DKA and HHS (Urden Ch. 32)

A nurse is teaching the diabetic patient about insulin therapy. Which statement by the patient indicates the teaching was effective? "I will take my long-acting insulin before a meal." "I will monitor my blood sugar weekly." "If I am not going to eat right away, it is okay to take my short-acting insulin anyway." "I need to rotate the site I use to obtain blood for glucose monitoring."

"I need to rotate the site I use to obtain blood for glucose monitoring." - *Sites should be rotated to avoid trauma and bruising.* - Long-acting insulin is administered once or twice daily. Blood sugar should be monitored at least daily in the diabetic patient and probably more often depending on therapy. Short-acting insulin should be taken before a meal.

Thyroid Storm vs. Myxedema Coma

*Decrease stimulation is the first priority for Thyroid storm!* turn off lights, close doors, if someone is causing stress ask them to leave. Myxedema coma: *Respiratory is priority. Maintain Patent airway!* Replace fluids, administer hormones (levothyroxine). *Cardiac complication: Flabby heart. Put on EKG, monitor PULSE (irregular, too slow, etc.)*

Hyperglycemic Hyperosmolar State: Dx criteria *(BG greater than ___ ; pH greater than __)* *(Serum Bicarbonate greater than __)* *(Serum osmolality greater than ___)* *(How is HHS distinguished from DKA- 3 things)*

*HHS Dx Criteria:* - BG greater than 600 mg/dL - Arterial pH greater than 7.3 - Serum Bicarbonate greater than 18 - Serum osmolality greater than 320 (Normally 270-290) - Most patients with this level of metabolic disruption experience *visual changes, mental status changes, and potentially hypovolemic shock.* - *Clinically, HHS is distinguished from DKA by the presence of extremely elevated serum glucose, more profound dehydration, and minimal or absent ketosis.*

Diabetic Ketoacidosis: Diagnostic Criteria *(BG greater than ___ ; pH less than ___)* *(Serum bicarbonate less than ___)* *(Moderate or severe ___ or ____)* *(Most common cause of DKA?)*

- *Blood Glucose greater than 250 mg/dl* - *pH less than 7.3* (normal 7.35-7.45) - *Serum Bicarbonate less than 18* (normal 21-28) - *Moderate or severe Ketonemia or Ketonuria.* - DKA is categorized as mild, moderate, or severe depending on the *severity of the metabolic acidosis (assessed by blood pH, bicarbonate, ketones) and by the presence of altered mental status.* - *INFECTION* is the most common precipitating cause of DKA. Symptoms of fatigue and polyuria may precede full-blown DKA, which can *develop in less than 24 hours in a patient with type 1 diabetes. (ACUTE)* - Patients with DKA are kept on NPO status (nothing by mouth) until hyperglycemia is under control. - The coordination involved in monitoring *blood glucose, potassium, and often blood gases on an HOURLY basis is considerable.*

Surveillance for Complications: Hypokalemia and hyperkalemia *(How would hypokalemia occur?)* *(s/s of Hyperkalemia- ecg reading)*

- *HYPOKALEMIA can occur within the first hours of rehydration and insulin treatment.* *Continuous cardiac monitoring is required* because low serum potassium (hypokalemia) can cause ventricular dysrhythmias. - *HYPERKALEMIA occurs with acidosis or with overaggressive administration of potassium replacement in patients with kidney disease.* Severe hyperkalemia is demonstrated on the cardiac monitor by a *large, peaked T wave; flattened P wave; and widened QRS complex.*

Surveillance for Complications: Hypoglycemia *(Hypoglycemia is defined as a serum glucose level lower than ___ mg/dL)*

- *Hypoglycemia is defined as a serum glucose level lower than 70 mg/dL.* - Unexpected behavior change or decreased level of consciousness, diaphoresis, and tremors are physical warning signs that the patient has become hypoglycemic

DKA/HHS Management: *(When to give Bicarbonate?)* *(If greater than ___ don't give bicarb)*

- *If blood pH is greater than 6.9, DON'T give Bicarbonate.* -- If BG is less than 6.9: *100 mmol of Bicarb in 400 mL H2O plus 20 mEq of KCl. - This is more rare these days. *Adequate hydration and insulin replacement usually correct acidosis, and this treatment is sufficient for many patients with DKA.*

Surveillance for Complications: Fluid Volume Overload *(Signs and Symptoms- 3)* *(Tx of FVO- 3 things)* *(Best way to monitor patients fluids?)*

- *Neck vein engorgement, dyspnea without exertion, and pulmonary crackles on auscultation signal circulatory overload.* - *REDUCTION in the rate and volume of infusion, elevation of the head of the bed, and provision of oxygen may be required to manage increased intravascular volume.* - Hourly urine measurement (I&O) is mandatory to assess kidney function and adequacy of fluid replacement.

Replenishing Electrolytes: *( The K+ level must be ___mEq or greater BEFORE administering insulin)* *(____ is administed as soon as serum K+ falls below normal)* *(If serum Phosphate is less than ___, phosphate replacement is recommended)*

- *The potassium level must be 3.3 mEq or greater before administering insulin.* The potassium level must be checked frequently, as *insulin drives potassium into the cells* and the serum potassium can drop precipitously. - *Potassium chloride (KCl) is administered as soon as the serum potassium falls below normal.* - *If the serum PHOSPHATE level is less than 1 mg/dL, phosphate replacement is recommended.*

Surveillance for Complications: Risk for cerebral edema / Risk for infection

- Confusion and sudden complaints of headache are ominous signs that may signal cerebral edema. These observations require immediate action to prevent neurologic damage - Neurologic assessments are performed every hour or as needed during the acute phase of hyperglycemia and rehydration. Assessment of level of consciousness serves as the index of the patient's cerebral response to rehydration therapy. - Skin care takes on new dimensions for patients with DKA. Dehydration, hypovolemia, and hypophosphatemia interfere with oxygen delivery at the cell site and contribute to inadequate perfusion and tissue breakdown. Patients must be repositioned frequently to relieve capillary pressure and promote adequate perfusion to body tissues. *Maintenance of skin integrity prevents unwanted portals of entry for microorganisms.*

HHS Pathophysiology

- HHS represents a deficit of insulin and an excess of glucagon. - As the number of glucose particles increases in the blood, serum hyperosmolality increases. - *In an effort to decrease the serum osmolality, fluid is drawn from the intracellular compartment (inside the cells) into the vascular bed.* Profound intracellular volume depletion occurs if the patient's thirst sensation is absent or decreased. *HHS may evolve over days or weeks (insidious)*

DKA/HHS Management: *(The goals of Tx are- 4 things) *(Tx for severe hypovolemia!! 3 steps)* *(Evidence that fluid replacement is effective includes- 3 things)*

- The goals of Tx of DKA are: *Reverse dehydration, Replace insulin, Reverse Ketoacidosis, and Replenish electrolytes. - A patient with DKA is DEHYDRATED and may have lost 5-10% of body weight in fluids. *Aggressive IV fluid replacement is required for rehydration and to prevent circulatory collapse.* -- For *Severe Hypovolemia (DKA or HHS):* - *0.9% NS 1L/Hr immediately* - When Serum Na high or slightly normal: *0.45% NS at 250-500 mL/Hr.* -When Serum Glucose reaches 200 (DKA) or 300 (HHS): *Change to D5W 0.45% NS at 200 mL/Hr.* - *Accurate intake and output (I&O) measurements must be maintained to monitor reversal of dehydration.* Hourly urine output is an indicator of kidney function and provides information to prevent overhydration or insufficient hydration. - Evidence that fluid replacement is effective includes decreased HR, normal BP, and normalizing blood glucose levels

Management- HHS

- The goals of medical management are *rapid rehydration, insulin replacement, and correction of electrolyte abnormalities, specifically potassium replacement.* - Serum sodium concentration is the parameter that is monitored to determine whether to change from isotonic (0.9%) to hypotonic (0.45%) saline. *For example, patients with sodium levels equal to or less than 140 mEq/L may be given 0.9% normal saline solution, whereas patients with levels greater than 140 mEq/L are given 0.45% saline solution.* - To prevent *hypoglycemia* in HHS, when the serum glucose decreases to *300 mg/dL,* the hydrating solution is changed to* D5W with 0.45% NaCl at 150 to 250 mL/h.*

DKA/HHS Management: *(Tx for replacing insulin)*

-- *For Replacing Insulin (DKA or HHS):* - An initial dose of *REGULAR INSULIN* at *0.1 unit/kg of body weight to start.* (ex: In a 70-kg adult, the infusion would be *7 units of insulin per hour*) - After Bolus, *0.1 U/kg/hr IV continuous insulin infusion.* - If serum Glucose does NOT fall at least 10% in first hour, give 0.14 U/kg as IV BOLUS, then continue previous insulin infusion.* - Blood Glucose monitoring hourly! Keep serum glucose b/t 150-200 mg/dL, and lower titration as necessary. - Replacement of fluid volume and insulin interrupts the ketotic cycle and reverses the metabolic acidosis. *In the presence of insulin, glucose enters the cells, and the body ceases to convert fats into glucose.* - The goal is to achieve a fall in glucose levels of approximately 50 to 70 mg/dL each hour. *#1 PRIORITY is FLUID REPLACEMENT* even with Kussmall

The postoperative craniotomy patient has a serum osmolality of 320 mOsm/L and urine output of 400 mL/h for the past 3 hours with a urine specific gravity of 1.003. Which treatment would the nurse anticipate the practitioner ordering for this patient? 0.9 NaCl at 150 mL/h intravenously 1.5 mcg desmopressin acetate (DDAVP) subcutaneously every 12 hours Insulin drip at 7 units/h Oral vasopressin 5 units every 12 hours

1.5 mcg desmopressin acetate (DDAVP) subcutaneously every 12 hours - The patient has *diabetes insipidus (DI), and desmopressin acetate (DDVAP) is the appropriate treatment.* - *Hypotonic saline (not isotonic) is normally used for DI.* Insulin is not indicated for DI, and vasopressin is not an oral medication.

A patient is admitted with severe dehydration resulting from diabetic ketoacidosis (DKA) with a serum glucose of 842 and a serum sodium is 154 mEq/L. Which intravenous therapy order would be appropriate at this time? 1000 mL 0.9% saline bolus followed by 0.9% saline infusion 1000 mL 0.9% saline bolus followed by 0.45% saline infusion 1000 mL Ringer lactate bolus followed by 0.9% saline infusion 1000 mL Ringer lactate bolus followed by a 5% dextrose infusion

1000 mL 0.9% saline bolus followed by 0.45% saline infusion - *For a severely dehydrated patient, 1 L of normal saline is infused immediately.* *If the serum osmolality is elevated and serum sodium is high (hypernatremia), infusions of hypotonic sodium chloride (0.45%) follow the initial saline replacement.* - Dextrose is added to replenish depleted cellular glucose as the circulating serum glucose decreases to 200 mg/dL.

Which statement is true regarding the treatment of hypoglycemia? Treatment should begin when serum glucose levels fall below 50 mg/dL. A fingerstick glucose should be validated by serum glucose drawn by the laboratory. Immediate treatment includes administration of 50 mL of 50% glucose solution intravenous piggyback. An intravenous infusion of 10% dextrose should be started at 150 mL/h.

A fingerstick glucose should be validated by serum glucose drawn by the laboratory. - *Hypoglycemia is defined as a serum glucose less than 70 mg/dL.* - When a fingerstick glucose of less than 70 is obtained, *verification with the laboratory is required in most protocols.* - Administration of replacement glucose depends on the patient's clinical condition and may be given orally or parenterally as appropriate.

Which laboratory finding would suggest a differential diagnosis of hyperosmolar hyperglycemic state (HHS)? Serum glucose of 500 mg/dL Serum potassium of 3.4 mEq/L Absence of serum ketones Serum osmolality of 250 mOsm/L

Absence of serum ketones - *Hyperosmolar hyperglycemic state (HHS) is distinguished from diabetic ketoacidosis (DKA) by the presence of extremely elevated serum glucose, more profound dehydration, and minimal or absent ketosis.*

Which patient with a fasting blood sugar of 110 mg/dL has the highest risk for development of metabolic syndrome? African American woman with a 40-inch waist, blood pressure of 140/90 mm Hg, triglycerides of 180, and high-density lipoprotein (HDL) of 25 Asian American man with a 30-inch waist, blood pressure of 130/60 mm Hg, triglycerides of 140, HDL of 45 Native American man with a 28-inch waist, blood pressure of 120/50 mm Hg, triglycerides of 130, HDL of 50 Hispanic American woman with a 34-inch waist, blood pressure of 130/50 mm Hg, triglycerides of 145, HDL of 40

African American woman with a 40-inch waist, blood pressure of 140/90 mm Hg, triglycerides of 180, and high-density lipoprotein (HDL) of 25 - Although all of the patients have some risk factors for metabolic syndrome, the African American woman has the highest number of risk factors *(waist greater than 40 inches in men and greater than 35 inches in women, triglycerides greater than 150, high-density lipoprotein [HDL] less than 40 for men and less than 35 for women).* - All of the patients have a genetic risk factor and high fasting blood sugar.

The nurse is trying to decrease the temperature of the patient in thyroid storm. Which treatment should the nurse question? Tepid water sponge bath Cold packs to the groin and axilla Aspirin suppository Circulating fan at the bedside

Aspirin suppository - Pyrexia is treated with hypothermia measures such as a cooling blanket, tepid sponge baths, cold packs, fans, and *acetaminophen.* - *Salicylates (aspirin) are contraindicated because they prevent protein binding of T3 to T4, increasing the free, metabolically active thyroid hormone.*

A patient is recovering from a lung resection because of malignant bronchogenic small cell carcinoma. The patient's serum sodium is 120 mEq/L, and syndrome of inappropriate antidiuretic hormone secretion (SIADH) is suspected. Which statement is TRUE regarding SIADH? SIADH occurs when excessive ADH is released by the anterior pituitary. Edema is a hallmark sign of SIADH caused by fluid shifts into the extracellular space. Management includes rapid restoration of serum sodium levels to normal. Clinical manifestations include concentrated urine output and overhydration.

Clinical manifestations include concentrated urine output and overhydration. - Patients with syndrome of inappropriate antidiuretic hormone secretion (SIADH) present with *very dilute serum and very concentrated urine output!* - *ADH is released by the* *POSTERIOR pituitary, and excessive ADH stimulates the kidney tubules to retain fluid regardless of need, which results in overhydration.* - Serum hypoosmolality leads to a shift of fluid from the extracellular fluid space into the intracellular fluid compartment. Because minimal sodium is present in this fluid, *edema usually does not result.* - *Too-rapid serum sodium correction must be avoided to reduce the risk of osmotic DEMYELINATION.*

The stress of critical illness triggers the hypothalamic-pituitary axis (HPA). Which statement accurately reflects the results of this action? Secretion of antidiuretic hormone (ADH) is reduced to promote reabsorption of water and maintain circulating volume. Catecholamine release results in vasodilation and control of stress-induced hypertension. Corticotropin (ACTH) is released from the anterior pituitary, stimulating the release of cortisol and resultant increase in fat and carbohydrate metabolism. HPA activity continues to increase as illness-related stress progresses.

Corticotropin (ACTH) is released from the anterior pituitary, stimulating the release of cortisol and resultant increase in fat and carbohydrate metabolism. - *During the stress of critical illness, the hypothalamic-pituitary axis (HPA) is activated by the release of epinephrine.* The anterior pituitary releases antidiuretic hormone (ADH), promoting vasoconstriction and maintenance of blood pressure and flow to tissues. *Cortisol increases fat and carbohydrate metabolism, providing needed energy to cells.* - *The HPA may not be able to maintain this response if critical illness is prolonged.*

Which clinical manifestations are indicative of thyroid storm? Hypotension, elevated TSH and T4, and subnormal T3 Tachycardia, hyperthermia, subnormal TSH, and elevated T3 and T4 Hyperthermia, diarrhea, low TSH, and elevated T3 and T4 Bradycardia, hypothermia, normal TSH, and elevated T3 and T4

Hyperthermia, diarrhea, low TSH, and elevated T3 and T4 - Thyroid storm is identified by clinical signs such as *high fever, tachycardia, hypertension, and tremor as evidence of the rapid metabolic rate.* - Laboratory values are similar to values seen in hyperthyroidism: *low TSH and high T4 levels.* - When treating thyroid storm, one should consider the four 'Bs': *B*lock release *(i.e. iodide)*; *B*lock T4 into T3 synthesis (i.e. high-dose propylthiouracil [PTU] and methimazole) *B*eta-blocker (propranolol); and *B*lock enterohepatic circulation (i.e. cholestyramine).

A patient admitted with hyperglycemic hyperosmolar state (HHS). The admission blood glucose is 785 mg/dL. The patient is started on an insulin drip at 7 units/h at 9:00. A blood sugar check at 1000 yields a glucose level of 745 mg/dL. Which action would be appropriate at this time? Leave the insulin drip at 7 units/h and recheck her glucose in 1 hour. Increase the insulin drip to 9 units/h and recheck her glucose in 1 hour. Increase the insulin drip to 14 units/h and recheck her glucose in 1 hour. Leave the insulin drip at 7 units/h and recheck her glucose in 30 minutes.

Increase the insulin drip to 14 units/h and recheck her glucose in 1 hour. - Methods to lower the blood glucose level vary. One method is to administer an *intravenous BOLUS of regular insulin (0.1 unit/kg of body weight) initially followed by a continuous insulin drip.* - *Regular insulin, infusing at an initial rate calculated as 0.1 unit/kg hourly (eg, 7 units/h for a person weighing 70 kg)* should lower the plasma glucose concentration by *50 to 70 mg/dL during the first hour of treatment.* If the measured glucose level does NOT decrease by this amount, the insulin infusion rate may be *DOUBLED until the blood glucose is declining at a rate of 50 to 70 mg/dL per hour.*

Which pathophysiologic process best explains the severe acidosis of diabetic ketoacidosis (DKA)? Inability of renal tubules to reabsorb glucose and potassium Increased serum osmolality caused by high glucose levels The catecholamine surge in response to dehydration Increased glucagon production, breakdown of fats, and gluconeogenesis

Increased glucagon production, breakdown of fats, and gluconeogenesis - In insulin deficiency states, gluconeogenesis occurs. *Fat is converted into glucose. The byproduct of fat metabolism is the release of fatty acids, which are rapidly reduced to ketones, producing acidosis.*

An older female patient admitted with weight gain, depression, and cold intolerance has respiratory acidosis and hypoventilation. She is unarousable. Which treatment would the nurse anticipate the practitioner ordering for this patient? Propranolol 1 mg IV every 4 hours Sodium iodine 1 g IV every 12 hours Reserpine 1 mg every 24 hours Levothyroxine 100 mcg IV followed by 75 mg/day

Levothyroxine 100 mcg IV followed by 75 mg/day - *The patient is experiencing myxedema coma, and the treatment is levothyroxine 100 mcg IV followed by 75 mg/day.* - Sodium iodine, reserpine, and propranolol are treatments for thyroid storm or thyrotoxicosis.

A patient is admitted with diabetic ketoacidosis (DKA), and an insulin drip is begun. The insulin drip should be continued until what occurs? Serum ketones are absent and a normal serum pH is achieved. Serum glucose levels fall below 200 mg/dL. Serum glucose levels are reduced by 50% of admission levels. Signs of dehydration are absent and the patient is able to tolerate oral fluids. *THE GOAL OF TREATING DKA IS TO ACHIEVE A STEADY DECLINE IN GLUCOSE LEVELS OF __ TO __ MG/DL/HR* *WHAT TO DO WHEN SERUM GLUCOSE LEVELS HAVE REACHED 200 MG/DL*

Serum ketones are absent and a normal serum pH is achieved. - *The goal when treating diabetic ketoacidosis (DKA) is to achieve a steady decline in glucose levels of 50 to 70 mg/dL/h.* - *When serum glucose levels have reached 200 mg/dL, 0.9% saline is changed to 5% dextrose as fluid replacement!* - *The insulin drip is continued until serum ketones are ABSENT and a NORMAL pH is achieved.*