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  1. Outline the nursing management of patients receiving blood glucose monitoring.

  2. Describe the etiology, pathophysiology, clinical presentation, patient needs, and principles of management for:

    • Hyperglycemic states

    • Diabetic ketoacidosis

    • Hyperosmolar hyperglycemic states

    • Acute hypoglycemia

    • Syndrome of inappropriate antidiuretic hormone secretion

    • Diabetes insipidus

    • Hyperthyroidism and thyroid crisis

    • Hypothyroidism and myxedema

    • Adrenal cortex hypersecretion: Cushing syndrome, aldosteronism, adrenal insufficiency and adrenal crisis

    • Adrenal medulla and pheochromocytoma


Pathologic endocrine conditions are managed in both the critical care and progressive care environments. By far the most common are those associated with hyperglycemic and hypoglycemic states and to that end they are the major focus of this chapter. While not as frequently seen, the chapter also discusses selected pituitary and thyroid disorders.


Diabetes is a common comorbidity in hospitalized patients. This disease, along with the specter of hyperglycemia, is associated with significant increase in hospital morbidity and mortality. Additionally, many patients, without a history of diabetes, will develop hyperglycemia during their hospitalization.

Hyperglycemia occurs in hospitalized patients due to natural metabolic responses to acute injury and stress. During acute illness, the liver produces and releases glucose in response to glucocorticoids, catecholamines, growth hormone, and various cytokines (interleukin-6 [IL-6], interleukin-1a [IL-1a], and tumor necrosis factor-alpha). As a result, fat and protein are catabolized and blood glucose surges. Conditions such as myocardial infarction, stroke, surgery, trauma, pain, and sepsis may cause the release of these biological mediators and counterregulatory hormones. In essence, the greater the stress response, the higher the blood glucose will be. To help minimize the adverse outcomes associated with hyperglycemia, rigorous glucose monitoring and effective management of blood glucose are essential. This is usually accomplished in critically ill patients by frequent blood glucose testing paired with a continuous insulin infusion. Infusion protocols, or standing order sets, are often used to standardize treatment and maintain glucose values in the targeted range.

Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar

Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar (HHS) are two extremes in the spectrum of decompensated diabetes. The incidence of DKA is defined as acute hyperglycemia with acidosis, and HHS is classified as acute hyperglycemia without acidosis (nonketotic).

Diabetes is a metabolic disease that results in inadequate uptake of glucose by cells, resulting in hyperglycemia. The key disorder in type 1 diabetes mellitus (DM) is minimal or absent insulin secretion by the pancreas. This is often caused by an autoimmune activation where the immune system attacks and destroys the pancreatic beta islet cells that normally produce insulin. Type 2 diabetes usually occurs in older adults, but can occur in youth, and is associated with impaired insulin receptor sensitivity. Insulin production in type 2 DM may initially be normal, and then fall dramatically as the disease progresses. Although hyperglycemia is a shared feature, the etiology, risk factors, pathophysiology, and management priorities vary considerably for ...

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