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KNOWLEDGE COMPETENCIES
Outline the nursing management of patients receiving blood glucose monitoring.
Describe the etiology, pathophysiology, clinical presentation, patient needs, and principles of management for:
Hyperglycemic states
Diabetic ketoacidosis
Euglycemic 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
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PATHOLOGIC CONDITIONS
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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.
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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.
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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 continuous infusions or intermittent corrective combined with nutritional doses of insulin. Infusion protocols, or standing order sets, are often used to standardize treatment and maintain glucose values in the targeted range.
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Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar
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Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar (HHS) are two extremes in the spectrum of decompensated diabetes. The diagnostic criteria utilized for DKA and HHS may vary slightly based on source. In general, DKA is defined as acute hyperglycemia (plasma glucose >250 mg/dL) with acidosis (arterial pH < 7.3), moderate ketonuria or ketonemia, and anion gap (>12 mEq/L), and HHS is classified as acute hyperglycemia (plasma glucose >600 mg/dL) without acidosis (nonketotic).
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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 DM usually occurs in older ...