• Endocrine disorders • Adult (II)

○ Julie Mann, NP • Problematic: Type I can occur in adults.

• Case Study #1 ○ Type I and Type II
○ Jimmy Johns a 7-year-old boy presents with • Difference in how it develops and how
recent onset of polydipsia (really thirsty), it presents.
polyuria (has to pee a lot), and polyphagia ○ Gestational Diabetes
(very hungry). He has experienced some • Pregnancy related diabetes
weight loss and n/v despite no change in
his diet. His parents are concerned.
○ What might be going on with Jimmy?
• Maybe diabetes.
• Case Study #2
○ 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.
○ What might be going on with George Glass?
• Diabetes Type II
○ What tests might be ordered for Jimmy and
George?
• Fasting glucose - electrolyte panel
• "Casual sample" of glucose.
○ What do you anticipate these tests to
show?
• Hyperglycemia
• Naming of Diabetes • Pancreas secretes insulin through islet of
○ NIDDM and IDDM langerhans into blood stream.
• Noninsulin dependent Diabetes (II) vs
• Type I Diabetes
insulin dependent diabetes (type I) ○ pancreatic beta cells destroyed, can no
• Problematic: Some of our Type II's need longer form insulin, can't countereffect
insulin. actions of glucose.
○ Juvenile onset and Adult onset ○ Two types:
• Juvenile (I) • immune mediated diabetes
  most common of skin, weightgain) does not stop liver
 autoimmune destruction from producing glucose -->
 total lack of insulin, elevated blood ○ 3. Increased glucose production in liver
glucose, breakdown of body fats (from glycogen)
and proteins • Pathogenesis of Type II
• 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.
○ http://www.youtube.com/watch?v=_OOWhuC_9L
w
• Type II Diabetes
○ hyperglycemia and insulin deficiency.
○ most commonly found in older overweight
people but becoming more common in
children and older adolescents
○ family history increases risk 2-4x’s! • Criteria for Diagnosis (either/or)
○ Either not making enough insulin, or insulin ○ Symptoms of diabetes (polyuria,
made is not effective. plolydipsia, and unexplained weight loss)
○ http://www.youtube.com/watch?v=VLiTbb6MaEU plus casual blood glucose >200 mg/dL
• What causes Type II? • Yeast infex with women.
○ 1. Insulin Resistance: effect of insulin less • Itchy, visual changes, fatigue.
then expected ○ Fasting blood glucose >126 mg/dL
○ 2. Deranged secretion of insulin by beta • Anythying over 105 puts pt in
cells (cannot be maintained) prediabetic state, will moniter pt.
• Ppl go into a hyperinsulin state ○ Two hour postload blood glucose >200
(hyperinsulinemia, may have darkening during OGTT
 • Oral Glucose Tolerance Test
• Signs of Diabetes
• Diagnostic Criteria for Metabolic Syndrome
• Case Study con’t
○George Glass’s pmh indicates he has
multiple comorbidities. What are they?
• Obesity, HTN, high triglycerides, high
cholesterol
○ How might this be connected to Type II
diabetes?
• Metabolic Syndrome (Syndrome X)
○ 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)
○ Contains three or more of the following
symptoms
○ Abdominal Obesity: waist >35 in. in women
or 40 in. in men.
○ Triglycerides >150 mg/dL
○ HDL <50 mg/dL in women, <40 mg/dL in
men
○ Blood pressure >130/85 mm Hg
○ Fasting blood glucose >100 mg/dL
○ Greater chance to develop diabetes II
○ 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.
○ What might happen to Mr. Glass
• Hyperglycemia (hypoglycemia is more
dangerous…) from large CHO meal--
>(see pic below)
 electrolytes out with fluid, depressed
sensorium
• Bring down BS slowly, follow neuro
status, tricky to treat.
• Case Study con’t
○ 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

○ Should stay hydrated, reeducate on diet

measures, take meds, use up glucose
(walk).
• Hyperosmolar Hyperglycemic State
○ Extreme Hyperglycemia (blood glucose
>600 mg/dL)
○ Hyperosmolarity (plasma osmolarity >3210
mOsm/L)
○ Dehydration, absence of ketoacidosis (no
breakdown of fats/proteins), pull
 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 Sink
○ 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.

○ Can pass out and die!

○ Raise blood sugar fast with glucose tablet,
then something that will sustain
(complicated carbs).
• Case Study con’t
○ 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 Screen clipping taken: 8/2/2009, 10:00 PM

• Mr. Glass the saga continues
○ 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.
○ 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 Complications
○ 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.
○ Autonomic Neuropathy: disorders of
vasomotor function, impaired GI fxn, GU
fxn, and cranial nerve involvement (ie optic
nerve)
○ Nephropathies: changes to the glomerulus
(capillary basement membrane thickening
in glomerulus leading to chronic kidney
disease)
○ Retinopathies: abnormal retinal vascular
permeability, microaneurysm,
neovascularization and hemorrhage,
scaring and retinal detachment
• Recommend diabetes see an
ophthalmologist annually.
• Macrovascular Complications
○ CAD
○ Cerebral Vascular Disease
○ Peripheral Vascular Disease
○ Risk: obesity, Htn, hyperglycemia,
hyperinsulinemia, hyperlipidemia, altered
platelet fxn, endothelial dysfxn, systemic
inflammation, elevated fibrinogen levels
• Case Study #3
○ 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.
○ What does this indicate?
• Gestational diabetes.
○ 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 Diabetes
○ Any degree of glucose intolerance first
detected in pregnancy
○ 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.
○ Screening at first prenatal visit in high risk
mom’s and at week 24-28 gestation for
normal mom’s.
○ GDM means higher risk of complications,
mortality and fetal abnormalities
(macrosomia, hypoglycemia, hypocalcemia,
polycythemia, and hyperbilirubinemia)
• Case Study #4
○ 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.
○ What might be going on with Peggy?
 • Hyperthyroidism
• Exophthalmos (protrusion of the eyes)
○ most common cause is graves disease
○ manifestations are related to increased O2
consumption, increased metabolic state,
and increased SNS activity
○ (see below) Fine shiny hair, hair loss.

• Hypothalamus-->TRH-->ant pit-->TSHThyroid-- • Graves Disease

>T3&T4 ○ A state of hyperthyroidism, goiter, and
• Hyperthyroidism ophthalmopathy (eye changes).
○ high levels of circulating thyroid hormone ○ Onset between ages 20-40, more common
(regulates metabolism) in women
 ○ Autoimmune disorder
○ abnormal stimulation of the thyroid gland
by TSH-receptor antibodies, which keep
secreting thyroid hormone.
• Thyroid Storm
○ Life threatening condition, extreme
hyperthyroidism
○ precipitated by stress, infection, DKA
(Diabetic Ketoacidosis [autoimmune
condition]), or manipulation of thyroid in
thyroidectomy
○ 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’t
○ Peggy has a thyroidectomy. And now has
hypothyroidism.
○ What kind of management will she need?
• Synthetic thyroid hormone.
○ What manifestations might you see with
her?
• Weight gain, fatigue
• Hypothyroidism
○ general slowing of metabolic processes and
myxedema (non-pitting mucous edema in
connective tissue)
○ dysfunction or destruction of the thyroid
gland
○ Most common cause is Hashimoto’s
Thyroiditis: autoimmune process
○ Manifestations result from slowed
metabolic processes or myxedematous
process in the tissues
• Myxedematous Coma
○ Life threatening, end-stage hypothyroid
state, rare
○ 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)
○ most often in elderly women, in the winter.
• Case Study #5
○ 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.
○ Mr. Kase is a 40 year-old male with a benign
adrenal tumor.
○ What are they both at risk of developing?
• Cushing Syndrome
• Hypothalamus-->CRF-->Ant Pit-->ACTH--
>adrenal cortex-->Cortisol
• Cushing Syndrome
○ excess in cortisol
○ causes: pituitary tumors, benign or
malignant adrenal tumors, ACTH secreting
tumors, or excessive glucocorticoid
administration,
○ exaggeration of actions of cortisol (see
below)
○ Severe thin skin like parchment paper.