case Study #1o Jimmy Johns a 7-year-old boy presents with recent

onset of polydipsia (really thirsty), polyuria (has to pee a lot), and polyphagia (very hungry). He has experienced some weight loss and n/v despite no change in his diet. His parents are concerned.

o What might be going on with Jimmy? Maybe diabetes.

Case Study #2o George Glass is a 45-year-old obese man with a pmh

significant for high cholesterol, high triglycerides, and htn. He presents with c/o increasing fatigue and thirst.

o What might be going on with George Glass? Diabetes Type II

o What tests might be ordered for Jimmy and George? Fasting glucose - electrolyte panel "Casual sample" of glucose.

o What do you anticipate these tests to show? Hyperglycemia

Naming of Diabeteso NIDDM and IDDM

Noninsulin dependent Diabetes (II) vs insulin dependent diabetes (type I)

Problematic: Some of our Type II's need insulin.o Juvenile onset and Adult onset

Juvenile (I) Adult (II) Problematic: Type I can occur in adults.

o Type I and Type II Difference in how it develops and how it

presents. o Gestational Diabetes

Pregnancy related diabetes

Pancreas secretes insulin through islet of langerhans into blood stream.

Type I Diabeteso pancreatic beta cells destroyed, can no longer form

insulin, can't countereffect actions of glucose.o Two types:

immune mediated diabetes most common autoimmune destruction total lack of insulin, elevated blood glucose,

breakdown of body fats and proteins Ideopathic

beta cell destruction without evidence of autoimmune response

strongly inherited

African and Asian descent (genetic history) Periods with a lot of insulin produced

followed by periods of reduced insulin production.

episodes of ketoacidosis due varying degrees of insulin deficiency.

o http://www.youtube.com/watch? v=_OOWhuC_9Lw

Type II Diabeteso hyperglycemia and insulin deficiency.o most commonly found in older overweight people but

becoming more common in children and older adolescents

o family history increases risk 2-4x’s!o Either not making enough insulin, or insulin made is

not effective.o http://www.youtube.com/watch?v=VLiTbb6MaEU

What causes Type II?o 1. Insulin Resistance: effect of insulin less then

expectedo 2. Deranged secretion of insulin by beta cells (cannot

be maintained) Ppl go into a hyperinsulin state

(hyperinsulinemia, may have darkening of skin, weightgain) does not stop liver from producing glucose -->

o 3. Increased glucose production in liver (from glycogen)

Pathogenesis of Type II

Criteria for Diagnosis (either/or)o Symptoms of diabetes (polyuria, plolydipsia, and

unexplained weight loss) plus casual blood glucose >200 mg/dL

Yeast infex with women. Itchy, visual changes, fatigue.

o Fasting blood glucose >126 mg/dL Anythying over 105 puts pt in prediabetic state,

will moniter pt.o Two hour postload blood glucose >200 during OGTT

Oral Glucose Tolerance Test Signs of Diabetes

o George Glass’s pmh indicates he has multiple comorbidities. What are they?

Obesity, HTN, high triglycerides, high cholesterolo How might this be connected to Type II diabetes?

Metabolic Syndrome (Syndrome X)o a cluster of abnormalities including: obesity, high

triglycerides, low HDL’s, HTN, systemic inflammation (CRP - C reactive protein), abnormal fibrinolysis (higher risk for clots), abnormal fxn of vascular endothelium and macrovascular disease (Atherosclerosis, heart disease)

Diagnostic Criteria for Metabolic Syndromeo Contains three or more of the following symptomso Abdominal Obesity: waist >35 in. in women or 40 in.

in men.

o Triglycerides >150 mg/dLo HDL <50 mg/dL in women, <40 mg/dL in meno Blood pressure >130/85 mm Hgo Fasting blood glucose >100 mg/dLo Greater chance to develop diabetes II

Case Study con’t o Mr. Glass has been relatively non-compliant with his

DM management and manages to take is BS once or twice a week. He also frequently misses his Oral Diabetes medications. He is celebrating his 46th birthday and decides to go out to dinner with a group of friends at a local italian restaurant.

o What might happen to Mr. Glass Hyperglycemia (hypoglycemia is more

dangerous…) from large CHO meal-->(see pic below)

o Should stay hydrated, reeducate on diet measures, take meds, use up glucose (walk).

Hyperosmolar Hyperglycemic Stateo Extreme Hyperglycemia (blood glucose >600 mg/dL) o Hyperosmolarity (plasma osmolarity >3210 mOsm/L)o Dehydration, absence of ketoacidosis (no breakdown

of fats/proteins), pull electrolytes out with fluid, depressed sensorium

Bring down BS slowly, follow neuro status, tricky to treat.

Case Study con’t

o Mr. Glass hasn’t leaned the importance of managing his dietary intake. He wakes up late for work, doesn’t check his blood glucose, skips breakfast,and rushes to his job stocking the supermarket. 2 hours after starting work Mr. Glass doesn’t feel so good, what might be happening?

Hypoglycemia

o Can pass out and die!o Raise blood sugar fast with glucose tablet, then

something that will sustain (complicated carbs). Case Study con’t

o Jimmy Johns has done a great job learning how to manage his diabetes. He is now 16 and decides to hang out with his friends on Saturday night. They all go to the movies and share popcorn and soda’s and then head to the local ice cream shop. All his friends are having the “Kitchen sink” so he orders one too. He doesn’t have his insulin with him so he skips it, eats the whole ice cream treat and heads home. The next morning his mom finds him in his room lethargic and complaining of nausea and abdominal pain. His mom brings him to the ED.

The Kitchen Sinko What might be going on with him?

Hyperglycemia, ketoacidosis (metabolic acidosis) seen more with Type I.

Muscle does not take up glucose because there is no glucose-->muscle breaks down protein & fat for energy, raise ketones (acidic). (See diagram below)

Need to work with pt carefully, insulin IV (monitor blood glucose, fluid/electrolyte replacements, manage metabolic acidosis).

Kussmal's respirations to compensate.

Screen clipping taken: 8/2/2009, 10:00 PM

Mr. Glass the saga continueso Poor Mr. Glass he never did embrace the

management of his diabetes. He is now 67 years old and continues to be a poorly controlled diabetic now on insulin therapy.

o what chronic complications are in store for Mr. Glass? Blindness, neuropathy, cardiac arrest,

amputation (bad peripheral vascular disease), renal failure. (see pic below)

Almost all type I will have these complications, about 60% of type II's.

More complications = more uncontrolled.

Chronic Complicationso Somatic Neuropathy (peripheral neuropathy):

diminished perception of vibration, pain, &temperature.

Use tuning forks on different bony prominences on foot to see if can sense vibrations. Test for pain in foot using monofilament (bendable wire). Test temp with test tubes of warm/cold water.

o Autonomic Neuropathy: disorders of vasomotor function, impaired GI fxn, GU fxn, and cranial nerve involvement (ie optic nerve)

o Nephropathies: changes to the glomerulus (capillary basement membrane thickening in glomerulus leading to chronic kidney disease)

o Retinopathies: abnormal retinal vascular permeability, microaneurysm, neovascularization and hemorrhage, scaring and retinal detachment

Recommend diabetes see an ophthalmologist annually.

Macrovascular Complicationso CADo Cerebral Vascular Diseaseo Peripheral Vascular Diseaseo Risk: obesity, Htn, hyperglycemia, hyperinsulinemia,

hyperlipidemia, altered platelet fxn, endothelial dysfxn, systemic inflammation, elevated fibrinogen levels

Case Study #3o Julie Mann is a 32-year-old overweight female with a

pmh significant for polycystic ovarian syndrome (hyper insulin state affecting the reproductive tract) and a family history significant for DM in both parents. She presents to the clinic for her 5 month check up and with results of her one hour OGTT which is 183 mmol/L.

o What does this indicate? Gestational diabetes.

o What nursing considerations do you have for her and her unborn baby?

Macrosomia (big babies), spontaneous abortion, cardiac anomalies can develop, greater risk of development of diabetes, hypoglycemia at birth.

Gestational Diabeteso Any degree of glucose intolerance first detected in

pregnancyo Risk factors: family history of DM; history of stillbirth

or spontaneous abortion, fetal anomalies in previous pregnancy, or previous large-for-gestational age infant; obesity, advanced maternal age (over 35), >5 pregnancies.

o Screening at first prenatal visit in high risk mom’s and at week 24-28 gestation for normal mom’s.

o GDM means higher risk of complications, mortality and fetal abnormalities (macrosomia, hypoglycemia, hypocalcemia, polycythemia, and hyperbilirubinemia)

Case Study #4o Peggy Sams is an 22 year old female with no

significant pmh. She develops a fullness in her throat and has trouble swallowing. She brags she can eat what ever she likes and not gain weight and states that she is glad she lives in Michigan because she hates to be hot. The NP notices she is restless and seldom blinks.

o What might be going on with Peggy? Hyperthyroidism Exophthalmos (protrusion of the eyes)

Hypothalamus-->TRH-->ant pit-->TSHThyroid-->T3&T4 Hyperthyroidism

o high levels of circulating thyroid hormone (regulates metabolism)

o most common cause is graves diseaseo manifestations are related to increased O2

consumption, increased metabolic state, and increased SNS activity

o (see below) Fine shiny hair, hair loss.

Graves Diseaseo A state of hyperthyroidism, goiter, and

ophthalmopathy (eye changes).o Onset between ages 20-40, more common in womeno Autoimmune disordero abnormal stimulation of the thyroid gland by TSH-

receptor antibodies, which keep secreting thyroid hormone.

Thyroid Stormo Life threatening condition, extreme hyperthyroidism

o precipitated by stress, infection, DKA (Diabetic Ketoacidosis [autoimmune condition]), or manipulation of thyroid in thyroidectomy

o Manifestations: very high fever, extreme cardiac effects (tachycardia, CHF, angina), severe CNS effects (aggitation, restlessness, and delirium).

Put into ICU, cooling blankets, supportive measures until thyroid hormone out of system.

Case Study Con’to Peggy has a thyroidectomy. And now has

hypothyroidism. o What kind of management will she need?

Synthetic thyroid hormone.o What manifestations might you see with her?

Weight gain, fatigue Hypothyroidism

o general slowing of metabolic processes and myxedema (non-pitting mucous edema in connective tissue)

o dysfunction or destruction of the thyroid glando Most common cause is Hashimoto’s Thyroiditis:

autoimmune processo Manifestations result from slowed metabolic

processes or myxedematous process in the tissues

Myxedematous Comao Life threatening, end-stage hypothyroid state, rareo manifested by coma (possibly d/t body no longer able

to metabolize medications), hypothermia, CV collapse, hypoventilation, and severe metabolic disorders (lactic acidosis, hyponatremia, hypoglycemia)

o most often in elderly women, in the winter. Case Study #5

o Ms. Puffer is a 60 year old female s/p bilateral lung transplant. She is taking her anti-rejection regime which includes high dose Solumedrol and then Prednisone.

o Mr. Kase is a 40 year-old male with a benign adrenal tumor.

o What are they both at risk of developing? Cushing Syndrome

Hypothalamus-->CRF-->Ant Pit-->ACTH-->adrenal cortex-->Cortisol

Cushing Syndromeo excess in cortisolo causes: pituitary tumors, benign or malignant adrenal

tumors, ACTH secreting tumors, or excessive glucocorticoid administration,

o exaggeration of actions of cortisol (see below)

o Severe thin skin like parchment paper.