Diabetes MELLITUS ASSESSMENT FINDINGS

- is a metabolic disorder of the pancreas, affecting 3 P’s

carbohydrates, fat, and protein metabolism. c. Weight loss
Is believes to be a sequel of METABOLIC SYNDROME d. Weakness
Etiology e. Paresthesia
Type 1 diabetes f. Thirst
- Injury to the beta cells of the pancreas or disease g. Fatigue
that impair insulin production. g. Dehydration
- Result of interactions of genetic, environmental
and immunologic factors. DIAGNOSTICS
- Urine test (Tes-Tape and Diastix) which facilitates
Type 1 diabetes early detection of diabetes
- May develop abruptly , over a period of a few days or o Normal glucose in the urine 0 to 0.8
weeks with 3 principal sequelae mmol/L (millimole/liter)
1. Increased blood glucose o Normal ketone is less than 0.6 mmol/L
2. Increased utilization of fats for energy and for formation - Glucometer (ideal results)
of cholesterol by the liver o 90-130 mg/dL before meals
3. Depletion of body proteins o <180mg/dL 1 to 2 hrs. after meals
This is how
 absence of insulin DIAGNOSTIC
= very high blood glucose level TEST
= none to distribute glucose for cell energy
 source of alternative cellular energy
= Increased utilization of fats for energy and protein thru
LIPOLYSIS
= resulting to fatty acids accumulation and
KETONES(metabolic by-product of fats) = KETOACIDOSIS

Etiology
Type 2 diabetes
- Initially caused by decreased sensitivity of target
tissues to the metabolic effect of insulin.
- Insulin resistance and abnormal insulin secretion
are central to the development of type 2 DM.
- Obesity is the most important factor for type 2
diabetes in children and adults
- Often referred as adult onset diabetes

MEDICAL MNGT.
Treatment depends on different factors such as type of
3 P CLASSIC SYMTPOMS OF DIABETES diabetes and the ability of the pancreas to manufacture
Polyuria insulin and involves the following:
Polydipsia - Diet and weight loss
Polyphagia - Exercise
 - Oral antidiabetic agents
- Insulin
- Pancreas transplantation
- Islet cell transplantation

Exercise
- If the blood glucose level is higher than 250 mg/dL
(14.2 mmol/L) and urinary ketones (type 1
diabetes mellitus) are present, (instruct not to
exercise until the blood glucose level is closer to
normal and urinary ketones are absent)
- Exercise at the same time each day and should
exercise when glucose from the meal is peaking,
NOT when insulin or glucose-lowering medications
are peaking

Oral hypoglycemic medications

- clients with diabetes mellitus type 2
- Criteria
o FBS level less than 200 mg/dl
o Insulin requirements of less than 40
units/day
o No ketoacidosis
o No renal or hepatic disease

Medications for Type 2 Diabetes

Insulin
- to treat type 1 DM and
- may be used to treat type 2 DM
- DO NOT withheld during times of illness, infection,
or stress
- Explain action time of insulin to the client
= ONSET – how fast insulin can lower the blood glucose
level (the length of time before insulin reach the blood
stream to lower down blood glucose level
= PEAK – the time of maximum strength of insulin (the
maximum strength of lowering blood glucose level)
= DURATION – the length of time for the insulin to work in
lowering the blood glucose level
INSULIN PREPARATION
ADMINISTRATION OF INSULIN
- U100 means 1ml contains 100 units of insulin
- When combining two types of insulin in the same
syringe
o Short-acting regular insulin is withdrawn
first
o And the intermediate insulin should be
added next
Remember:
mixing is from “clear to cloudy”
Glargine (Lantus) insulin and Detemir (Levemir) cannot be
mixed with other types of insulin in the same syringe
Mixture is administered within 15 minutes to ensure that
onset, peak, and duration of each separate insulin remains
intact
= Regular insulin can be administered intravenously and
subcutaneously.
- IV Route is used
=to treat severe route is used to treat severe
hyperglycemia
= to prevent or control elevated blood glucose by
adding it to a total parenteral nutrition solution that
contains a high concentration of glucose
 Abdomen – insulin is rapidly absorb in this site
than the other site
 Injection site needs to be rotated to avoid:
 Lipoatrophy – is the breakdown of subcutaneous
fat at the site of repeated injection
 Lipohypertrophy – buildup of subcutaneous fat at
the site of repeated injection
 NOTE: either of the two can inhibits insulin
absorption in the tissue
 Insulin may cause weight gain because it is
anabolic
 OTHER TECHNIQUE
 Insulin pen which contains a cartridge of 150-
300 units/ select the unit to be injected once
loaded 1-2 units increment, uses disposable
needle
 Jet injector uses high pressure and high speed
than needle to instill insulin thru the skin, the
pressure transform the liquid into a fine mist
that is distributed over a wide area of tissue
resulting in faster absorption.
 Insulin Pump delivers insulin by continuous
infusion, compose of pump, tubing and
needle. Needle is inserted in the
subcutaneous fat in the abdomen that can
remain up to three days. The pump is worn in
a pouch or belt
PANCREAS TRANSPLANTATION & ISLET CELL
TRANSPLANTATION
- Candidates are those with type 1 diabetes who has
renal failure and will benefit with combined kidney
transplant. (pancreas transplantation)
- Insulin producing component of the pancreas is
used rather than the whole or part of the
pancreas. (islet cell transplantation)
COMPLICATION OF INSULIN THERAPY
- Dawn Phenomenon – is an increase in blood sugar
early in the morning due to the release of certain
hormones., these may occur both in an individual
with or without diabetes
 - This hormones that cause the Dawn effect are Contraindications and concerns
CORTISOL, GLUCAGON, EPINEPHRINE, GROWTH a. Oral antidiabetic agents, except the sodium-glucose co-
HORMONE transporter 2 (SGLT-2) inhibitors, are contraindicated in
- The release of this hormones by the body is said type 1 diabetes mellitus.
to stimulate the liver to release glucose or a short b. β-Adrenergic blocking agents may mask signs and
period of insulin resistance occurs that also raises symptoms of hypoglycemia associated with hypoglycemia-
blood glucose level producing medications.
c. Anticoagulants, chloramphenicol, salicylates, propranolol,
Complications of insulin therapy: Dawn phenomenon monoamine oxidase inhibitors, pentamidine, and
a. Dawn phenomenon sulfonamides may cause hypoglycemia
– hyperglycemia between 8 & 10 hours after bed d. Corticosteroids, sympathomimetics, thiazide diuretics,
time for people with diabetes phenytoin, thyroid preparations, oral contraceptives, and
b. Treatment estrogen compounds may cause hyperglycemia.
- Avoid intake carbohydrates at bedtime e. Side and adverse effects of the sulfonylureas include GI
Adjustment in the administration of insulin or antidiabetic symptoms and dermatological reactions;
medication hypoglycemia can occur when an excessive dose is
Signs And Symptoms Of Dawn Phenomenon administered or when meals are omitted or delayed, food
- Nausea intake is decreased, or activity is increased
- Vomiting
- Faintness
- Blurry vision Acute Complications of Diabetes Mellitus: A.
- Weakness Hypoglycemia
- Disorientation - Hypoglycemia - blood glucose level below 70
- Extreme thirst mg/dL (4.0 mmol/ L), or when the blood glucose
- Feeling tired level drops rapidly from an elevated level.
- The client needs to be instructed always to carry
Complications of insulin therapy: some form of fast-acting simple carbohydrate with
Somogyi phenomenon him or her
- Also known as post-hypoglycemic hyperglycemia, - hypoglycemic reaction, no emergency food
chronic Somogyi rebound= a rebound high blood available, any available food should be eaten
glucose level to counter low blood glucose - BUT remember high-fat foods may not resolve
- Very low blood glucose – release of hypoglycemia quickly.
counterregulatory hormones (glucagon and
epinephrine – convert glycogen to glucose = Assessment:
increase in blood glucose level a. Mild hypoglycemia:
Symptoms The client remains fully awake but displays adrenergic
- low blood glucose levels at 2:00 a.m. or 3:00 a.m. symptoms; the blood glucose level is lower than 70 mg/dL
- night sweats (4.0 mmol/L)
- thirst - Hunger -Tremor
- a rapid heart rate - Nervousness -Tachycardia
- increased appetite - Palpitations -Sweating
- waking up with a headache Assessment:
- fatigue b. Moderate hypoglycemia
- blurred vision symptoms of worsening hypoglycemia;
- dry mouth
- the blood glucose level is usually lower than 40
- Confusion
mg/dL (2.2 mmol/L
- dizziness
-Confusion - Inability to concentrate
Causes
-Double vision - irrational or combative behavior
- too much insulin at night
-Drowsiness -Lightheadedness
- No food intake before bed
-Emotional changes -Numbness of the lips and -
- A person may be experiencing the Somogyi effect
tongue
if they:
o unexplained high glucose levels in the -Headache - Slurred speech
morning -Impaired coordination
o hyperglycemia in the morning but
increased insulin injection is ineffective
Assessment:
c. Severe hypoglycemia
- displays severe neuroglycopenic symptoms
the blood glucose level is usually lower than 20 mg/dL (1.1
mmol/L)
- Difficulty arousing
- Disoriented behavior
- Loss of consciousness
- Seizures
NOTE:
- Do not attempt to administer oral food or fluids to
the client experiencing a severe hypoglycemic
reaction who is semiconscious or unconscious and
is unable to swallow. This client is at risk for
aspiration.
- For this client, an injection of glucagon is
administered subcutaneously or intramuscularly.
- In the hospital or emergency department, the
client may be treated with an IV injection of 25 to
50 mL of 50% dextrose in water.
PRIORITY NURSING ACTIONS:
Suspected Hypoglycemic Reaction (the 15/ 15 rule)
1. Check the client’s blood glucose level.
- What If the client is experiencing symptoms
suggestive of hypoglycemia such as diaphoresis,
hunger, pallor, and shakiness, and a blood glucose
monitor is not readily available?
2. For the client whose blood glucose is below 70 mg/ dL
(4.0 mmol/ L), or for the client with an unknown blood
glucose who is exhibiting signs of hypoglycemia,
- administer 15 g of a simple carbohydrate such as
½ cup of fruit juice or 15 g of glucose gel
3. Recheck the blood glucose level in 15 minutes.
4. If the blood glucose remains below70 mg/dL(4.0
mmol/L), administer another 15 g of a simple
carbohydrate.
5. Recheck the blood glucose level in 15 minutes; if still
below 70 mg/ dL (4.0 mmol/ L), treat with an additional 15
g of a simple carbohydrate
6. Recheck the blood glucose level in 15 minutes; if still
below 70 mg/ dL (4.0 mmol/ L),
- treat with 25 to 50 mL of 50% dextrose
intravenously or, if no intravenous (IV)
equipment is present, treat with 1 mg of glucagon
subcutaneously or intramuscularly.
7. After the blood glucose level has recovered, have the
client ingest a snack that includes a complex carbohydrate
and a protein.
8. Document the client’s complaints, actions taken, and
outcome.
9. Explore the precipitating cause of the hypoglycemia with
the client.
10. If the client is experiencing an altered level of
consciousness, bypass oral treatment and start with
injectable glucagon or 50% dextrose. If the client is at home
and does not have access to injectable glucagon, the client
should seek immediate medical care
Acute Complications of Diabetes Mellitus:
B. Diabetic ketoacidosis (DKA)
- Diabetic ketoacidosis is a life-threatening
complication of type 1 diabetes mellitus that
develops when a severe insulin deficiency occurs.
- diabetic ketoacidosis often have BHB levels of 10
mmol/L or above, which is directly related to
their inability to produce insulin
- The main clinical manifestations include
hyperglycemia, dehydration, ketosis, and acidosis
Assessment: Diabetic ketoacidosis (DKA)
- Onset Sudden
- Precipitating factors Infection
- Other stressors, Inadequate insulin dose
- Manifestations Ketosis: Kussmaul’s respiration,
“fruity” breath, nausea, abdominal pain
- Dehydration or electrolyte loss: Polyuria,
polydipsia, weight loss, dry skin, sunken eyes, soft
eyeballs, lethargy, coma
Assessment: Diabetic ketoacidosis (DKA)
- Laboratory Findings
- Serum glucose > 300 mg/ dL (> 17.1 mmol/ L)
- Serum ketones Positive at 1:2 dilution
- Serum pH < 7.35
- Serum HCO3 < 15 mEq/ L (15 mmol/ L)
- Serum Na Low, normal, or high
- Serum K Normal; elevated with acidosis, low
following dehydration
- BUN > 20 mg/dL (> 7.1 mmol/ L);
- Creatinine > 1.5 mg/ dL (> 132.5 mcmol/ L
- Urine ketones Positive
Diabetic ketoacidosis (DKA):
Interventions
a. Restore circulating blood volume and protect against
cerebral, coronary, and renal hypoperfusion.
b. Treat dehydration with rapid IV infusions of
0.9% or 0.45% NS as prescribed
dextrose is added to IV fluids when the blood glucose level
reaches 250 to 300 mg/dL (14.2 to 17.1 mmol/L).
c. Treat hyperglycemia with insulin administered
intravenously as prescribed.
d. Correct electrolyte imbalances (potassium level may be
elevated as a result of dehydration and acidosis).
e. Monitor potassium level closely because when the client
receives treatment for the dehydration and acidosis, the
serum potassium level will decrease and potassium
replacement may be required.
f. Cardiac monitoring should be in place for the client with
DKA due to risks associated with abnormal serum
potassium level

Diabetic ketoacidosis (DKA):
Insulin IV administration
a. Use short-duration insulin only.
b. An IV bolus dose of short-duration regular U100 insulin
(usually 5 to 10 units) may be prescribed before a
continuous infusion is begun.
c. The prescribed IV dose of insulin for continuous infusion
is prepared in 0.9% or 0.45% NS as prescribed.
d. Always place the insulin infusion on an IV infusion
controller
e. Insulin is infused continuously until subcutaneous
administration resumes, to prevent a rebound of the blood
glucose level.
f. Monitor vital signs.
g. Monitor urinary output and monitor for signs of fluid
overload.
h. Monitor potassium and glucose levels and for signs of
increased intracranial pressure.
i. The potassium level will fall rapidly within the first hour of
treatment as the dehydration and the acidosis are treated.
j. Potassium is administered intravenously in a diluted
solution as prescribed; ensure adequate renal function
before administering potassium
Acute Complications of Diabetes Mellitus: Hyperosmolar
hyperglycemic syndrome (HHS)
a. Extreme hyperglycemia occurs without ketosis or
acidosis.
b. The syndrome occurs most often in individuals with type
2 diabetes mellitus.
c. What is the major difference between HHS and DKA?
Hyperosmolar hyperglycemic syndrome (HHS)
:Assessment
- Onset Gradual
- Precipitating factors Infection
- Other stressors: Poor fluid intake
- Manifestations Altered central nervous system
function with neurologic symptoms, Dehydration
or electrolyte loss: Same as for DKA
Assessment
Laboratory Findings Urine ketones Negative
Serum glucose Creatinine Elevated
> 800 mg/dL (> 45.7 mmol/ L) BUN Elevated
Osmolarity > 350 mOsm/ L Serum K Normal or low
Serum ketones Negative Serum Na Normal or
low
Serum pH > 7.4
Serum HCO3 > 20 mEq/L (> 20 mmol/L)
Interventions
a. Treatment is similar to that for DKA.
b. Treatment includes
- fluid replacement,
- correction of electrolyte imbalances,
- insulin administration.
c. Fluid replacement in the older client must be done very
carefully d. Insulin plays a less critical role in the treatment
of HHS than it does in the treatment of DKA.
Chronic Complications of Diabetes Mellitus: Diabetic
retinopathy
a. Chronic and progressive impairment of the retinal
circulation that eventually causes hemorrhage
b. Permanent vision changes and blindness can occur.
c. The client has difficulty with carrying out the daily tasks
of blood glucose testing and insulin injection
Assessment
a. A change in vision is caused by the rupture of small
microaneurysms in retinal blood vessels
b. Blurred vision results from macular edema.
c. Sudden loss of vision results from retinal detachment.
d. Cataracts result from lens opacity.
Interventions
a. Maintain safety.
b. Early prevention via the control of hypertension and
blood glucose levels
c. Photocoagulation (laser therapy) may be done to remove
hemorrhagic tissue to decrease scarring and prevent
progression of the disease process.
d. Vitrectomy may be done to remove vitreous
hemorrhages and thus decrease tension on the retina,
preventing detachment.
e. Cataract removal with lens implantation improves vision
Chronic Complications of Diabetes Mellitus: Diabetic
nephropathy
Progressive decrease in kidney function
Assessment
a. Microalbuminuria
b. Thirst
c. Fatigue
d. Anemia
e. Weight loss
f. Signs of malnutrition
g. Frequent urinary tract infections
h. Signs of a neurogenic bladder
Interventions
- Early prevention measures include the control of
hypertension and blood glucose levels.
- Assess vital signs.
- Monitor intake and output.
- Monitor the blood urea nitrogen, creatinine, and
urine albumin levels.
Chronic Complications of Diabetes Mellitus: Diabetic
nephropathy
- Restrict dietary protein, sodium, and potassium
intake as prescribed.
- Avoid nephrotoxic medications.
- Prepare the client for dialysis procedures if
planned.
- Prepare the client for kidney transplant if planned.
- Prepare the client for pancreas transplant if
planned
- General deterioration of the nervous system
throughout the body
- Complications include the development of
nonhealing ulcers of the feet, gastric paresis, and
erectile dysfunction
Chronic Complications of Diabetes Mellitus: Diabetic
neuropathy
Classifications
A. Focal neuropathy or mononeuropathy:
Involves a single nerve or group of nerves, most frequently
cranial nerves III (oculomotor) and VI (abducens), = diplopia
B . Sensory or peripheral neuropathy: Affects distal portion
of nerves, most frequently in the lower extremities
C. Autonomic neuropathy: Symptoms vary according to the
organ system involved.
D. Cardiovascular: Cardiac denervation syndrome (heart
rate does not respond to changes in oxygenation needs)
and orthostatic hypotension occur
E. Pupillary: Pupil does not dilate in response to decreased
light.
F. Gastric: Decreased gastric emptying (gastroparesis)
G. Urinary: Neurogenic bladder
H. Skin: Decreased sweating
I. Adrenal: Hypoglycemic unawareness
J. Reproductive: Impotence (male), painful intercourse
(female)
Chronic Complications of Diabetes Mellitus: Diabetic
neuropathy
Assessment: Findings depend on the classification
a. Paresthesia
b. Decreased or absent reflexes
c. Decreased sensation to vibration or light touch
d. Pain, aching, and burning in the lower extremities
e. Poor peripheral pulses
f. Skin breakdown and signs of infection
g. Weakness or loss of sensation in cranial nerves III
(oculomotor), IV (trochlear), V (trigeminal), and VI
(abducens)
h . Dizziness and postural hypotension
i. Nausea and vomiting
j. Diarrhea or constipation
k. Incontinence
l. Dyspareunia \
m. Impotence
n . Hypoglycemic unawareness
Interventions
a. Early prevention measures include the control of
hypertension and blood glucose levels.
b. Careful foot care is required to prevent trauma (Box 50-
17).
c. Administer medications as prescribed for pain relief.
d. Initiate bladder training programs.
e. Instruct in the use of estrogen-containing lubricants for
women with dyspareunia.
f. Prepare the male client with impotence for penile
injections or other possible treatment options as
prescribed.
g. Prepare for surgical decompression of compression
lesions related to the cranial nerves as prescribed.
Preventive Foot Care Instructions
- Provide meticulous skin care and proper foot care
- Inspect feet daily and monitor feet for redness,
swelling, or break in skin integrity.
- Notify the health care provider if redness or a
break in the skin occurs.
- Avoid thermal injuries from hot water, heating
pads, and baths.
- Wash feet with warm (not hot) water and dry
thoroughly (avoid foot soaks). Avoid treating
corns, blisters, or ingrown toenails.
- Do not cross legs or wear tight garments that may
constrict blood flow.
- Apply moisturizing lotion to the feet but not
between the toes.
- Prevent moisture from accumulating between the
toes
 - Wear loose socks and well-fitting (not tight) shoes; g. Inform the client that insulin may be needed during times
do not go barefoot. of increased stress, surgery, or infection.
- Wear clean cotton socks to keep the feet warm h. Instruct the client on the necessity for compliance with
and change the socks daily. prescribed medication.
- Avoid wearing the same pair of shoes 2 days in a i. Instruct the client about how to take each specific
row. medication, such as with the first bite of the meal for
- Avoid wearing open-toed shoes or shoes with a meglitinides and α-glucosidase inhibitors.
strap that goes between the toes. j. Advise the client to wear a MedicAlert bracelet
- Check shoes for cracks or tears in the lining and for
foreign objects before putting them on.
Alert
- Break in new shoes gradually.
- Cut toenails straight across and smooth nails with - Metformin needs to be withheld temporarily
an emery board. Avoid smoking before and for 48 hours after having any
radiological study that involves the administration
of intravenous contrast dye because of the risk of
Care of the Diabetic Client Undergoing Surgery
contrast-induced nephropathy and lactic acidosis.
Preoperative care - The HCP needs to be consulted for specific
1. Check with HCP regarding withholding oral hypoglycemic prescriptions
medications or insulin.
2. Some long-acting oral antidiabetic medications are Insulin
discontinued 24 to 48 hours before surgery.
1. Insulin acts primarily in the liver, muscle, and adipose
3. Metformin may need to be discontinued 48 hours before tissue by attaching to receptors on cellular membranes and
surgery and may not be restarted until renal function is facilitating the passage of glucose, potassium, and
normal postoperatively. magnesium.
4. All other oral antidiabetic medications are usually 2. Insulin is prescribed for clients with type 1 diabetes
withheld on the day of surgery. mellitus and for clients with type 2 diabetes mellitus whose
5. Insulin dose may be adjusted or withheld if IV insulin blood glucose levels are not adequately controlled with oral
administration during surgery is planned. antidiabetic agents.
6. Monitor blood glucose level.
7. Administer IV fluids as prescribed Types of Insulin: Time Course of Activity After
Care of the Diabetic Client Undergoing Surgery Subcutaneous Injection
Postoperative care
1. Administer IV glucose and insulin infusions as prescribed
until the client can tolerate oral feedings.
2. Administer supplemental short-acting insulin as
prescribed based on blood glucose results.
3. Monitor blood glucose levels frequently, especially if the
client is receiving parenteral nutrition.
4. When the client is tolerating food, ensure that the client
receives an adequate amount of carbohydrates daily to
prevent hypoglycemia
5. Client is at higher risk for cardiovascular and renal
complications postoperatively.
6. Client is also at risk for impaired wound healing.

Interventions
a. Assess the client’s knowledge of diabetes mellitus and
the use of oral antidiabetic agents.
b. Obtain a medication history regarding the medications
that the client is taking currently.
c. Assess vital signs and blood glucose levels.
d. Instruct the client to recognize the signs and symptoms
of hypoglycemia and hyperglycemia.
e. Instruct the client to avoid over-the counter medications
unless prescribed by the HCP.
f. Instruct the client not to ingest alcohol with sulfonylureas
 Administering insulin
Storing Insulin
- Avoid exposing insulin to extremes in temperature.
- Insulin should not be frozen or kept in direct
sunlight or a hot car.
- Before injection, insulin should be at room
temperature.
- If a vial of insulin will be used up in 1 month, it may
be kept at room temperature; otherwise, the vial
should be refrigerated
Insulin injection sites
a. The main areas for injections are the abdomen,
arms (posterior surface), thighs (anterior surface),
and hips
b. Insulin injected into the abdomen may absorb
more evenly and rapidly than at other sites
c. Systematic rotation within 1 anatomical area
is recommended to prevent lipodystrophy
and to promote more even absorption;
clients should be instructed not to use the
same site more than once in a 2- to 3-week
period.
d. Injections should be 1 to 1.5 inches (2.5 to
3.8 cm) apart within the anatomical area.
e. Heat, massage, and exercise of the injected
area can increase absorption rates and may
result in hypoglycemia.
f. Injection into scar tissue may delay
absorption of insulin
A. To prevent dosage errors, be certain that there is a
match between the insulin concentration noted on
the vial and the calibration of units on the insulin
syringe; the usual concentration of insulin is U-100
(100 units/mL).
B. The Humulin R brand of regular insulin is the only
insulin that is formulated in a U-500 strength. U-
500 strength insulin is reserved for clients with
severe insulin resistance who require large doses
of insulin.
- A special syringe calibrated for use with
U-500 insulin is required
C. Most insulin syringes have a 27- to 29-gauge
needle that is about 1 2 -inch long (1.3 cm).
D. NPH insulin is an insulin suspension; the
appearance is cloudy.
- All other insulin types are solutions; the
appearance of all other insulin products is
clear
E. Before use, NPH insulins must be rotated, or
rolled, between the palms to ensure that the
insulin suspension is mixed well; otherwise, an
inaccurate dose will be drawn; vigorously shaking
the bottle will cause bubbles to form. It is not
necessary to rotate or roll clear insulins before
using.
F. Inject air into the insulin bottle (a vacuum makes it
difficult to draw up the insulin).
G. When mixing insulins, draw up the shortest acting
insulin first
H. Short-duration (i.e., regular, lispro, aspart, and
glulisine) insulin may be mixed with NPH.
I. Administer a mixed dose of insulin within 5 to 15
minutes of preparation; after this time, the short-
acting insulin binds with the NPH insulin and its
action is reduced.
J. Aspiration after insertion of the needle generally is
not recommended with self-injection of insulin.
K. Administer insulin at a 45- to 90-degree angle in
clients with normal subcutaneous mass and at a
45- to 60-degree angle in thin persons or those
with a decreased amount of subcutaneous mass
D. Glucagon-like peptide (GLP-1) receptor agonists Glucagon
1. Non-insulin injectable agents that are analogs of 1. Hormone secreted by the alpha cells of the islets of
human GLP-1 and cause the same effects as the GLP-1 Langerhans in the pancreas
incretin hormone in the body, which are to stimulate 2. Increases blood glucose level by stimulating
the glucose level–dependent release of insulin, to glycogenolysis in the liver
suppress the postprandial release of glucagon, to slow 3. Can be administered subcutaneously, intramuscularly,
gastric emptying, and to suppress appetite or intravenously
2. Used for clients with type 2 diabetes mellitus (not 4. Used to treat insulin-induced hypoglycemia when the
recommended for clients taking insulin, nor should client is semiconscious or unconscious and is unable to
clients be taken off of insulin and given a GLP-1 ingest liquids
receptor agonist 5. The blood glucose level begins to increase within 5 to
3. GLP-1 receptor agonists restore the first-phase insulin 20 minutes after administration.
response (first 10 minutes after food ingestion), lower 6. Instruct the family in the procedure for administration.
the production of glucagon after meals, slow gastric
emptying (which limits the rise in blood glucose level
after a meal), reduce fasting and postprandial blood
glucose levels, and reduce caloric intake, resulting in
weight loss
4. Packaged in premeasured doses (pens) that require
refrigeration (cannot be frozen)
5. Administered as a subcutaneous injection in the thigh,
abdomen, or upper arm. Exenatide is administered
twice daily within 60 minutes before morning and
evening meals (not taken after meals); if a dose is
missed, the treatment regimen is resumed as
prescribed with the next scheduled dose. Liraglutide is
administered subcutaneously once daily without
regard to meals. Albiglutide is injected subcutaneously
once weekly
6. Can cause mild to moderate nausea that abates with
use.
7. Because delayed gastric emptying slows the
absorption of other medications, other prescribed oral
medications should be given an hour before injection
of these medications.

Amylin Mimetic: Pramlintide

1. Synthetic form of amylin, a naturally occurring
hormone secreted by the pancreas
2. Used for clients with types 1 and 2 diabetes mellitus
who use insulin; administered subcutaneously before
meals to lower blood glucose level after meals, leading
to less fluctuation during the day and better long-term
glucose control
3. Associated with an increased risk of insulininduced
severe hypoglycemia, particularly in clients with type 1
diabetes mellitus
4. GI effects, including nausea, can occur.
5. Unopened vials are refrigerated; opened vials can be
refrigerated or kept at room temperature for up to 28
days
6. Reduces postprandial hyperglycemia by delaying
gastric emptying and suppressing postprandial
glucagon release
7. Because pramlintide delays gastric emptying, other
prescribed oral medications should be given 1 hour
before or 2 hours after an injection of pramlintide
Endocrine Medications
Pituitary Medications
1. The anterior pituitary gland secretes growth hormone
(GH), thyroid-stimulating hormone (TSH),
adrenocorticotropic hormone (ACTH), prolactin,
melanocyte-stimulating hormone (MSH), and
gonadotropins (follicle-stimulating hormone [FSH] and
luteinizing hormone [LH]).
2. The posterior pituitary gland secretes antidiuretic
hormone (vasopressin) and oxytocin
Pituitary Medications:
Growth hormones and related medications
Uses
a. Growth hormones are used to treat pediatric or adult
growth hormone deficiency.
b. Growth hormone receptor antagonists are used to treat
acromegaly.
c. Growth hormone–releasing factor is used to evaluate
anterior pituitary function.
Side and adverse effects
a. May vary depending on the medication
b. Development of antibodies to growth hormone
c. Headache, muscle pain, weakness, vertigo
d. Diarrhea, nausea, abdominal discomfort
e. Mild hyperglycemia
f. Hypertension
g. Weight gain
h. Allergic reaction (rash, swelling), pain at injection site
i. Elevated aspartate aminotransferase (AST) and alanine
aminotransferase (ALT)
Interventions
a. Assess the child’s physical growth and compare growth
with standards.
b. Recommend annual bone age determinations for
children receiving growth hormones.
c. Monitor vital signs, blood glucose levels, AST and ALT
levels, and thyroid function tests.
d. Teach the client and family about the clinical
manifestations of hyperglycemia, other side and adverse
effects of therapy, and the importance of follow-up
regarding periodic blood tests.
Growth Hormones and Related Medications
Growth Hormones
▪ Somatropin
▪ Norditropin
▪ Mecasermin
Growth Hormone Receptor Antagonists
▪ Octreotide acetate
▪ Lanreotide
▪ Pegvisomant
Antidiuretic Hormones:
Desmopressin acetate; vasopressin
1. Antidiuretic hormones enhance reabsorption of
water in the kidneys, promoting an antidiuretic
effect and regulating fluid balance.
2. Antidiuretic hormones are used in diabetes
insipidus.
3. Vasopressin is used less commonly than
desmopressin acetate to treat diabetes insipidus;
vasopressin is commonly used to treat septic shock
Side and adverse effects
1. Flushing
2. Headache
3. Nausea and abdominal cramps
4. Water intoxication
5. Hypertension with water intoxication
6. Nasal congestion with nasal administration
Interventions
1. Monitor weight.
2. Monitor intake and output and urine osmolality.
3. Monitor electrolyte levels.
4. Monitor for signs of dehydration, indicating the
need to increase the dosage.
5. Monitor for signs of water intoxication
(drowsiness, listlessness, shortness of breath, and
headache), indicating the need to decrease
dosage.
6. Monitor blood pressure.
7. Instruct the client in how to use the intranasal
medication.
8. Instruct the client to weigh himself or herself daily
to identify weight gain
9. Instruct the client to report signs of water
intoxication or symptoms of headache or
shortness of breath
Thyroid Hormones:
Levothyroxine sodium ▪ Liothyronine sodium ▪ Liotrix ▪
Thyroid, dessicated
1.Thyroid hormones control the metabolic rate of tissues and
accelerate heat production and oxygen consumption. 2.
Thyroid hormones are used to replace the thyroid
hormone deficit in conditions such as hypothyroidism
and myxedema coma
2.Thyroid hormones enhance the action of oral
anticoagulants, sympathomimetics, and antidepressants
and decrease the action of insulin, oral hypoglycemics,
and digitalis preparations; the action of thyroid
hormones is decreased by phenytoin and carbamazepine.
3.Thyroid hormones should be given at least 4 hours apart
from multivitamins, aluminum hydroxide and magnesium
hydroxide, simethicone, calcium carbonate, sevelamer,
lanthanum, bile acid sequestrants, iron, and sucralfate
because these medications decrease the absorption of
thyroid replacements.
Side and adverse effects
1. Nausea and decreased appetite
2. Abdominal cramps and diarrhea
3. Weight loss
4. Nervousness and tremors
5. Insomnia
6. Sweating
7. Heat intolerance
8. Tachycardia, dysrhythmias, palpitations, chest pain
9. Hypertension
10. Headache
11. Toxicity: Hyperthyroidism
Interventions
1. Assess the client for a history of medications currently
being taken.
2. Monitor vital signs.
3. Monitor weight.
4. Monitor triiodothyronine, thyroxine, and TSH levels.
5. Instruct the client to take the medication at the same
time each day, in the morning without food.
6. Instruct the client in how to monitor the pulse rate.
7. Inform the client that it is important to discuss which
foods to specifically avoid that may inhibit thyroid
secretion based on the client’s individualized diet plan
and medication regimen.
8. Advise the client to avoid over-the-counter
medications.
9. Instruct the client to wear a MedicAlert bracelet
- Advise the client taking a thyroid hormone to
report symptoms of hyperthyroidism, such as a
fast heart beat (tachycardia), chest pain,
palpitations, and excessive sweating. These
indicate signs of toxicity.
- Iodism is a concern for clients taking strong iodine
solution, also known as Lugol’s solution. Because of
the risk of iodism, the use of strong iodine solution is
limited to about 2 weeks, generally used for clients
with hyperthyroidism in preparation for thyroid
surgery
Interventions
1. Monitor vital signs.
2. Monitor triiodothyronine, thyroxine, and TSH levels.
3. Monitor weight.
4. Instruct the client to take medication with meals to
avoid gastrointestinal (GI) upset.
5. Instruct the client in how to monitor the pulse rate.
6. Inform the client of side and adverse effects and
when to notify the health care provider (HCP).
7. Instruct the client in the signs of hypothyroidism
8. Instruct the client regarding the importance of
medication compliance and that abruptly stopping
the medication could cause thyroid storm.
9. Instruct the client to monitor for signs and symptoms
of thyroid storm (fever, flushed skin, confusion and
behavioral changes, tachycardia, dysrhythmias, and
signs of heart failure).
10. Instruct the client to monitor for signs of iodism.
11. Advise the client to consult the HCP before eating
iodized salt and iodine-rich foods
12. Instruct the client to avoid acetylsalicylic acid and
medications containing iodine.
Methimazole causes agranulocytosis. Therefore, advise the
client to contact the HCP if a fever or sore throat develops.
In pregnancy, propylthiouracil is usually used during the
first trimester, then the woman is normally switched to
methimazole.

Antithyroid Medications:
▪ Methimazole ▪ Propylthiouracil ▪ Potassium iodide and Parathyroid Medications:
strong iodine solution
1. Antithyroid medications inhibit the synthesis of thyroid
hormone.
2. Antithyroid medications are used for hyperthyroidism, or
Graves’ disease.

Side and adverse effects

1. Nausea and vomiting
2. Diarrhea
3. Drowsiness, headache, fever
4. Hypersensitivity with rash
5. Agranulocytosis with leukopenia and
thrombocytopenia
6. 6. Alopecia and hyperpigmentation
7. Toxicity: Hypothyroidism
8. Iodism: Characterized by vomiting, abdominal
pain, metallic or brassy taste in the mouth, rash,
and sore gums and salivary glands.
 1. Parathyroid hormone regulates serum calcium Side and adverse effects
levels. 1. Sodium and water retention, edema, hypertension
2. Low serum levels of calcium stimulate parathyroid 2. Hypokalemia
hormone release. 3. Hypocalcemia
3. Hyperparathyroidism results in a high serum 4. Osteoporosis, compression fractures
calcium level and bone demineralization; 5. Weight gain
medication is used to lower the serum calcium
6. Heart failure
level.
4. Hypoparathyroidism results in a low serum calcium
Interventions
level, which increases neuromuscular excitability;
treatment includes calcium and vitamin D 1. Monitor vital signs.
supplements. 2. Monitor intake and output, weight, and for edema.
5. Calcium salts administered with digoxin increase 3. Monitor electrolyte and calcium levels.
the risk of digoxin toxicity. 4. Instruct the client to take medication with food or
6. Oral calcium salts reduce the absorption of milk. 5. Instruct the client to consume a
tetracycline hydrochloride highpotassium diet.
5. Instruct the client to report signs of illness.
6. Instruct the client to notify the HCP if low blood
Interventions
pressure, weakness, cramping, palpitations, or
1. Monitor electrolyte and calcium levels.
changes in mental status occur.
2. Assess for signs and symptoms of hypocalcemia and
7. Instruct the client to wear a MedicAlert bracelet
hypercalcemia.
8. Instruct the client taking a corticosteroid not to
3. Assess for symptoms of tetany in the client with
stop the medication abruptly because this could
hypocalcemia.
result in adrenal insufficiency.
4. Assess for renal calculi in the client with hypercalcemia.
5. Instruct the client in the signs and symptoms of
Corticosteroids: Glucocorticoids
hypercalcemia and hypocalcemia.
5. Instruct the client to check over-the-counter ▪ Betamethasone
medication labels for the possibility of calcium content ▪ Cortisone acetate
6. Instruct the client receiving oral calcium supplements ▪ Dexamethasone
to maintain an adequate intake of vitamin D because ▪ Hydrocortisone
vitamin D enhances absorption of calcium. ▪ Methylprednisolone
7. Instruct the client receiving calcium regulators such as ▪ Prednisolone
alendronate sodium to swallow the tablet whole with ▪ Prednisone
water at least 30 minutes before breakfast and not to ▪ Triamcinolone
lie down for at least 30 minutes.
8. Instruct the client using nasal spray of calcitonin to Corticosteroids: Glucocorticoids
alternate nares
1. Glucocorticoids affect glucose, protein, and bone
9. Instruct the client using antihypercalcemic agents to
metabolism; alter the normal immune response and
avoid foods rich in calcium such as green, leafy
suppress inflammation; and produce antiinflammatory,
vegetables; dairy products; shellfish; and soy.
antiallergic, and antistress effects.
10. Instruct the client not to take other medications within
2. Glucocorticoids may be used as a replacement in
1 hour of taking a calcium supplement.
adrenocortical insufficiency.
11. Instruct the client to increase fluid and fiber in the diet
3. Glucocorticoids are used for their antiinflammatory
to prevent constipation associated with calcium
and immunosuppressant effects both shortterm and
supplements.
long-term in the treatment of several nonendocrine
disorders
Corticosteroids: Mineralocorticoids
A. Fludrocortisone acetate Side and adverse effects
1. Mineralocorticoids are steroid hormones that 1. Adrenal insufficiency
enhance the reabsorption of sodium and chloride and
2. Hyperglycemia
promote the excretion of potassium and hydrogen
3. Hypokalemia
from the renal tubules, thereby helping to maintain
4. Hypocalcemia, osteoporosis
fluid and electrolyte balance
2. Mineralocorticoids are used for replacement therapy 5. Sodium and fluid retention
in primary and secondary adrenal insufficiency in 6. Weight gain and edema
Addison’s disease 7. Mood swings
8. Moon face, buffalo hump, truncal obesity
9. Increased susceptibility to infection and masking of the
signs and symptoms of infection
10. Cataracts
11. Hirsutism, acne, fragile skin, bruising
12. Growth retardation in children
13. GI irritation, peptic ulcer, pancreatitis
14. Seizures
15. Psychosis (usually occurs with hydrocortisone and
dexamethasone in clients receiving very high doses long-
term and is most likely due to their effects on blood
glucose)
glucocorticoids that may be used to treat
nonendocrine conditions.
15. Note that the client may need additional doses
during periods of stress, such as surgery.
16. Instruct the client not to stop the medication
abruptly because abrupt withdrawal can result in
severe adrenal insufficiency.
17. Advise the client to consult with the HCP before
receiving vaccinations; live virus vaccines should not
be administered to the client taking glucocorticoids.
18. Advise the client to wear a MedicAlert bracelet.

Contraindications and cautions Androgens

1. Contraindicated in clients with hypersensitivity, - Methyltestosterone
psychosis, and fungal infections - Testosterone Preparations
2. Should be used with caution in clients with diabetes ▪ Testosterone, pellets
mellitus ▪ Testosterone, transdermal
3. Should be used with extreme caution in clients with ▪ Testosterone cypionate
infections because they mask the signs and symptoms ▪ Testosterone enanthate
of an infection ▪ Testosterone propionate
4. They can increase the potency of medications taken ▪ Testosterone undecanoate
concurrently, such as aspirin and nonsteroidal ▪ Testosterone, buccal patch
antiinflammatory drugs, thus increasing the risk of GI ▪ Testosterone, topical gel
bleeding and ulceration ▪ Testosterone, nasal gel
5. Use of potassium-losing diuretics increases potassium
loss, resulting in hypokalemia. Androgens
6. Dexamethasone decreases the effects of orally 1. Used to replace deficient hormones or to treat hormone-
administered anticoagulants and antidiabetic agents. sensitive disorders
7. Barbiturates, phenytoin, and rifampin decrease the 2. Can cause bleeding if the client is taking oral
effect of prednison anticoagulants (increase the effect of anticoagulants)
3. Can cause decreased serum glucose concentration,
Interventions thereby reducing insulin requirements in the client with
1. Monitor vital signs. diabetes mellitus
2. Monitor serum electrolyte and blood glucose levels. 4. Hepatotoxic medications are avoided with the use of
3. Monitor for hypokalemia and hyperglycemia. androgens because of the risk of additive damage to the
4. Monitor intake and output, weight, and for edema. liver.
5. Monitor for hypertension. 5. Androgens usually are avoided in men with known
6. Assess medical history for glaucoma, cataracts, prostate or breast carcinoma because androgens often
peptic ulcer, mental health disorders, or diabetes stimulate growth of these tumors
mellitus.
7. Monitor the older client for signs and symptoms of
increased osteoporosis. Side and adverse effects
8. Assess for changes in muscle strength. 1. Masculine secondary sexual characteristics (body
9. Prepare a schedule as needed for the client, with hair growth, lowered voice, muscle growth)
information on short-term tapered doses. 2. Bladder irritation and urinary tract infections
10. Instruct the client that it is best to take medication in 3. Breast tenderness
the early morning with food or milk. 4. Gynecomastia
11. Advise the client to eat foods high in potassium. 5. Priapism
12. Instruct the client to avoid individuals with 6. Menstrual irregularities
infections. 7. Virilism
13. Advise the client to inform all HCPs of the 8. Sodium and water retention with edema
medication regimen. 9. Nausea, vomiting, or diarrhea
14. Instruct the client to report signs and symptoms of 10. Acne
Cushing’s syndrome, including a moon face, puffy 11. Changes in libido
eyelids, edema in the feet, increased bruising, 12. Hepatotoxicity, jaundice
dizziness, bleeding, and menstrual irregularities, 13. Hypercalcemia
which often results from the large doses of long-term
Interventions b. Use estrogens with caution in clients with
1. Monitor vital signs. hypertension, gallbladder disease, or liver
2. Monitor for edema, weight gain, and skin changes. or kidney dysfunction.
3. Assess mental status and neurological function. c. Estrogens increase the risk of toxicity
4. Assess for signs of liver dysfunction, including right when used with hepatotoxic medications.
upper quadrant abdominal pain, malaise, fever, d. Barbiturates, phenytoin, and rifampin
jaundice, and pruritus. decrease the effectiveness of estrogen
5. Assess for the development of secondary sexual 2. Progestins are contraindicated in clients with
characteristics thromboembolic disorders and should be avoided
6. Instruct the client to take medication with meals or a in clients with breast tumors or hepatic disease
snack.
7. Instruct the client to notify the HCP if priapism Side and adverse effects
develops. 1. Breast tenderness, menstrual changes
8. 8. Instruct the client to notify the HCP if fluid 2. Nausea, vomiting, and diarrhea
retention occurs. 3. Malaise, depression, excessive irritability
9. Instruct women to use a nonhormonal contraceptive 4. Weight gain
while on therapy. 5. Edema and fluid retention
10. For women, monitor for menstrual irregularities and
6. Atherosclerosis
decreased breast size.
7. Hypertension, stroke, myocardial infarction
8. Thromboembolism (estrogen)
Estrogens and Progestins
9. Migraine headaches and vomiting (estrogen)
Estrogens
- ▪ Esterified estrogens
Interventions
- ▪ Estradiol
1. Monitor vital signs.
- ▪ Estrogens, conjugated
2. Monitor for hypertension.
- ▪ Ethinyl estradiol
3. Assess for edema and weight gain.
Progestins
4. Advise the client not to smoke.
- ▪ Estradiol/ drospirenone
- ▪ Estradiol/ norgestimate 5. Advise the client to undergo routine breast and pelvic
- ▪ Estradiol/ levonorgestrel examinations
- ▪ Estradiol/ norethindrone
- ▪ Estradiol/ etonogestrel
- ▪ Medroxyprogesterone acetate
- ▪ Medroxyprogesterone and conjugated estrogens
- ▪ Megestrol acetate
- ▪ Norethindrone acetate
- ▪ Levonorgestrel
- ▪ Progesterone

. Estrogens and Progestins

1. Estrogens are steroids that stimulate female
reproductive tissue.
2. Progestins are steroids that specifically stimulate the
uterine lining.
3. Estrogen and progestin preparations may be used to
stimulate the endogenous hormones to restore
hormonal balance or to treat hormonesensitive
tumors (suppress tumor growth) or for
contraception

Contraindications and cautions

1. Estrogens
a. Estrogens are contraindicated in clients
with breast cancer, endometrial
hyperplasia, endometrial cancer, history
of thromboembolism, known or
suspected pregnancy, or lactation.