Structures and Functions of Endocrine

The endocrine system consists of cells, tissues, and organs that secrete hormones as a primary or secondary function. The endocrine gland is the major player in this system. The primary function of these ductless glands is to secrete their hormones directly into the surrounding fluid. The interstitial fluid and the blood vessels then transport the hormones throughout the body. The endocrine system includes the pituitary, thyroid, parathyroid, adrenal, and pineal glands.

Some of these glands have both endocrine and non-endocrine functions. For example, the pancreas contains cells that function in digestion as well as cells that secrete the hormones insulin and glucagon, which regulate blood glucose levels. The hypothalamus, thymus, heart, kidneys, stomach, small intestine, liver, skin, female ovaries, and male testes are other organs that contain cells with endocrine function. Moreover, adipose tissue has long been known to produce hormones, and recent research has revealed that even bone tissue has endocrine functions.

Diagnostic

The Romberg test is a component of a neurological examination to assess vestibular function (perception of head position in space), proprioception (perception of the body in space), and vision.

The Heel-to-shin test is another means of assessing cerebellar function.  An abnormal examination is evident when the client is unable to keep the foot on the shin.

Normal serum calcium is 8.6-10.2 mg /dL (2.15-2.55 mmol/L) (REMEMBER 9-11) .  Hypocalcemia (serum calcium <8.6 mg/dL [2.15 mmol/L]) is a potential complication of thyroidectomy.  The nurse should monitor for signs and symptoms of tetany (tingling of hands, toes, and circumoral region; positive Trousseau or Chvostek sign), confirm with serum calcium results, and administer calcium gluconate as prescribed.

Phalen’s maneuver is used to diagnose carpal tunnel syndrome.

A RAIU test involves administering a low dose of radioactive iodine, in contrast to radioactive iodine treatment for some types of thyroid cancer, which uses a high dose to destroy all thyroid tissue.  The thyroid gland is the only tissue that uses iodine, which is a key component of thyroid hormones.  A scan is performed at 2, 6, and 24 hours to assess the areas actively absorbing iodine, which can narrow the diagnosis to hyperfunctioning thyroid disorders (eg, Graves’ disease).

RAIU measures the metabolic activity in the thyroid gland in order to differentiate between the many types of thyroid disorders.  For an accurate measurement, medications affecting the thyroid should be held 7 days prior to the test date and clients are NPO for 4 hours prior to iodine administration.  Premenopausal women must take a pregnancy test.  Dentures, metal, and jewelry should be removed.

Interventions 

Education

The American Diabetic Association recommends a simple “Create My Plate“ method for meal planning.  Specific dietary recommendations include:

1. Monitor carbohydrate intake
2. Manage caloric intake if weight loss is desired
3. High-fiber foods (30-35 g of fiber per day), including whole grains, legumes, fruits, vegetables, and low-fat dairy products
4. Use monounsaturated fats, limit use of saturated fat, and eliminate trans fatty acids
5. Choose foods with a low glycemic index
6. Consume total cholesterol of <300 mg per day
7. Reduce sodium intake
8. Limit intake of foods containing sucrose
9. Limit intake of alcoholic beverages

Thyroidectomy involves partial or complete removal of the thyroid, often to treat hyperthyroidism or thyroid cancer.  Clients undergoing thyroidectomy require close monitoring because they are at increased risk for airway compromise due to potential neck swelling, hypocalcemia, and nerve damage.  Nursing care following thyroidectomy focuses on promoting client recovery and monitoring for and preventing complications, and includes:

• Assessing for and immediately reporting signs of hypocalcemia (eg, facial or extremity numbness or tingling, stridor, Trousseau and Chvostek signs), which may occur from parathyroid gland trauma during surgery . 
• Keeping emergency airway equipment (eg, tracheostomy kit, suction, oxygen) at the bedside in case respiratory distress develops .
• Maintaining the client in semi-Fowler position, which promotes drainage of surgical site edema around the neck and reduces the risk of respiratory distress.
• Postoperatively, the client should avoid excessive neck flexion and extension, which may strain and cause disruption of the incision site, leading to hemorrhage.  Encourage the client to maintain neutral head and neck alignment.

Stridor is a high-pitched, vibratory, harsh sound during inspiration or expiration that indicates partial airway obstruction.  When stridor occurs after a thyroidectomy, a delicate surgery involving a highly vascularized area, the most immediate concern is airway compromise secondary to hemorrhage or laryngeal edema.  This is a life-threatening complication requiring immediate intervention.  The nurse should ensure that suctioning devices, oxygen, and a tracheostomy tray are readily available in the recovery room as immediate tracheostomy may be necessary.

Respiratory stridor, also observed in epiglottitis, is very different from the minor laryngeal edema that commonly occurs after intubation and results in transient hoarseness in the postoperative period.

Persistent hoarseness and the inability to raise one’s voice more than 24 hours postoperatively may indicate damage to the laryngeal nerve, a frequent complication of thyroid surgery.

Thyrotoxicosis (ie, thyroid storm) is a life-threatening condition characterized by an increase in thyroid hormone levels that results in a hypermetabolic state.  Most commonly, thyrotoxicosis occurs as an exacerbation of hyperthyroidism, an overactive thyroid disorder, and is treated with antithyroid medications and/or surgical removal of the thyroid (ie, thyroidectomy).  However, thyrotoxicosis may also occur due to excess thyroid hormone intake from medications and physical manipulation of the thyroid gland.

The nurse caring for a client after thyroidectomy must closely monitor for and immediately report any clinical manifestations of thyrotoxicosis (eg, fever, anxiety, tachycardia), particularly in clients with hyperthyroidism.  After surgery, thyroid hormone levels can remain elevated for several days, and may even increase, from intraoperative thyroid gland manipulation.  Without treatment, thyrotoxicosis can rapidly progress to lethal complications (eg, hyperthermia, malignant hypertension, ventricular tachycardia).

Foot injury prevention

The nurse should teach the client about foot injury prevention because peripheral neuropathy may impair the ability to feel injuries until they have become severe enough to require amputation.  For a client with DM, the nurse should teach the client to:

• Inspect for any break in skin integrity using a mirror or a second person to visualize the bottom of the feet.
• Wear shoes that are comfortable, supportive, and well-fitting (preferably leather).  The nurse should teach the client to avoid open-toed shoes (eg, sandals) 
• Report nonhealing or infected injuries to the health care provider immediately; do not self-treat corns, calluses, or ingrown toenails.

Common pathologies 

Hypothyroidism is associated with symptoms of a low metabolic rate; hyperthyroidism causes symptoms of a high metabolic rate.

Primary hypothyroidism is an endocrine disorder identified by low thyroid hormone (ie, triiodothyronine [T3], thyroxine [T4]) and high thyroid-stimulating hormone (TSH) levels.  Primary hypothyroidism occurs when TSH is unable to stimulate the thyroid to produce thyroid hormones, often after trauma or autoimmune-related tissue damage (eg, Hashimoto thyroiditis).  Therefore, TSH levels remain elevated as primary counterregulatory hormone (ie, T3, T4) levels remain low.

Clinical features of myxedema coma

– Hypothermia – Hypoventilation – Bradycardia – Hypertension or hypotension with narrow pulse pressure – Decreased mental status, psychosis, seizure & coma – Non-pitting edema of hands, face & tongue – Pericardial effusion – Hyponatremia & hypoglycemia – Possible concurrent adrenal insufficiency or hypothalamic/pituitary dysfunction

Myxedema coma refers to a state of severe hypothyroidism causing decreased level of consciousness (eg, lethargy, stupor) that may progress to a comatose state.  Myxedema coma is characterized by hypothermia, bradycardia, hypotension, and hypoventilation.  Hypoventilation may occur as a result of respiratory muscle fatigue and mechanical obstruction by an edematous tongue.

Clients with signs of respiratory failure (eg, slow or shallow breathing, low oxygen saturation) require emergency endotracheal intubation and mechanical ventilation.  The nurse should provide respiratory support (eg, ventilation with a bag-valve-mask) and prepare to assist with intubation.

Hyperthyroidism results from excessive secretion of thyroid hormones.  Affected clients are at risk for developing thyroid storm, a life-threatening form of hyperthyroidism.  Symptoms of thyroid storm include fever, tachycardia, cardiac dysrhythmias (eg, atrial fibrillation), nausea, vomiting, diarrhea, and altered mental status.  Client management includes reducing fever, maintaining hydration, and preventing cardiac compromise (eg, heart failure).

Hyperthyroidism refers to sustained hyperfunctioning of the thyroid gland due to excessive secretion thyroid hormones (T₃, T₄); this leads to an increased metabolic rate.  In clients with hyperthyroidism, teaching and learning objectives to satisfy hunger and prevent weight loss and tissue wasting include:

• Adherence to a high calorie diet (4000-5000 calories per day).
• Consumption of approximately 6 full meals and snacks per day.  These should be packed with protein (1-2 g/kg of ideal body weight), carbohydrates, and be full of vitamins and minerals
• Avoidance of high-fiber foods due to the constant hyperstimulation of the gastrointestinal (GI) tract.  High-fiber foods may increase GI symptoms (eg, diarrhea) However, high-fiber diets are recommended if the client with hyperthyroidism has constipation.
• Avoidance of stimulating substances (eg, caffeinated drinks: coffee, tea, soft drinks).
• Avoidance of spicy foods as these can also increase GI stimulation.

Graves’ disease is an immune system disorder that results in the overproduction of thyroid hormones (hyperthyroidism). Although a number of disorders may result in hyperthyroidism, Graves’ disease is a common cause. Thyroid hormones affect many body systems, so signs and symptoms of Graves’ disease can be wide ranging.

Thyroid storm is a serious and potentially life-threatening emergency for clients with Graves disease.  This condition occurs when the thyroid gland releases large amounts of thyroid hormone in response to stress (eg, trauma, surgery, infection).  Characteristic features include tachycardia, hypertension, cardiac arrhythmias (eg, atrial fibrillation), and fever up to 104-106 F (40-41 C).  Other findings include severe nausea, vomiting, anxiety, altered mentation, and seizures.The client often feels anxious, tremulous, or restless.  Confusion and psychosis can occur, as can seizures and coma. 

Exophthalmos (protruding eyeball) is commonly seen in Graves disease.  The eyelids do not close over the eyeballs properly, leading to excessive dryness and resultant corneal damage (exposure keratitis).  Although it is important to treat exophthalmos, it is not immediately life-threatening.

Nursing care for a client with exophthalmos includes:

• Maintaining the head of the bed in a raised position to facilitate fluid drainage from the periorbital area
• Using artificial tears or other similar products to moisten the eyes to prevent corneal drying (causes abrasions/ulcers)
• Taping the client’s eyelids shut during sleep if they do not close on their own
• Teaching the client the following:
  • Regular visits to the ophthalmologist are necessary to measure eyeball protrusion and evaluate condition.
  • If recommended, anti-thyroid drugs should be taken to prevent further exacerbation of exophthalmos.
  • Smoking cessation is necessary as smoking increases the risk of Graves’ disease and associated eye problems.
  • Restrict salt intake to decrease periorbital edema.
  • Use dark glasses to decrease glare and prevent external irritants and infection.
  • Perform intraocular muscle exercises (turning the eyes using complete range of motion) to maintain flexibility.

Diabetes 

Type 1 diabetes mellitus is an endocrine disorder characterized by the absence of insulin production in the pancreas, causing hyperglycemia and intracellular energy deficits.  Clients with type 1 diabetes mellitus require consistent insulin administration, typically of both short- or rapid-acting and intermediate- or long-acting insulins, to prevent hyperglycemia and provide energy to the cells. The nurse should contact the health care provider (HCP) to report the serum glucose (270 mg/dL [14.9 mmol/L]) and request an additional insulin prescription 

Type 2 diabetes is an impairment in the way the body regulates and uses sugar (glucose) as a fuel. This long-term (chronic) condition results in too much sugar circulating in the bloodstream. Eventually, high blood sugar levels can lead to disorders of the circulatory, nervous and immune systems. In type 2 diabetes, there are primarily two interrelated problems at work. Your pancreas does not produce enough insulin — a hormone that regulates the movement of sugar into your cells — and cells respond poorly to insulin and take in less sugar. Type 2 diabetes used to be known as adult-onset diabetes, but both type 1 and type 2 diabetes can begin during childhood and adulthood. Type 2 is more common in older adults, but the increase in the number of children with obesity has led to more cases of type 2 diabetes in younger people.

Hemoglobin A1C is a diagnostic test used to measure the percentage of glycosylated hemoglobin in the blood.  A normal hemoglobin A1C is 4%-6% in clients without diabetes; the goal is to keep the level <7% in clients with diabetes.  The A1C test measures blood glucose control over a period of 2-3 months; higher measurements indicate higher glycemic levels.  High levels may indicate poor adherence to the recommended diet and exercise plan or ineffective antihyperglycemic medication regimen.  It is important for the nurse to review the diet, exercise, and medication plan with the client who has a high hemoglobin A1C.

Hypoglycemia, a potentially life-threatening complication of diabetes mellitus, is identified by blood glucose <70 mg/dL (<3.9 mmol/L) and often occurs as a result of illness or inappropriate use of antidiabetic medications.  When blood glucose levels (BGLs) are low, the body activates the autonomic nervous system, causing shakiness, palpitations, and sweating.  Without intervention, hypoglycemia may cause altered mental status (eg, difficulty speaking, confusion), which may progress to seizures, coma, and death. Counterregulatory hormones (eg, epinephrine) are then released and the autonomic nervous system is activated, causing symptoms of hypoglycemia such as sweating, tremor, and hunger. Nurses caring for clients with hypoglycemia and altered mental status or dysphagia should immediately administer IV glucose replacement (eg, 50% dextrose in water) to quickly restore BGLs and prevent potentially lethal neurological changes

High blood sugar, also called hyperglycemia, affects people who have diabetes. Several factors can play a role in hyperglycemia in people with diabetes. They include food and physical activity, illness, and medications not related to diabetes. Skipping doses or not taking enough insulin or other medication to lower blood sugar also can lead to hyperglycemia.

It’s important to treat hyperglycemia. If it’s not treated, hyperglycemia can become severe and cause serious health problems that require emergency care, including a diabetic coma. Hyperglycemia that lasts, even if it’s not severe, can lead to health problems that affect the eyes, kidneys, nerves and heart

Diabetes insipidus (DI) is a condition that occurs due to insufficient production/suppression of antidiuretic hormone (ADH).  Neurogenic DI is a type of DI that results from impaired ADH secretion, transport, or synthesis.  It sometimes occurs after manipulation of the pituitary or other parts of the brain during surgery, brain tumors, head injury, or central nervous system infections.

Diabetic ketoacidosis (DKA) is a complication of diabetes mellitus that results from lack of insulin.  Insulin is required to transport glucose into cells for energy; therefore, lack of insulin leads to intracellular starvation despite a high level of glucose circulating in the blood (hyperglycemia).  Physiologic responses to hyperglycemia include osmotic diuresis (polyuria) for reduction of blood glucose levels, and breakdown of fat into acidic ketone bodies for energy (ketosis).  DKA results in dehydration, electrolyte imbalances, and metabolic acidosis that can lead to life-threatening complications (eg, hypovolemic shock, cardiac arrhythmias) without prompt intervention.

DKA is an acute life-threatening complication, typically of type I diabetes, characterized by hyperglycemia, ketosis, and acidosis.  It is caused by an intense deficit of insulin and should be treated first with rehydration (normal saline) and then insulin administration.

Hyperosmolar hyperglycemic state is a serious complication usually associated with type 2 diabetes.  With this condition, clients are able to produce enough insulin to prevent diabetic ketoacidosis but not enough to prevent extreme hyperglycemia, osmotic diuresis, and extracellular fluid deficit.  Because some insulin is produced, blood glucose rises slowly and symptoms may not be recognized until hyperglycemia is extreme, often >600 mg/dL (33.3 mmol/L).  This eventually causes neurological manifestations such as blurry vision, lethargy, obtundation, and progression to coma.  Because some insulin is present, symptoms associated with ketones and acidosis, such as Kussmaul respirations (hyperventilation) and abdominal pain, are typically absent.

The nurse should prioritize fluid resuscitation with isotonic IV fluid (eg, 0.9% sodium chloride) to stabilize fluid volume before intervention that shifts blood glucose.  Insulin administration will cause a shift of water, potassium, and glucose into cells, which worsens dehydration and electrolyte imbalances and can increase the risk of hypovolemic shock if fluid is not initiated first.

Acanthosis nigricans is a skin disorder characterized by the presence of symmetric, hyperpigmented velvety plaques located in flexural and intertriginous regions of skin (axilla, neck).  Skin tags (acrochordons) are commonly present on regions affected by acanthosis nigricans.  Both indicate insulin resistance (diabetic dermopathy).  The client should be referred to the primary health care provider for evaluation of undiagnosed diabetes mellitus and/or metabolic syndrome.

Diabetic neuropathy is caused by nerve damage as a result of the metabolic disturbances associated with diabetes mellitus.  Autonomic neuropathy is nerve damage to the autonomic nervous system, the system responsible for involuntary body functions such as blood pressure, heart rate, perspiration, sexual function, and digestion.  Impairment to the autonomic nervous system caused by neuropathy can cause symptoms such as postural hypotension, tachycardia, painless myocardial infarction, bowel incontinence, diarrhea, urinary retention, and hypoglycemic unawareness.  The client with postural hypotension is also at risk for falls and should be taught to get up from a lying or sitting position slowly.

Individuals with type I or II diabetes mellitus are at increased risk for developing an infection or ulcer on their feet.  

This is due to the chronic complication of peripheral neuropathy, which results from nerve damage in the extremities.

Instructions for diabetic foot care include:

1. Wash feet daily with warm water and mild soap; test water temperature with thermometer beforehand.  Gently pat feet dry, particularly between the toes.  Use lanolin to prevent dry and cracked skin, but do not apply between the toes.
2. Inspect for abrasions, cuts, or sores.  Have others inspect the feet if eyesight is poor.
3. To prevent injury, use cotton or lamb’s wool to separate overlapping toes.  Cut toenails straight across and use a nail file to file along the curves of the toes.  Avoid going barefoot and wear sturdy leather shoes.  Use mild foot powder to absorb perspiration and wear clean, absorbent socks with seams aligned.
4. Avoid using over-the-counter products (eg, iodine, alcohol, strong adhesives) on cuts or abrasions.
5. To improve circulation, do not sit with legs crossed or for extended periods, avoid tight-fitting garments, and perform daily exercise.
6. Report other types of problems such as infections or athlete’s foot immediately.

Addison’s disease, or chronic adrenal insufficiency, occurs when the adrenal glands do not produce adequate amounts of steroid hormones (mineralocorticoids, glucocorticoids, androgens).  Symptoms include weight loss, muscle weakness, low blood pressure, hypoglycemia, and hyperpigmented skin (skin folds, buccal area, palmar crease).  Hyperpigmented skin is a characteristic universal finding; this results from increased adrenocorticotropic hormone which is due to a decrease in cortisol negative feedback.  Treatment consists of replacement therapy with oral mineralocorticoids and corticosteroids

Addisonian crisis, clients report nausea, vomiting, and abdominal pain.  Addisonian crisis is triggered by stress, and its manifestations include the following:

• Hypotension and tachycardia
• Dehydration
• Hyperkalemia and hyponatremia
• Hypoglycemia
• Fever
• Weakness and confusion

Emergency management includes shock management with fluid resuscitation using 0.9% normal saline and 5% dextrose, and administration of high-dose hydrocortisone replacement IV push.

SIADH is an endocrine condition in which too much ADH is produced, causing water retention, increased total body water, and dilutional hyponatremia (low serum sodium).  Some cancer cells, particularly those of small cell lung cancer, have the ability to produce and secrete ADH, leading to SIADH.  Other causes include central nervous system disorders (eg, stroke, trauma, neurosurgery) and some commonly used medications (eg, desmopressin, carbamazepine).

Syndrome of inappropriate antidiuretic hormone secretion (SIADH) is associated with increased water reabsorption and excessive intra- and extracellular fluid, which result in hypervolemia from fluid retention and dilutional hyponatremia.  In the setting of SIADH, the nurse should question a prescription for a hypotonic solution (eg, 0.45% NaCl; or dextrose water) as it would worsen the fluid and electrolyte imbalance.  A prescription for fluid restriction and a hypertonic IV solution (eg, 3% NaCl) administered in small quantities would be appropriate to shift fluid back into the vascular compartment and correct hyponatremia.

Cushing syndrome is the result of prolonged exposure to excess corticosteroids, especially glucocorticoid steroids.  The most common cause is the administration of corticosteroids, such as prednisone or hydrocortisone, for other conditions.  However, pituitary adenomas can secrete adrenocorticotropic hormone (ACTH), which in turn causes the adrenal glands to produce too much cortisol.

Clinical manifestations of Cushing syndrome include:

• Androgen excess from adrenal gland stimulation can result in acne, hirsutism, and menstrual irregularities (eg, oligomenorrhea).
• Metabolic complications include truncal obesity (subsequently causing peripheral insulin resistance), hypertension, and hyperglycemia (ie, excess cortisol stimulating gluconeogenesis).  Fat accumulation in the face (ie, moon face) and the back of neck (ie, dorsocervical fat pad) is common.
• Dermatological changes are possible and include easy bruising, purple striae, and skin atrophy; these result from loss of collagen.
• Proximal muscle weakness and bone loss (ie, osteoporosis) due to steroid catabolism on muscles and bone can develop in untreated clients.

Hirsutism is a condition in women that consists of male-pattern hair growth on the face, lower abdomen, chest, and back.  Common causes are polycystic ovary syndrome and Cushing’s syndrome. 

Pheochromocytoma is a condition caused by a tumor in the adrenal medulla.  This results in excess release of catecholamines such as epinephrine and norepinephrine, leading to paroxysmal hypertensive crisis.

Important points to note when caring for these clients include the following:

1. Hypertension is difficult to treat and is often resistant to multiple drugs.
2. The client should avoid activities that can precipitate a hypertensive crisis (eg, bending, lifting, Valsalva maneuver).
3. Abdominal palpation should be avoided as manipulation of the adrenal gland and release of catecholamines can precipitate a hypertensive crisis.

Hypertensive crisis puts the client at risk for stroke and so has the highest priority for treatment.  Nitroprusside (Nitropress, Nipride) is a vasodilator given via infusion and can be titrated to keep the BP within a desired parameter.

Metabolic syndrome is the presence of ≥3 metabolic health factors that increase a client’s risk for stroke, diabetes mellitus, and cardiovascular disease.  A mnemonic for metabolic syndrome is “We Better Think High Glucose” (Waist circumference, Blood pressure, Triglycerides, HDL, Glucose).  Criteria includes:

• Abdominal obesity:  Waist circumference ≥40 in (102 cm) in men, ≥35 in (89 cm) in women
• High serum triglycerides:  >150 mg/dL (1.7 mmol/L) or hypertriglyceridemia drug treatment
• Low HDL cholesterol:  <40 mg/dL (1.04 mmol/L) in men, <50 mg/dL (1.3 mmol) in women or hyperlipidemia drug treatment
• High blood pressure:  ≥130/85 mm Hg or hypertension drug treatment
• Increased fasting blood glucose:  ≥100 mg/dL (5.6 mmol/L) or hyperglycemia drug treatment

Acromegaly is an uncommon condition caused by an overproduction of growth hormone (GH).  It is usually due to pituitary adenoma, and onset in adult clients generally occurs at age 40-45.  In an adult, increased GH results in overgrowth of soft tissues of the face, hands, feet, and organs.  Additional heart sounds (S3, S4) require further assessment for cardiac conditions (eg, heart failure).

Insulin

Lispro is a rapid-acting insulin with a peak of 30 minutes to 3 hours and should be given only if it is certain the client will eat within 15 minutes

Regular Human Insulin which has an onset of action of 1/2 hour to 1 hour, peak effect in 2 to 4 hours, and duration of action of 6 to 8 hours. The larger the dose of regular the faster the onset of action, but the longer the time to peak effect and the longer the duration of the effect.

NPH insulin is intermediate-acting with an onset of 1-2 hours, peak of 4-12 hours, and duration of 12-18 hours. 

Detemir, is a long-acting (basal) insulin, prescribed once or twice daily.  Long-acting insulins are given to prevent, not correct, hyperglycemia. 

Glargine is a long-acting (basal) insulin given to prevent hyperglycemia for 24 hours.  The drug has no peak, and so timing of administration is not dependent on food intake.

Stress-induced hyperglycemia 

(gluconeogenesis) can occur in hospitalized clients in relation to surgery, trauma, acute illness, and infection.  Hyperglycemia (glucose level >140 mg/dL [7.8 mmol/L]) affects both diabetic and non-diabetic hospitalized clients, especially those who are critically ill.  Approximately 80% of clients in the intensive care unit who develop hyperglycemia have no history of diabetes before admission.

Electrolytes and Labs 

Potassium is never given as a rapid IV bolus, as cardiac arrest may result. Potassium should never be given until the serum potassium level is known to be normal or low and urinary voiding is observed.  Peaked T waves indicate hyperkalemia in this client.  Clients with insulin deficiency frequently have increased serum potassium levels due to the extracellular shift despite having total body potassium deficit from urinary losses.  Once insulin is given, serum potassium levels drop rapidly, often requiring potassium replacement.  

The normal serum creatinine for an adult is 0.6-1.3 mg/dL (53-115 µmol/L).  It provides an estimation of the glomerular filtration rate and is an indicator of kidney function.  A level of 2 mg/dL (177 µmol/L) is clearly abnormal.  The client with diabetes mellitus is at risk for diabetic nephropathy, a complication associated with microvascular blood vessel damage in the kidney.  Early treatment and tight control of blood glucose levels are indicated to prevent progressive renal injury in a client with diabetic nephropathy.

Solutions 

The most common way to categorize IV fluids is based on their tonicity:

• Isotonic. Isotonic IV solutions that have the same concentration of solutes as blood plasma.
• Hypotonic. Hypotonic solutions have lesser concentration of solutes than plasma.
• Hypertonic. Hypertonic solutions have greater concentration of solutes than plasma.

IV solutions can also be classified based on their purpose:

• Nutrient solutions. May contain dextrose, glucose, and levulose to make up the carbohydrate component – and water. Water is supplied for fluid requirements and carbohydrate for calories and energy. Nutrient solutions are useful in preventing dehydration and ketosis. Examples of nutrient solutions include D5W, D5NSS.
• Electrolyte solutions. Contains varying amounts of cations and anions that are used to replace fluid and electrolytes for clients with continuing losses. Examples of electrolyte solutions include 0.9 NaCl, Ringer’s Solution, and LRS.
• Alkalinizing solutions. Are administered to treat metabolic acidosis. Examples: LRS.
• Acidifying solutions. Are used to counteract metabolic alkalosis. D51/2NS, 0.9 NaCl.
• Volume expanders. Are solutions used to increase the blood volume after a severe blood loss, or loss of plasma. Examples of volume expanders are dextran, human albumin, and plasma.

Positions 

The Trendelenburg position (body laid flat and supine with feet higher than the head by at least 15–30 degrees) is contraindicated in most neurological conditions.

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