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.
NCLEX
Concepts Covered:
- Cardiovascular
- Emergency Care of the Cardiac Patient
- Cardiac Disorders
- Circulatory System
- Nervous System
- Skeletal System
- Shock
- Shock
- Disorders of the Posterior Pituitary Gland
- Endocrine
- Disorders of Pancreas
- Disorders of the Thyroid & Parathyroid Glands
- Hematology
- Gastrointestinal
- Upper GI Disorders
- Liver & Gallbladder Disorders
- Newborn Complications
- Lower GI Disorders
- Multisystem
- Neurological
- Central Nervous System Disorders – Brain
- Renal
- Respiratory
- Urinary System
- Respiratory System
- Noninfectious Respiratory Disorder
- Test Taking Strategies
- Note Taking
- Basics of NCLEX
- Prefixes
- Suffixes
- Medication Administration
- Gastrointestinal Disorders
- Respiratory Disorders
- Pregnancy Risks
- Labor Complications
- Hematologic Disorders
- Fundamentals of Emergency Nursing
- Factors Influencing Community Health
- Delegation
- Perioperative Nursing Roles
- EENT Disorders
- Basics of Chemistry
- Adult
- Emergency Care of the Neurological Patient
- Acute & Chronic Renal Disorders
- Emergency Care of the Respiratory Patient
- Respiratory Emergencies
- Studying
- Substance Abuse Disorders
- Disorders of the Adrenal Gland
- Behavior
- Documentation and Communication
- Preoperative Nursing
- Endocrine System
- Legal and Ethical Issues
- Communication
- Understanding Society
- Immunological Disorders
- Infectious Disease Disorders
- Oncology Disorders
- Female Reproductive Disorders
- Fetal Development
- Terminology
- Anxiety Disorders
- Cognitive Disorders
- Musculoskeletal Trauma
- Intraoperative Nursing
- Tissues and Glands
- Vascular Disorders
- Renal Disorders
- Eating Disorders
- Prenatal Concepts
- Microbiology
- Male Reproductive Disorders
- Sexually Transmitted Infections
- Infectious Respiratory Disorder
- Depressive Disorders
- Personality Disorders
- Psychotic Disorders
- Trauma-Stress Disorders
- Peripheral Nervous System Disorders
- Integumentary Disorders
- Neurologic and Cognitive Disorders
- Integumentary Disorders
- Newborn Care
- Basics of Mathematics
- Statistics
- Labor and Delivery
- Proteins
- Emergency Care of the Trauma Patient
- Hematologic System
- Hematologic Disorders
- Developmental Considerations
- Digestive System
- Urinary Disorders
- Postpartum Care
- Basic
- Musculoskeletal Disorders
- Bipolar Disorders
- Metabolism
- Cardiovascular Disorders
- Concepts of Population Health
- Musculoskeletal Disorders
- EENT Disorders
- Postpartum Complications
- Basics of Human Biology
- Postoperative Nursing
- Neurological Emergencies
- Prioritization
- Disorders of Thermoregulation
- Writing
- Community Health Overview
- Dosage Calculations
- Neurological Trauma
- Concepts of Mental Health
- Health & Stress
- Endocrine and Metabolic Disorders
- Childhood Growth and Development
- Prenatal and Neonatal Growth and Development
- Concepts of Pharmacology
- Integumentary Important Points
- Emotions and Motivation
- Renal and Urinary Disorders
- Developmental Theories
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- Psychological Emergencies
- Growth & Development
- Basics of Sociology
- Somatoform Disorders
- Reading
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- Oncologic Disorders
- Med Term Basic
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- Central Nervous System Disorders – Spinal Cord
- Muscular System
- Neonatal
- Learning Pharmacology
- Pediatric
- Psychological Disorders
- State of Consciousness
- Sensory System