Diabetic Emergencies for Certified Emergency Nursing (CEN)
Included In This Lesson
Study Tools For Diabetic Emergencies for Certified Emergency Nursing (CEN)
Outline
Diabetic Emergencies
Definition/Etiology:
DKA:
results from an inadequate amount of available insulin and is characterized by profound dehydration, electrolyte losses, ketonuria, and you guessed it, acidosis.
Classic findings of DKA include:
- BG over 250
- pH less than 7.3
- Serum HCO3 less than 15-20
- Ketonemia
Causes of DKA can include:
- New onset DM
- Poor insulin dosing
- Illness or infection in known diabetic (most common)
- Alcohol or drug use
- MI
- Pancreatitis and abd disorders
HHS:
- Hyperosmolar Hyperglycaemic State (HHS) occurs in people with type 2 diabetes who experience very high blood glucose levels (often over 40mmol/l). It can develop over a course of weeks through a combination of illness (e.g.infection) and dehydration.
- Many patients who suffer from HHS have a precipitant medical or surgical condition such as an infection, AMI, or stroke. Meds such as thiazide diuretics, steroids, dilantin, inderal, tagamet can causes.
Pathophysiology:
DKA – when insulin is unavailable to transport glucose into the cells, the liver metabolizes fatty acids into ketone bodies. This accumulation of ketones produces metabolic acidosis.
HHS: Elevated levels of counterregulatory hormones (glucagon, catecholamines, cortisol, and growth hormone) initiate HHS by stimulating hepatic glucose production through glycogenolysis and gluconeogenesis, leading to hyperglycemia, intracellular water depletion, and subsequent osmotic diuresis
Clinical Presentation:
Differences in presentation-
DKA:
- Usually <40 years old
- Symptoms usually <2 days
- Glucose <600
- Sodium normal or low
- Bicarb Low
- Ketones at least 4+
- pH usually low <7.3
- Prognosis – 3-10% mortality
- Subsequent course – ongoing insulin therapy
- Most commonly seen with Type 1 DM
S&S:
- Tachycardia, Hypotension
- Dry skin, poor skin turgor
- Fatigue
- Changes in LOC
- Kussmaul respirations (rapid deep breathing) – body trying to blow off CO2
- Upon exhalation, breath may smell like fruity nail polish remover
- Abd pain without rebound tenderness
HHS:
- Usually, >60 years old
- Symptoms usually >5 days
- Glucose >600
- Sodium normal or high
- Bicarb normal
- Ketones at least <2+
- pH Normal
- Prognosis – 20-60% mortality
- Subsequent course – insulin therapy not often required
S&S:
- Weakness
- Polyuria, polydipsia
- Dry mucosa, dry skin
- Orthostatic hypotension
- N/V
- Acute changes in LOC
- Seizures
Collaborative Management:
DKA-
- Obviously – get a finger stick to start but confirm with a serum glucose level
- Test for glucose and ketones in urine
- UA
- CBC, CMP (BUNm Cr Phosphate, Amylase)
- ABG
- Chest x-ray, 12-lead
Interventions:
- Fluid replacement – OK so more and more facilities are developing protocols for fluid replacement with DKA, so check your own policies. That being said, commonly we start with NS and change to ½ ns if hypovolemia reverses, or the sodium stays high.
- IV insulin – Treatment of choice
- Measure serum glucose hourly and titrate the infusion according to your protocols.
- Replace electrolytes:
- Potassium, phosphate, bicarb
HHS-
The main difference between DKA and HHS is that HHS is indicated by a more elevated serum glucose and the absence of ketoacidosis.
Labs: Serum glucose, UA, Bicarb, ABG
Treatment:
- Similar to DKA though we need less insulin
- Replace fluids – NS
- Monitor I&O – Foley
- Admin insulin
- Replace electrolytes – specifically watch the potassium.
Evaluation | Patient Monitoring | Education:
- Evaluation of DKA involves repeated lab work. Is there a reduction in glucose, are we correcting the anion gap, are the electrolytes returning to normal levels, and of course, how is our patient. Neuro status and hemodynamics are constantly monitored throughout treatment.
- Eval of HHS is similar to DKA. Is the glucose normalizing? Are the electrolytes normalizing? And is our patient showing less symptoms.
Linchpins: (Key Points)
- Early identification
- Fluids
- Insulin
Transcript
For more great CEN prep, got to the link below to purchase the “Emergency Nursing Examination Review” book by Dr. Laura Gasparis Vonfrolio RN, PHD
https://greatnurses.com/
References:
- Adeyinka A, Kondamudi NP. Hyperosmolar Hyperglycemic Syndrome. [Updated 2022 May 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482142/
- Emergency Nurses Association. (2022). Emergency Nursing Orientation 3.0. Cambridge, MA: Elsevier, Inc.
- Sheehy, S. B., Hammond, B. B., & Zimmerman, P. G. (2013). Sheehy’s manual of emergency care (Vol. 7th Edition). St. Louis, MO: Elsevier/Mosby.
Tiona RN
Concepts Covered:
- Studying
- Medication Administration
- Adult
- Emergency Care of the Cardiac Patient
- Intraoperative Nursing
- Microbiology
- Cardiac Disorders
- Vascular Disorders
- Nervous System
- Upper GI Disorders
- Central Nervous System Disorders – Brain
- Immunological Disorders
- Fundamentals of Emergency Nursing
- Dosage Calculations
- Understanding Society
- Circulatory System
- Concepts of Pharmacology
- Hematologic Disorders
- Newborn Care
- Adulthood Growth and Development
- Disorders of Pancreas
- Postoperative Nursing
- Pregnancy Risks
- Neurological
- Postpartum Complications
- Noninfectious Respiratory Disorder
- Peripheral Nervous System Disorders
- Learning Pharmacology
- Prenatal Concepts
- Tissues and Glands
- Developmental Considerations
- Factors Influencing Community Health
- Childhood Growth and Development
- Prenatal and Neonatal Growth and Development
- Developmental Theories
- Basic
- Neonatal
- Pediatric
- Gastrointestinal
- Newborn Complications
- Labor Complications
- Fetal Development
- Terminology
- Labor and Delivery
- Postpartum Care
- Communication
- Basics of Mathematics
- Statistics
- Basics of Sociology
- Cardiovascular
- Shock
- Shock
- Disorders of the Posterior Pituitary Gland
- Endocrine
- Disorders of the Thyroid & Parathyroid Glands
- Liver & Gallbladder Disorders
- Lower GI Disorders
- Respiratory
- Delegation
- Perioperative Nursing Roles
- Acute & Chronic Renal Disorders
- Respiratory Emergencies
- Disorders of the Adrenal Gland
- Documentation and Communication
- Preoperative Nursing
- Legal and Ethical Issues
- Oncology Disorders
- Female Reproductive Disorders
- Musculoskeletal Trauma
- Renal Disorders
- Male Reproductive Disorders
- Sexually Transmitted Infections
- Infectious Respiratory Disorder
- Integumentary Disorders
- Emergency Care of the Trauma Patient
- Urinary Disorders
- Musculoskeletal Disorders
- EENT Disorders
- Neurological Emergencies
- Disorders of Thermoregulation
- Neurological Trauma
- Basics of NCLEX
- Integumentary Important Points
- Multisystem
- Test Taking Strategies
- Urinary System
- Emergency Care of the Neurological Patient
- Central Nervous System Disorders – Spinal Cord
- Respiratory System
- Emergency Care of the Respiratory Patient
- Cognitive Disorders
- Anxiety Disorders
- Depressive Disorders
- Trauma-Stress Disorders
- Substance Abuse Disorders
- Bipolar Disorders
- Psychotic Disorders
- Concepts of Mental Health
- Eating Disorders
- Personality Disorders
- Health & Stress
- Psychological Emergencies
- Somatoform Disorders
- Prioritization
- Community Health Overview
- Gastrointestinal Disorders
- Integumentary Disorders
- Respiratory Disorders
- Neurologic and Cognitive Disorders
- Renal and Urinary Disorders
- Infectious Disease Disorders
- EENT Disorders
- Hematologic Disorders
- Cardiovascular Disorders
- Musculoskeletal Disorders
- Endocrine and Metabolic Disorders
- Oncologic Disorders
- Behavior
- Emotions and Motivation
- Growth & Development
- Intelligence and Language
- Psychological Disorders
- State of Consciousness
- Note Taking
- Concepts of Population Health
- Basics of Human Biology