WEEK 7: ENDOCRINE DISORDERS the Autonomic Nervous System (ANS), which secretes
catecholamines (epinephrine/adrenaline and norepinephrine).
Adrenal Gland Disorders: Cushing’s Syndrome & Addison’s Disease
Cushing’s Syndrome
Anatomy
• The endocrine system is made up of a network of glands, which
secrete chemicals called hormones in order to regulate many
bodily functions, including growth & metabolism. The endocrine
system works to regulate internal processes through the
bloodstream.
• The endocrine system helps control the following processes and
systems:
o Growth and development
o Homeostasis (the internal balance of body systems)
o Metabolism (body energy levels)
o Reproduction
o Response to stimuli (stress and/or injury)
• The endocrine system completes these tasks through its network
of glands, which are small but highly important organs that
produce, store, and secrete hormones. These glands produce
different types of hormones that evoke a specific response in
other cells, tissues, and/or organs located throughout the body.
The hormones reach these faraway targets using the
bloodstream. Like the nervous system, the endocrine system is
one of the body’s main communicators, but instead of using
nerves to transmit information, the endocrine system uses blood
vessels to deliver hormones to cells as they are chemical
messengers that carry information and instructions from one set
of cells to another.
• The major glands of the endocrine system are the hypothalamus,
pituitary, thyroid, parathyroids, adrenals, and the reproductive
organs such as ovaries and testes. Although the pancreas is not
a gland, it also belongs to the endocrine system.
• When glands produce an incorrect amount of hormones,
endocrine diseases usually occur and impacts may aspect of life.
• Each person has two adrenal glands, each one is attached to the
upper portion of the kidney and is also termed as “suprarenal
glands”.
• Although adrenal gland appears to be a single organ, each
adrenal gland, however, is in reality, 2 adrenal glands with their
own separate, independent functions.
• The adrenal medulla at the center of the gland is considered to
be the inner core. It is innervated by the sympathetic division of
• Adrenal glands (one each upper portion of kidney)
• Adrenal medulla (center)
• Secretes catecholamines (epinephrine [90%] and
norepinephrine [10%])
• Part of the autonomic nervous system
• Stimulated preganglionic sympathetic nerve fibers → release of
the catecholamines → regulate metabolic pathways to promote
catabolism of stored fuels → release of free fatty acids, increase
the basal metabolic rate, and elevate the blood glucose level
• The adrenal cortex is considered to be the outer core of the
adrenal gland, and is subdivided into 3 zones: (1) zona
glomerulosa (2) Zona fasicluata (3) zona reticulari, which
secretes steroid hormones (glucocorticoids, mineralocorcticoids,
adrenal sex hormones).
• Adrenal cortex (outer portion)
• Secretes steroid hormones (glucocorticoids, mineralocorticoids,
and sex hormones)
• Regulated by the hypothalamic– pituitary–adrenal axis
• Release of ACTH from the anterior lobe of the pituitary gland →
adrenal cortex → glucocorticoids → inhibit the inflammatory
response to tissue injury and to suppress allergic manifestations.
• Presence of Angiotensin II in blood or increased Na → release of
aldosterone (mineralocorticoids) → promote sodium
reabsorption by the kidney and the GI tract → restore BP
• ACTH → adrenal cortex → secretion of adrenal androgens (sex
hormones)
Definition
• Is caused by prolonged exposure to elevated levels of either
endogenous glucocorticoids or exogenous glucocorticoids.
Exogenous use of glucocorticoids should always be considered
and excluded in the etiology of Cushing syndrome.
• Endogenous glucocorticoid overproduction, or hypercortisolism,
can be dependent on or independent of adrenocorticotropic
hormone (ACTH).
• Sometimes called hypercortisolism, may be caused by the use of
oral corticosteroid medication
• The condition can also occur when your body makes too much
cortisol on its own.
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Risk factors • Moon face • Hypocalcemia
• Buffalo hump • Hypertension
• The main risk factor for developing Cushing’s syndrome is taking • Truncal obesity with • Fragile skin that
high-dose corticosteroids over a long period of time. thin extremities bruises easily
• Other risk factors can include: • Supraclavicular fat • Reddish-purple striae
o Type-2 diabetes that isn’t properly managed pads on the abdomen and
o High blood pressure (hypertension) • Weight gain upper thighs
o Obesity • Hirsutism (masculine
• Some cases of Cushing’s syndrome are due to tumor formation. characteristics in
Although there can be a genetic predisposition to develop females)
endocrine tumors (familial Cushing’s syndrome), there’s no way
to prevent tumors from forming.
Clinical Manifestations
Causes
Ophthalmic • Cataracts
• Cushing’s syndrome is caused by an excess of the hormone
• Glaucoma
cortisol. Your adrenal glands produce cortisol. It helps with a
Cardiovascular • Hypertension
number of your body’s functions, including:
• Heart failure
o Regulating blood pressure and the
Endocrine/Metabolic • Truncal obesity
cardiovascular system
• Moon face
o Reducing the immune system’s inflammatory
• Buffalo hump
response
• Sodium retention
o Converting carbohydrates, fats, and proteins
• Hypokalemia
into energy
• Metabolic alkalosis
o Balancing the effects of insulin
• Hyperglycemia
o Responding to stress
• Menstrual
Complications irregularities
• Impotence
• Heart attack and stroke • Negative nitrogen
• Blood clots in the legs and lungs balance
• Infections • Altered calcium
• Bone loss and fractures metabolism
• High blood pressure • Adrenal suppression
• Unhealthy cholesterol levels
• Depression or other mood changes Immune function • Decreased
• Memory loss or trouble concentrating inflammatory
• Insulin resistance and prediabetes responses
• Type 2 diabetes • Impaired wound
• Although Cushing’s syndrome can usually be cured, it can be healing
fatal if not treated. • Increased
susceptibility to
Prevention infections
• Eat a healthy diet Skeletal • Osteoporosis
o Choose a variety of low-calorie foods that are • Spontaneous
high in protein and calcium. fractures
o Take calcium and vitamin D supplements to • Aseptic necrosis of
decrease bone loss femur
o Limit salt (sodium) in your diet. • Vertebral
• Take good care of yourself compression
o Get regular exercise. fractures
o Avoid falls, which can lead to broken bones and Gastrointestinal • Peptic ulcer
other injuries. • Pancreatitis
o See your doctor regularly to watch for other Muscular • Myopathy
problems such as diabetes, high blood pressure, • Muscle weakness
and osteoporosis. Dermatologic • Thinning of skin
• Taking care to avoid long term use of cortisol-containing • Petechiae
medications • Hirsutism (masculine
characteristics in
Signs and Symptoms females)
• Ecchymoses
• Generalized muscle • Hyperglycemia • Striae
wasting and • Hypernatremia • Acne
weakness • Hypokalemia Psychiatric • Mood alterations
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 • Psychoses
Pathophysiology
Diagnostic procedures
• If the results of all three tests are normal, the patient likely does
not have Cushing syndrome (but may have a mild case, or the
manifestations may be cyclic).
• Can falsely elevate cortisol levels; stress, obesity, depression,
and medications such as anticonvulsant agents, estrogen (during
pregnancy or as oral medications), and rifampin (Rifadin)
• Serum cortisol levels
o Usually higher in the early morning (6 to 8 am)
and lower in the evening (4 to 6 pm). This
variation is lost in patients with Cushing
syndrome
• Urinary cortisol test
• Requires a 24-hour urine collection.
• If the results of the urinary cortisol test are three times the upper
limit of the normal range and one other test is abnormal, Cushing
syndrome can be assumed.
• Dexamethasone suppression test/ Overnight dexamethasone
suppression test
o Widely used and most sensitive screening test for
diagnosis of pituitary and adrenal causes of
Cushing syndrome.
o Can be performed on an outpatient basis
o Dexamethasone (1 mg or 8 mg) is given orally late
in the evening or at bedtime, and a plasma
cortisol level is obtained at 8 am the next
morning.
o Suppression of cortisol to less than 5 mg/dL
indicates that the hypothalamic–pituitary–
adrenal axis is functioning properly
• Other tests that help indicate Cushing syndrome
o CBC with differentials and other blood test
▪ increase serum sodium and blood glucose
levels
▪ decrease serum potassium
▪ decrease eosinophils, lymphocytes, and
basophils
▪ increased neutrophils, monocytes
▪ increased WBC count
▪ increased RBC count
▪ Increased platelet count
• Radioimmunoassay
o A sensitive in vitro assay technique that uses radio-
labeled molecules which is used to measure
concentrations of substances, usually measuring
antigen concentrations by use of antibodies
o Measurement of plasma ACTH level which is used to
identify adrenal causes (AA) of Cushing's syndrome.
• Imaging test to detect abnormalities, such as tumor in pituitary
and adrenal glands
o Computed tomography (CT)
o Magnetic resonance imaging (MRI)
★ Several blood samples are collected to determine whether
the normal diurnal variation in plasma levels is present; this
variation is frequently absent in adrenal dysfunction.
Medical/Surgical Management
HYPOPHYSECTOMY
a. Description
• Hypophysectomy is the surgical removal of the pituitary gland to
treat cancerous or benign tumors. It is a high-risk surgical
procedure, and the approach is carefully selected to manage risk
and maximize benefit.
• The surgery is carried out under general anesthetic, and it takes
1-2 hours to complete.
b. Purpose of the Surgery
• To prevent the possible malignant tumor from spreading to
other parts of the body. To cease the overproduction of the
hormone cortisol which is the contributing factor of Cushing’s
disease.
c. Indications
• Diabetic patients whose vision is threatened by neovascular
changes characterizing proliferative retinopathy.
• Advancing breast cancer for postmenopausal (natural or
induced) patients who have received two trials of hormonal
therapy
• Advancing prostate cancer
• Cushing’s Syndrome
• Benign or malignant tumor in the pituitary gland
• Biopsy of midline spheno clival lesions (e.g. chordoma,
aspergilloma, meningioma etc.)
d. Contraindications
• The main limitation of a hypophysectomy, especially the
transsphenoidal approach, is when the operative corridor is
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 narrow and lateral tumor is difficult to resect. For instance, when • Fluids are usually given after nausea ceases, and the
the epicenter of the tumor is lateral to the carotid artery. patient then progresses to a regular diet.
• Instruct the patient that after the surgery he or she
e. Types of Pituitary Gland Removal Approaches will need to avoid vigorous coughing, blowing the
nose, sucking through a straw, or sneezing, because
• Transfrontal - This approach invades the cranial cavity. The these actions may place increased pressure at the
approach begins by performing a complete ethmoidectomy. This surgical site and cause a CSF leak.
is followed by identification and dissection of the frontal recess. • For transsphenoidal approach:
This area is then widened via a modified endoscopic procedure • Keep the head of the patient’s bed raised
to provide a panoramic exposure of the posterior table of the to decrease pressure on the sella turcica
frontal sinus. and to promote normal drainage.
• Subcranial - It is a technique in which the anterior skull base is • Check the nasal packing inserted during
approached directly by disarticulating the nasal root and glabella surgery for blood or CSF drainage.
to directly access the frontal and ethmoid sinuses and the • Oral care is provided every 4 hours or
more frequently. Use warm saline mouth
anterior fossa.
rinses. Avoid brushing teeth until the
• Oronasal–transsphenoidal - The usual choice of approach for
incision above the teeth has healed.
the procedure. Incision is made beneath the upper lip to gain • Because of the anatomic proximity of the
access into the nasal cavity and into the sella turcica and pituitary gland to the optic chiasm, visual
pituitary region. This is often done with the assistance of either acuity and visual fields are assessed at
a surgical microscope or an endoscopic camera. regular intervals.
• Cryo Hypophysectomy - It is a transseptal-transsphenoidal • 3-4 days after surgery, have the packing
hypophysectomy using a cryogenic probe that produces a cold removed and only then can the area
injury to reduce the release of growth hormone. around the nares be cleaned with the
• Irradiation Hypophysectomy - It is a neurosurgical procedure in prescribed solution to remove crusted
which focused, high-dose radiation therapy is targeted at the blood and moisten the mucous
membranes.
pituitary gland. This procedure is done collaboratively with
Pharmacology with Nursing Considerations
radiation oncologists. This procedure does not require any
anesthesia or implants, and does not involve directly lesioning Ketoconazole
the brain or spinal cord. It relieves symptoms, but it is not a cure Classification: Antifungal
and long-term efficacy is not as reliable. Therefore, this is usually Action: inhibits synthesis of ergosterol, damaging the
reserved for patients with severe pain cell membrane and resulting loss of essential
intracellular material. Also inhibits biosynthesis of
Nursing Care triglycerides and phospholipids and inhibits oxidative
and preoxidative enzyme activity.
Preoperative
Indication: indicated for treatment of candidiasis,
• Gather preoperative assessment of baseline data.
chronic mucocutaneous candidiasis, candiduria,
• Ensure patient’s and family’s understanding of and
histoplasmosis, chromomycosis, oral thrush,
reactions to the anticipated surgical procedure and
blastomycosis, coccidioidomycosis,
its possible effects by explaining what to expect
paracoccidioidomycosis, onychomycosis, CNS fungal
during and after surgery.
infection, and Cushing’s syndrome.
• Make sure an Informed consent is secured.
Contraindication: Patients with hypersensitivity and
• Acquire the necessary imaging tests and lab tests
fungal meningitis. Contraindicated with pregnancy.
before procedure.
Cautiously with hepatic failure.
• Funduscopic examination and visual field
determinations are performed, because the most Adverse Effects:
serious effect of pituitary tumor is localized • Nausea and Vomiting
pressure on the optic nerve or chiasm. • Headache
• Explain the use of general anesthesia and its • Abdominal pain
possible effects. • Diarrhea
• Explain that the existing features and symptoms of • Hepatotoxicity
the Cushing’s disease will remain unaffected after • Somnolence
surgery. • Fever
• Chills
Postoperative
• Suicidal Tendencies
General Considerations
• Thrombocytopenia
• Monitor and manage vital signs especially blood
• Leukopenia
pressure and central venous pressure.
• Pruritus
• Morphine sulfate may be used in the management
• Gynecomastia
of postoperative pain in patients who have
• Urticaria
undergone a craniotomy.
• Anaphylaxis
• Measure I/O to guide fluid-electrolyte
replacement. Nursing Consideration

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• Assess for allergy to ketoconazole.
• Note indications for therapy, clinical presentation,
other agents trialed and outcome.
• Monitor liver function tests before and during
therapy.
• Give 2 hr before drugs that increase gastric pH (such
as antacids).
• Keep epinephrine readily available in case of severe
anaphylaxis after the first dose.
• Administer oral drug with food to decrease GI
upset.
• Report persistent fever, pain, rash, severe N&V,
unusual bruising/bleeding, yellow skin or eyes, dark
urine, pale stools, or diarrhea.
• Complete the full course of therapy.
Mitotane (Lysodren)
Classification: antineoplastic
Action: directly suppresses activity of adrenal cortex and
changes the peripheral metabolism of corticosteroids,
resulting in a decrease in 17-hydroxycorticosteroids.
Indication: indicated for treatment of inoperable
carcinoma of adrenal cortex and cushing’s syndrome
Contraindication: Patients with hypersensitivity to the
drug, adrenal insufficiency, infection, shock, surgery,
trauma, reproductive risk, pregnancy and breastfeeding.
Adverse Effects:
• Nausea and Vomiting
• Diarrhea
• Hypertension
• Orthostatic Hypotension
• Flushing
• Transient Skin Rashes
• Visual Blurring
• Toxic Retinopathy
• Hematuria
• Hemorrhagic Cystitis
• General Aching
• May result in brain damage and impairment of
function
Nursing Consideration:
• Assess for allergy to mitotane.
• Note indications for therapy, clinical presentation,
other agents trial and outcome.
• Monitor pulse and BP for early signs of shock
(adrenal insufficiency).
• Observe for symptoms of hepatotoxicity. Report
them promptly, since reduced hepatic capacity can
increase toxicity of mitotane and because dose may
have to be decreased.
• Discontinue immediately following shock or severe
trauma.
• Notify the physician if following persist and become
more severe: Aching muscles, fever, flushing, and
muscle twitching.
• Keep epinephrine readily available in case of severe
anaphylaxis after the first dose.
• Monitor obese patient for symptoms of adrenal
hypofunction. Because a large portion of the drug
deposits in fatty tissue, the obese are particularly
susceptible to prolonged adverse effects.
• Make neurologic and behavioral assessments at
regular intervals throughout therapy.
Metyrapone (Metopirone)
Classification: glucocorticoid synthesis inhibitor
Action: inhibits 11-beta-hydroxylase, thereby inhibiting
synthesis of cortisol from 11-deoxycortisol and
corticosterone from desoxycorticosterone in the adrenal
gland.
Indication: Testing hypothalamic-pituitary ACTH
function.
Contraindication: Patients with adrenal cortical
insufficiency, or hypersensitivity to Metopirone or to any
of its excipients. Use cautiously in patients with reduced
adrenal secretory capacity.
Adverse Effects:
• Abdominal discomfort
• Bone marrow depression
• Decreased leukocyte count
• Dizziness
• Fall in arterial blood pressure
• Headache
• Nausea
• Increased pulse rate
• Sedation
• Vertigo
Nursing Consideration:
• Before performing the Metopirone tests, drugs
influencing pituitary or adrenocortical function
must be withdrawn.
• Monitor vital signs especially, blood pressure.
• Store at room temperature below 86 degrees F (30
degrees C).
• Store away from moisture, light, and heat.
• Advice the patient to avoid driving or performing
tasks that require excessive effort after taking the
medication.
• Inform the patient that the drug may dizzy,
lightheaded, drowsy, or less alert.
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 Mifepristone (Korlym, Mifeprex)
Classification: abortifacients, antidiabetics, anti
progestational agents
Action: Antagonizes endometrial and myometrial effects
of pro- gesterone. Sensitizes the myometrium to
contraction inducing activity of prostaglandins.
Antagonizes the glucocorticoid receptor.
Indication:
• Mifeprex: Medical termination of intrauterine
pregnancy up to day 49 of pregnancy.
• Korlym: Hyperglycemia secondary to
hypercortisolism in patients with endogenous
Cushing’s syndrome who have type 2 diabetes or
glucose intolerance and have failed or are not
candidates for surgery.
Caution and Contraindication:
• Contraindicated for patients with : Hypersensitivity,
presence of IUD, confirmed or suspected ectopic
pregnancy, Undiagnosed adnexal mass , Chronic
adrenal failure, Concurrent long-term
corticosteroid therapy; Bleeding disorders or
concurrent anticoagulant therapy; Inherited
porphyrias; Severe hepatic impairment ;
pregnancy; Concurrent use with simvastatin,
lovastatin, cyclosporine, dihydroergotamine,
ergotamine, fentanyl, pimozide, quinidine,
sirolimus, or tacrolimus; Vaginal bleeding;
Endometrial hyperplasia with atypia or endometrial
carcinoma.
• Use cautiously in patients with: Chronic medical
conditions such as cardiovascular, hypertensive,
hepatic, renal, or respiratory disease. Women older
than 35 yrs old or who smoke more than or equal
to 10 cigarettes/day ; Concurrent use with
moderate CYP3A4 inhibitors; Bleeding disorders or
concurrent anticoagulant therapy
Adverse Effects:
• CNS: anxiety, headache, dizziness, fainting , fatigue,
weakness.
• CV: peripheral edema, hypertension , QT interval
prolongation.
• GI: abdominal pain, anorexia, constipation,
diarrhea, dry mouth , nausea, vomiting.
• Resp: dyspnea, Pneumocystis jiroveci pneumonia.
• Endo: hypothyroidism, adrenal insufficiency.
• F and E: hypokalemia.
• MS: arthralgia, myalgia.
• Derm: rash.
• GU: uterine bleeding, uterine cramping , ruptured
ectopic pregnancy, pelvic pain.
Nursing Considerations:
• Determine duration of pregnancy
• Assess the amount of bleeding and cramping during
treatment. Determine if termination is complete on
day 14.
• Monitor for changes in cushingoid appearance
(acne, hirsutism, striae, body weight) during
therapy.
• Monitor for signs and symptoms of adrenal
insufficiency (weakness, nausea, increased fatigue,
hypotension, hypoglycemia) during therapy. If
adrenal insufficiency is suspected, discontinue and
administer glucocorticoids immediately.
• Assess serum potassium 1 – 2 wk after starting or
increasing dose of medication and periodically
thereafter. Obtain a negative pregnancy test for
women prior to starting therapy or before
restarting therapy if stopped for more than 14 days.
Nursing Management
Nursing Diagnosis
• Risk for injury related to weakness
• Risk for infection related to altered protein metabolism and
inflammatory response
• Self-deficit related to weakness, fatigue, muscle wasting, and
altered sleep patterns
• Impaired skin integrity related to edema, impaired healing, and
thin and fragile skin
• Disturbed body image related to altered physical appearance,
impaired sexual functioning, and decreased activity level
• Ineffective coping related to mood swings, irritability, and
depression
Planning and Goals
The major goals of the patient include:
• Decreased risk of injury
• Decreased risk of infection
• Increased ability to carry out self-care activities
• Improved skin integrity
• Improved body image
• Improved mental function
• Absence of complications
Nursing Considerations
• Monitor vital signs, particularly blood pressure
• Monitor intake and output and weight
• Monitor laboratory values, particularly WBC count and serum
glucose, sodium, potassium, and calcium levels
• Assess for and protect against postoperative thrombus
formation
• Clients requiring lifelong glucocorticoid replacement following
adrenalectomy should obtain instructions from their HCPs about
increasing their glucocorticoid during times of stress.
• Assess for and protect against postoperative thrombus
formation
• Allow the client to discuss feelings related to body appearance.
• Instruct the client about the need to wear a MedicAlert bracelet.
Nursing Interventions
• Decreasing Risk of Injury
o Establishing a protective environment helps
prevent falls, fractures, and other injuries to
bones and soft tissues.
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 o The patient who is very weak may require
assistance from the nurse in ambulating to avoid
falling or bumping into sharp corners of furniture.
o Foods high in protein, calcium, and vitamin D are
recommended to minimize muscle wasting and
osteoporosis.
o Referral to a dietician may assist the patient in
selecting appropriate foods that are also low in
sodium and calories.
• Decreasing Risk of Infection
o Patients should avoid unnecessary exposure to
others with infections.
o Nurse should frequently assess the patient for
subtle signs of infection. (because the anti-
inflammatory effects of corticosteroids may mask
the common signs of inflammation and infection)
• Encouraging Rest and Activity
o Encourage moderate activity to prevent
complications of immobility and promote
increased self-esteem. (Since patients with
Cushing syndrome experiences insomnia,
weakness, fatigue, and muscle wasting)
o Help patients plan and space rest periods
throughout the day.
o Promote a relaxing, quiet environment for rest
and sleep.
• Promoting Skin Integrity
o Meticulous skin care is done. (to avoid
traumatizing the patient’s fragile skin.
o Avoid using adhesive tape. (because it can irritate
the patient’s skin and tear the fragile tissue when
the tape is removed).
o Assess the skin and bony prominences and
encourage and assist the patient to change
positions frequently. (to prevent skin
breakdown).
• Improving Body Image
o Discussion of the effect the changes have had on
his or her self-concept and relationships with
others can benefit the patient.
o Weight gain and edema may be modified by a
low-carbohydrate, low-sodium diet, and a high
protein intake may reduce some of the other
bothersome symptoms.
• Improving Coping
o Explanations to the patient and family members
about the cause of emotional instability are
important in helping them cope with the mood
swings, irritability, and depression that may
occur.
o Psychotic behavior may occur in a few patients
and should be reported.
o The nurse encourages the patient and family
members to verbalize their feelings and concerns.
Monitoring and Managing Potential Complications
• Addisonian Crisis
o Patients with Cushing syndrome should be assessed
for signs and symptoms of addisonian crisis.
o If an addisonian crisis occurs, the patient is treated for
circulatory collapse and shock.
• Adverse Effects of Adrenocortical Activity
o Assess fluid and electrolyte status by monitoring
laboratory values and daily weights.
o Blood glucose monitoring is initiated. (because of the
increased risk of glucose intolerance and
hyperglycemia)
Promoting Home and Community-Based Care
▪ Educating Patients About Self-Care
o The patient, family, and caregivers should be educated that
acute adrenal insufficiency and underlying symptoms will
recur if medication is stopped abruptly without medical
supervision.
o Stresses the need for dietary modifications to ensure
adequate calcium intake (without increasing the risks for
hypertension, hyperglycemia, and weight gain)
o Educated the patient and family about how to monitor
blood pressure, blood glucose levels, and weight.
o Advised the patient to wear a medical alert bracelet and to
notify other health care providers about their condition.
• Continuing Care
▪ Follow-ups (depends on the origin and duration of the
disease and its management)
▪ For patients who have been treated by adrenalectomy
or removal of a pituitary tumor requires close
monitoring to ensure that adrenal function has
returned to normal and adequacy of circulating
adrenal hormones.
▪ Home care referral (may be indicated to ensure a safe
environment that minimizes stress and risk of falls and
other side effects)
▪ The home care nurse assesses the patient’s physical
and psychological status and reports to the primary
provider.
▪ The nurse assesses the patient’s understanding of the
medication regimen and his or her compliance with
the regimen and reinforces previous education about
the medications and the importance of taking them as
prescribed.
▪ The nurse emphasizes the importance of regular
medical follow-up, the side effects and toxic effects of
medications, and the need to wear medical
identification with Addison’s and Cushing diseases.
▪ The nurse reminds the patient and family about the
importance of health promotion activities.
▪ Recommended health screening, including bone
mineral density testing.
Addison’s Disease and Addisonian Crisis
Definition
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• Addison’s disease, primary adrenal insufficiency (PAI), occurs
when the adrenal glands are damaged and cannot produce
sufficient amounts of cortical and aldosterone hormones.
• Cortisol helps the body respond to stress, including the stress of
illness, injury, or surgery. It also helps maintain blood pressure,
heart function, the immune system and blood glucose or sugar
levels.
• On the other hand, aldosterone affects the balance of sodium
and potassium in the blood. This in turn controls the amount of
fluid the kidneys remove as urine, which affects blood volume
and blood pressure.
• Autoimmune or idiopathic atrophy of the adrenal glands is
responsible for 80% to 90% of all cases. People with Addison's
disease commonly have associated autoimmune diseases.
Addison's disease occurs in all age groups and both sexes, but is
most common in the 30-50 year-old age range. This disease can
be life-threatening.
• An Addisonian Crisis is a life-threatening situation that results in
low blood pressure, low blood levels of sugar and high blood
levels of potassium. The patient will need immediate medical
care.
Risk Factors
• An individual may be at a higher risk for Addison’s disease if they:
• Have cancer. Cancer cells that spread from other parts of the
body to the adrenal glands also can cause Addison's disease.
• Take Anticoagulants (blood thinners). Bilateral adrenal
hemorrhage is a rarely recognized cause of adrenal insufficiency
in adults. It is one of the complications of anticoagulation
therapy, including direct anticoagulant medications. It is not fully
understood and the diagnosis is difficult which is likely related to
the nonspecific clinical manifestations of adrenal insufficiency
within the context of a major concurrent illness. However, we
believe that due to the nature of blood thinners increasing the
risk of internal bleeding, and because Addison’s disease is an
autoimmune disease, the body can attack itself in this scenario
and the faster the damage can affect the person developing the
disease. Moreover, bleeding into the adrenal glands can result
to an Addisonian crisis without any previous symptoms.
• Have Chronic Infections. Long-lasting infections such as
tuberculosis, HIV, and some fungal infections can harm the
adrenal glands. Research has found that people suffering from
Addison's disease suffer from an immune system defect which
makes them prone to potentially deadly respiratory infections.
• Had surgery to remove any part of the adrenal gland. The
adrenal glands produce hormones that a person can't live
without, including sex hormones, cortisol, or aldosterone. In this
case, because of the removal of some parts of the adrenal gland
during surgery, it might not produce enough of the hormones.
As mentioned before, the hormone cortisol is important to
maintain blood pressure, heart function, the immune system
and blood glucose or sugar levels while aldosterone helps
regulate salt and water in the body. Addison’s disease is the
insufficiency of these hormones.
• Have an autoimmune disease such as myasthenia gravis, type
1 diabetes or Graves’ disease. Addison disease affects the
function of the adrenal glands, which are small hormone-
producing glands located on top of each kidney. It is classified as
an autoimmune disorder because it results from a
malfunctioning immune system that attacks the adrenal glands.
People with Addison's disease are more likely than others to
have another autoimmune disease as well due to the weakened
immune system.
• Sudden cessation of exogenous adrenocortical hormonal
therapy. Symptoms of adrenocortical insufficiency may result
from the sudden cessation of exogenous adrenocortical
hormonal therapy, which suppresses the body’s normal
response to stress and interferes with normal feedback
mechanisms.
• Prolonged administration of glucocorticoids (e.g. prednisone).
Treatment with daily administration of corticosteroids for 2 to 4
weeks may suppress function of the adrenal cortex; therefore,
adrenal insufficiency should be considered in any patient who
has been treated with corticosteroids. Inadequate secretion of
ACTH from the pituitary gland is a secondary cause of
adrenocortical insufficiency as a result of decreased stimulation
of the adrenal cortex.
Prevention
• Addison’s Disease cannot be prevented but there are steps that
can be taken in order to avoid Addisonian crisis such as the
following:
• Recognize signs of potential stress that may cause an acute
adrenal crisis.
• Most people with Addison’s disease are taught to give
themselves an emergency injection of hydrocortisone or
increase their dose of oral prednisone in times of stress.
• Always have a kit at home that stores hydrocortisone injection
in case of feeling weak or when starting to vomit.
• It can also be averted with oral medication that the doctor
prescribes such as anti-nausea medicine.
• Teach or instruct other family members how to give the
hydrocortisone injection properly.
• Always carry a medical identification card that states the type of
medication and the proper dose needed in case of an
emergency.
• Never omit medication. If unable to retain medication due to
vomiting, notify the health care provider.
• Consult a doctor if a noticeable weight loss is present or when
one is always feeling weak or tired.
Signs and Symptoms
• The symptoms of Addison’s disease can vary from one
individual to another. Addison's disease symptoms usually
develop slowly, often over several months. Often, the disease
progresses so slowly that symptoms are ignored until a stress,
such as illness or injury, occurs and makes symptoms worse.
• People who have Addison’s disease may experience the
following symptoms:
o Muscle weakness
o Fatigue and tiredness
o Dark pigmentation of the mucous membranes and the skin
o Weight loss or decreased appetite
o A decrease in heart rate or blood pressure
o Low blood sugar levels
8
 o Fainting spells ➢ Definition
o Sores in the mouth
o Cravings for salt • An abdominal X-ray is a safe and painless test that uses a small
o Nausea amount of radiation to make an image of a person's abdomen.
o Vomiting • It is a noninvasive medical test that helps physicians diagnose
o Neuropsychiatric symptoms and treat medical conditions. Imaging with x-rays involves
• Irritability or depression exposing a part of the body to a small dose of ionizing radiation
• Lack of energy to produce pictures of the inside of the body. X-rays are the
• Sleep disturbances oldest and most frequently used form of medical imaging.
• If Addison’s disease goes untreated for too long, it can become • During the examination, an X-ray machine sends a beam of
an Addisonian Crisis. radiation through the abdomen, and an image is recorded on
o This condition is characterized by cyanosis and the classic special film or a computer. This image shows the stomach, liver,
signs of circulatory shock: spleen, small and large intestines, and diaphragm.
• Pallor, • The X-ray image is black and white. Dense body parts that block
• Apprehension, the passage of the X-ray beam through the body, such as bones,
• Rapid and weak pulse, appear white on the X-ray image. Softer body tissues, such as the
• Rapid respirations, and skin and muscles, allow the X-ray beams to pass through them
• Low blood pressure. and appear darker. Gas in the stomach and intestines appears
• An untreated Addisonian crisis can lead to shock and death. An black.
Addisonian crisis is a life-threatening medical emergency, if the • An X-ray technician takes the X-rays. One or two pictures of the
patient begins to experience: abdomen are usually taken to get a view of the area from
o Mental status changes, such as confusion, fear, delirium, different angles.
or restlessness ➢ Procedure
o Agitation
o Visual and auditory hallucinations • The equipment typically used for an abdominal x-ray consists of
o Loss of consciousness a table on which the patient lies and a large x-ray machine
o High fever suspended from the ceiling. There is a drawer under the table to
hold the x-ray film or digital recording plate. The entire
Pathophysiology abdominal x-ray examination is usually completed within 15
minutes, although the actual exposure to radiation is usually less
than a second.

➢ Purpose

• Abdominal x-ray is often the first imaging test used to evaluate

and diagnose the source of acute pain in the abdominal region
and/or lower back as well as unexplained nausea and vomiting.
When an abdominal x-ray is performed to provide pictures of the
kidneys, ureters and bladder, it is called a KUB x-ray.
• Abdominal X-rays is usually done before other tests that look at
the GI tract or urinary tract. These include an abdominal CT scan
and renal or kidney tests.
• Abdominal x-ray is also performed if the doctor think that the
patient may have the following:
o Kidney and urinary bladder stones and gallstones
o An abdominal aortic aneurysm
o Addison’s disease
o Pancreatitis
o Appendicitis
o Ascariasis
o Kidney failure and a kidney injury

➢ Normal Findings

Laboratory and Diagnostic Procedures

1. Non-invasive procedures

a. Abdominal X-ray

9

• Normal results show that the stomach, small and large bowel,
liver, spleen, kidneys, and bladder are normal in size, shape,
and location. No growths, abnormal amounts of fluid (scites), or
foreign objects are seen.
➢ Significant Findings and Implications
• An abdominal x-ray may be helpful in the diagnosis of Addison's
disease.
• Findings on an abdominal x-ray suggestive of Addison's disease
include adrenal calcifications.
o Adrenal calcifications can either be caused by
previous tuberculosis infection (TB) or by adrenal
hemorrhage. Also, the presence of adrenal
calcification is suggestive of adrenal insufficiency
secondary to a fungal infection.
o It can be seen on X-ray results that both of the glands
are fully calcified
➢ Risks
• In general, X-rays are very safe. Although there's some minor
risk to the body with any exposure to radiation, the amount of
radiation used in an abdominal X-ray is small and not
considered dangerous. It's important to know that radiologists
use the minimum amount of radiation required to get the best
results.
➢ Nursing Care
Before the procedure
• Inform the patient the purpose of the procedure.
• Inform the patient that this procedure will not
cause any pain.
• Ask the patient if she is pregnant.
• Ask the patient if he/she has taken a medication
that contains bismuth, such as Pepto-Bismol, in the
past four days. Medications that contain bismuth
may interfere with testing procedures.
• Instruct the patient to refrain from eating or
drinking for a few hours
• Instruct the patient to wear loose and comfortable
clothing or change into a hospital gown if available.
• Instruct the patient to remove items such as
eyeglasses, jewelries, piercings, hair clips, dentures,
hearing aids, and bras with metal underwire.
• Inform the patient to be still and not move
frequently once the radiologist is configuring the
machine.
During the Procedure
• Instruct the patient to remain still while the
exposure is made, as any movement may distort
the image and even require another.
After the procedure
• Inform the patient that after the test he/she can go
back to his/her usual activities.
• Instruct the patient that he/she will be notified
once the result is available.
b. Abdominal Computed Tomography Scan (CT Scan)
➢ Definition
• A computerized tomography (CT) scan combines a series of X-ray
images taken from different angles around the body and uses
computer processing to create cross-sectional images (slices) of
the bones, organs, and other internal structures such as blood
vessels and soft tissues inside a person’s body.
• CT scan images provide a more-detailed information than plain
X-rays do. This procedure is done by placing the patient on a
table and preparing him/her to be slid into a doughnut-shaped
CT machine with a healthcare professional by the patient’s side.
➢ Purpose
• A CT scan of the abdomen is performed to help the doctors find
changes in a person’s adrenal glands. This test is used to see the
size of the adrenals glands and to see whether there are
calcifications present on the glands.
• Abdominal CT scan is performed when the patient is
experiencing symptoms such as abdominal pain, unexplained
10
 weight loss, injuries following a trauma, or when the patient is
recently diagnosed with cancer.
• Also, this imaging feature will give the doctors an idea on the
cause and diagnosis of the disease.
➢ Normal Findings
• Having an unremarkable result means that there is nothing
wrong or any problem within the person’s abdominal CT scan. It
means no change in shape, tumors, or calcifications were seen
upon conducting the test.
➢ Significant Findings and Implications
• In autoimmune Addison’s disease, the glands are small or
normal size and don’t have other visible abnormalities.
• Enlarged adrenal glands or a buildup of calcium in the glands
can occur when Addison’s disease is caused by infection,
bleeding in the adrenal glands, or cancer cells in the glands.
However, these changes don’t always occur if the disease is
caused by tuberculosis (TB).
• Abdominal CT findings in Addison's disease may include the ff:
o Small adrenal remnants bilaterally suggestive of
autoimmune adrenalitis, idiopathic atrophy, or long-
term tuberculosis infection.
o Dense calcification in one or both adrenal beds
without evidence of normal glandular remnants - in
TB.
o Enlarged non-homogeneous glands of normal contour
- in Histoplasmosis.
o Atrophic adrenal glands- in idiopathic autoimmune
Addison's disease.
➢ Risks
• Radiation exposure- The amount of radiation is greater than a
plain X-ray because the CT scan gathers more-detailed
information. The low doses of radiation used in CT scans have
not been shown to cause long-term harm, although at much
higher doses, there may be a small increase in your potential risk
of cancer. CT scans have many benefits that outweigh any small
potential risk. Doctors use the lowest dose of radiation possible
to obtain the needed medical information. Also, newer, faster
machines and techniques require less radiation than was
previously used.
• Harm to unborn babies - It is important to tell the doctor if the
patient is pregnant. Although the radiation from a CT scan is
unlikely to injure the baby, the doctor may recommend another
type of exam, such as ultrasound or MRI, to avoid exposing the
baby to radiation. At the low doses of radiation used in CT
imaging, no negative effects have been observed in humans.
• Reactions to contrast material - Before the procedure, the
patient will be asked to have contrast or dye. This can be
something that will be asked to drink before CT scan, or
something that is given through a vein in the arm or inserted into
the rectum. Although rare, the contrast material can cause
medical problems or allergic reactions. Most reactions are mild
and result in a rash or itchiness. In rare instances, an allergic
reaction can be serious, even life-threatening.
Nursing Care
Before the procedure
• Inform the patient the purpose of the procedure.
• Inform the patient that he/she must fast or not eat
anything 2 to 4 hours before the scan.
• Inform the patient that he/she may be asked to stop
taking certain medications before the test.
• Ask the patient if he/she is allergic to iodine or
seafood such as shellfish and inform the doctor if so.
• Ask the patient if he/she is claustrophobic.
• Instruct the patient that a contrast may be given
orally or intravenously.
• Inform the patient the purpose of the contrast.
• Ask the patient if she is pregnant.
• Instruct the patient to wear loose and comfortable
clothing or change into a hospital gown if available.
• Instruct the patient to remove items such as
eyeglasses, jewelries, piercings, hair clips, dentures,
hearing aids, and brads with metal underwire.
• Inform the patient to be still and not move
frequently once inside the machine.
After the procedure
• Inform the patient that the following symptoms may
be experienced due to the type of contrast used:
11
 ✓ Diarrhea
✓ Nausea or vomiting
✓ Constipation
✓ Abdominal cramping
✓ Skin rash
✓ Itching
✓ Headache
• Instruct the patient to notify the nurse immediately
if pain, redness, and/or swelling at the IV site is
present
• Instruct the patient that he/she will be notified
immediately once the results are available.
• Instruct the patient that he/she can return to his/her
normal routine.
• Instruct the patient to drink lots of fluid to eliminate
the contrast used out of the body.
c. Magnetic Resonance Imaging (MRI) Scan
➢ Definition
• Magnetic resonance imaging (MRI) is a test that uses powerful
magnets, radio waves, and a computer to make detailed cross-
sectional images of internal organs and structures.
• The scanner itself typically resembles a large tube with a table in
the middle, allowing the patient to slide in.
• MRI scan differs from CT scans and X-rays, as it does not use
potentially harmful ionizing radiation. An MRI scan combines
images to create a 3-D picture of your internal structures, so it’s
more effective than other scans at detecting abnormalities in
small structures of the brain such as the pituitary gland and brain
stem. Sometimes a contrast agent, or dye, can be given through
an intravenous (IV) line to better visualize certain structures or
abnormalities.
➢ Purpose
• There are no specific MRI findings associated with Addison's
disease.
• While MRI is not capable of distinguishing between acute
inflammatory and metastatic diseases of the adrenal glands, it
may be equally efficacious as CT in suggesting the diagnosis of
adrenal hemorrhage in patients with Addison's disease.
➢ Significant Findings and Implications
• Adrenal hemorrhage can result from a variety of traumatic and
non-traumatic causes.
• When unilateral, it is often clinically silent. In contrast, bilateral
adrenal hemorrhage can lead to catastrophic adrenal
insufficiency.
➢ Nursing Care
Before the procedure
• Inform the patient what is the procedure all about
and what is its purpose.
• Ask the patient if he/she is claustrophobic
• Instruct the patient to change into hospital gown
• Instruct the patient to remove all metal jewelries
or accessories that might interfere with the
machine
• Medical devices such as cochlear implants,
aneurysm clips, and pacemakers must also be
removed.
• Inform the patient that an intravenous contrast
might be injected to improve the visibility of the
scan.
• Inform the patient that he/she may be given
earplugs or headphones (especially the children),
to block out the loud noises of the scanner
• Instruct the patient to refrain from moving
excessively once inside the scanner
After the procedure
• Accompany the patient to the changing room and
allow him/her to change into his/her street
clothes. Offer help if needed.
• Inform the patient that certain side effects may be
experienced such as nausea, headache, and pain
or burning at the site of injection.
• Inform the patient to immediately seek help when
allergic reactions are experienced, such as hives or
itchy eyes.
• Inform the patient to schedule an appointment
with her doctor for the analysis of the result.
2. Laboratory tests
• Although the clinical manifestations presented appear specific,
the onset of Addison disease usually occurs with nonspecific
symptoms. The diagnosis is confirmed by laboratory test results.
12
• Combined measurements of early-morning serum cortisol and
plasma ACTH are performed to differentiate primary adrenal
insufficiency from secondary adrenal insufficiency and from
normal adrenal function.
o Patients with primary insufficiency have a greatly
increased plasma ACTH level and a serum cortisol
concentration lower than the normal range or in the
low-normal range.
• Other laboratory findings include decreased levels of blood
glucose (hypoglycemia) and sodium (hyponatremia), an
increased serum potassium concentration (hyperkalemia), and
an increased white blood cell count (leukocytosis).
a. Serum Biochemistry Description
• This is a test done on a sample of blood to measure the amount
of certain substances in the body. These substances include
electrolytes (such as sodium, potassium, and chloride), fats,
proteins, glucose (sugar), and enzymes.
➢ Purpose
• Blood chemistry tests give important information about how
well a person’s kidneys, liver, and other organs are working.
➢ Normal Findings
Sodium: 135 - 145 mEq/L
Potassium: 3.8 - 5.5 mEq/L - Chloride: 95 - 105 mEq/L
BUN: 8-18 mg/dL
Creatinine: 0.6 - 1.2 mg/dL
➢ Significant Findings and its Implications
• In Addison’s disease:
o Sodium and chloride levels may be decreased.
o Potassium levels may be increased
o BUN-to-creatinine ratio may be increased (prerenal
azotemia)
o Mild non-anion-gap metabolic acidosis
➢ Nursing Care
Before the procedure
• It is a nursing responsibility to be aware of the
normal and abnormal ranges of blood tests, in
order to understand the significance of the test
results.
• The nurse must have performed proper
handwashing before specimen collection.
• Verify and validate the patient’s identity using at
least 2 unique identifiers.
• The nurse must provide the client and/or significant
others with an explanation of the diagnostic test
and the purpose of the diagnostic tests.
• The nurse must explain that slight discomfort may
be felt when the skin is punctured.
• The nurse must encourage the patient to avoid
stress if possible because altered physiologic status
influences and changes normal hematologic values.
During the procedure
• The nurse should facilitate comfort of the patient at
all times by using therapeutic communication.
• If the patient shows signs of fear of needles, the
nurse may remind the patient that the withdrawal
of the blood sample will not take too long
After the procedure
• The nurse must monitor the puncture site for
oozing or hematoma formation
• The nurse may instruct the patient to resume
normal activities and diet.
• The nurse must perform proper handwashing after
specimen collection.
• The nurse must properly and accurately label the
specimen obtained. This may include the client's
full name, the date and time of the specimen
collection.
• The nurse must observe proper preservation and
transportation of the specimen to the laboratory in
a timely manner along with the proper laboratory
requisition slip.
• The nurse must observe proper disposal of all
supplies and equipment that was used for the
diagnostic test.
b. Blood tests
b.1 Plasma Cortisol Level
➢ Description
• Cortisol is a steroid hormone released by the adrenal glands.
Cortisol is the main hormone involved in stress and the fight-or-
flight response. This is a natural and protective response to a
perceived threat or danger.
• A cortisol level test may also be called a serum cortisol test. A
cortisol level test uses a blood sample to measure the level of
cortisol present in the blood.
➢ Purpose
• The cortisol level test is used to check if the cortisol production
levels are either too high or too low.
• Addison’s disease affects the amount of cortisol the adrenal
glands produce.
• This is a screening test used to diagnose adrenal insufficiency
and to assess the functioning of the adrenal and pituitary glands.
➢ Normal Findings
• Levels normally vary in the blood, peaking in the early morning.
o Plasma cortisol: > 18 μg/dL at 8AM
➢ Significant Findings and its Implications
• If the adrenal gland is either not functioning normally or not
being stimulated by ACTH, then cortisol levels will be
consistently low.
o <3 μg/dL: suggests evidence of adrenal insufficiency
o 3-18 μg/dL: non-diagnostic, although levels <10 μg/dL
raise suspicion of adrenal insufficiency
13
 o >18 μg/dL precludes the diagnosis of adrenal
insufficiency
b.2 Serum adrenocorticotropic hormone (ACTH) level
➢ Description
• Adrenocorticotropic hormone (ACTH) is a hormone produced in
the anterior, or front, pituitary gland in the brain. The function
of ACTH is to regulate levels of the steroid hormone cortisol,
which is released from the adrenal gland.
• An ACTH test measures the levels of both ACTH and cortisol in
the blood and helps the doctor detect the diseases that are
associated with too much or too little cortisol in the body.
➢ Purpose
• The doctor may order an ACTH blood test if the patient has
symptoms of too much or too little cortisol.
• This test is primarily ordered as a baseline test to evaluate if the
pituitary is producing appropriate amounts of ACTH.
• The combination of morning cortisol and ACTH measurement is
a preliminary option until the stimulation test can be performed
to confirm the diagnosis.
➢ Normal Findings
• Normal value ranges may vary slightly among different
laboratories. Some labs use different measurements or may test
different specimens.
o ACTH: 5-30 ng/mL
➢ Significant Findings and its Implications
• In someone with adrenal insufficiency, low ACTH levels indicate
secondary adrenal insufficiency, while high levels indicate
primary adrenal insufficiency (Addison disease).
o In Addison disease: ACTH elevated (usually >60 ng/mL)
in the face of a low or low-normal cortisol
o In secondary/tertiary adrenal insufficiency: ACTH is
low (usually <5 ng/mL) in the face of low cortisol
b.3 Plasma Renin Activity and Aldosterone Levels
➢ Description
• Aldosterone is a hormone that plays an important role in
maintaining normal sodium and potassium concentrations in
blood and in controlling blood volume and blood pressure. Renin
is an enzyme that controls aldosterone production.
• Aldosterone and renin tests are used to evaluate whether the
adrenal glands are producing appropriate amounts of
aldosterone and to distinguish between the potential causes of
excess or deficiency.
• These tests measure the levels of aldosterone and renin in the
blood and/or the level of aldosterone in urine. Renin is always
measured in blood.
➢ Purpose
• The simultaneous measurement of aldosterone and plasma
renin is recommended in cases of adrenal insufficiency to
determine whether the patient has mineralocorticoid deficiency.
• This test also helps in differentiating primary from secondary
adrenal insufficiency.
• Aldosterone and renin testing helps with diagnosis in the early
phase of primary adrenal insufficiency development, when the
deficiency may be the only indication.
• In secondary adrenal insufficiency, only cortisol is deficient,
because the adrenal gland is normal in this condition, and
aldosterone is regulated primarily by the renin-angiotensin
system, which is independent of the hypothalamus and the
pituitary.
➢ Normal Findings
• Normal PA (ng/dL) to PR (ng/mL/h) is less than 20 with plasma
aldosterone levels less than 15 ng/dL.
➢ Significant Findings and its Implications
• A high plasma renin activity measurement with a low or
inappropriately serum aldosterone concentration is suggestive
of primary adrenal insufficiency. Aldosterone deficiency leads
to low levels of sodium and high levels of potassium in the
blood.
• Both aldosterone and renin levels are typically normal in
secondary insufficiency.
c. Adrenocorticotropic Hormone Stimulation Test or Synacthen Test
➢ Description
• This uses a manufactured drug, Synacthen, to test how well the
adrenal glands make a hormone called cortisol.
• Synacthen is another name for tetracosactide, the chemical used
in the test.
• Synacthen acts like adrenocorticotropic hormone (ACTH) by
stimulating the adrenal gland to produce more cortisol and then
checking to see if they respond.
➢ Purpose
• By measuring the rise in cortisol in the blood, the doctor can see
if the adrenal glands are secreting normal amounts of cortisol
• A diagnosis of Addison’s disease may be confirmed through the
ACTH stimulation test along with the insulin-induced
hypoglycemia test and an x-ray examination.
➢ Indications
• Hyponatraemia, hypotension, hypoglycaemia, uraemia and/or a
cortisol concentration <480 nmol/L in a patient where there is a
high clinical suspicion of adrenal insufficiency.
➢ Normal Findings
• An increase in cortisol after stimulation by ACTH is expected.
• Cortisol level after ACTH stimulation should be higher than 18
to 20 mcg/dL or 497 to 552 nmol/L, depending on the dose of
ACTH used.
o It is important to note that normal value ranges may
vary slightly among different laboratories. Some labs
use different measurements or may test different
specimens.
14
➢ Significant Findings and its Implications • The nurse should facilitate comfort of the patient at
all times by using therapeutic communication and
• If the test fail to stimulate adequate cortisol production, it by ensuring that the test
indicates that the adrenal glands are damaged or not functioning After the procedure
properly. • The nurse must be alert for any signs and symptoms
• A serum cortisol concentration 30 minutes postsynacthen of hypersensitivity to synacthen as hypersensitivity
administration between 450 and 480 nmol/L, may require has been reported in some cases.
further assessment of the adrenal glands after discussion with a ✓ These signs and symptoms may be any of
consultant endocrinologist. the following:
• A serum cortisol concentration <450 nmol/L 30 minutes ▪ Skin rash
postsynacthen, suggests adrenal insufficiency. ▪ Hives
▪ Itching
• Note that patients who have been receiving long-term steroid
▪ Fever
replacement may also demonstrate an inadequate response to
▪ Swelling
synacthen.
▪ Shortness of breath
Nursing Care ▪ Wheezing
▪ Runny nose
Before the procedure ▪ Itchy, watery eyes
d. Corticotropin-Releasing Hormone (CRH) Stimulation Test
• The nurse must be aware that hydrocortisone and
fludrocortisone interfere with this test. Because of ➢ Description
this, the nurse must inform the patient that steroid
therapy should be discontinued the evening prior • CRH is a hormone released by the hypothalamus that stimulates
to performing the test. Steroid therapy can be ACTH (Adrenocorticotropic hormone, also known as
recommenced immediately after the synacthen • Corticotropin) production by the pituitary gland, which in turn
test has been performed. stimulates cortisol production by the adrenal glands.
• If a patient is on long-term steroid therapy, inform • This test is used when the ACTH test is abnormal, to help
the physician to consider a depot (1 mg) synacthen determine the cause of adrenal insufficiency.
test.
• The nurse must also check if the patient has had ➢ Purpose
pituitary surgery in the past 2 weeks because a
synacthen test gives unreliable results in the 2 • The CRH test has utility for differentiating pituitary from
weeks following this surgery. hypothalamic etiologies of adrenal insufficiency.
• The nurse must check if the patient has a history of • The CRH stimulation test has limited usefulness due to its cost,
atopic allergy such as asthma, eczema and hayfever availability and limited data defining responses in normal and
because these are contraindications for the test. hypoadrenal groups.
• The nurse may help explain the procedure to the • In one study the CRH stimulation test had high sensitivity (95%)
client which involves the following: for detection of adrenal insufficiency but had low specificity at
➢ The client will be asked to lie down for 33%.
this test. • The CRH stimulation test is not routinely recommended in the
➢ A needle or small polystyrene tube (a differential diagnosis of adrenal insufficiency.
cannula) with a valve mechanism on the • When the response to the short ACTH test is abnormal, a "long"
end is put into a vein in the client’s arm.
CRH stimulation test is required to determine the cause of
The end is taped to the arm and remains
adrenal insufficiency.
in place during the test.
➢ A baseline blood sample is taken through ➢ Normal Findings
the cannula before the test.
➢ A solution containing Synacthen is then • For this test, synthetic CRH is injected intravenously and blood
injected into the vein or a muscle. cortisol and ACTH levels are measured at timed intervals after
➢ After 30 minutes, a second sample of the injection, at baseline and at 15, 30, and 60 minutes following
blood is taken. Some clinics also take a
stimulation. The normal response is a peak in ACTH levels
third sample at 60 minutes.
followed by a peak in cortisol levels.
➢ Cortisol is measured in the blood
samples. The doctor may also ask for Increase
ACTH to be measured in the baseline Plasma Time to Peak
Peak Level From
sample. Concentration Level
Baseline
• The nurse should ensure to address any 10-120
outstanding questions the patient and their pg/mL
significant others may have. 10-30 min
Corticotropin (picograms 35-900%
During the procedure postinjection
per
milliliter)

15
 (2.2-24 • The CRH test must be performed only after a
pmol) patient has fasted for a minimum of 4 hours.
(picomole) • The CRH test can be performed at any time of the
day. Corticotropin increments are similar in the
morning and evening, but peak values are higher in
13-36
the morning; cortisol values peak similarly in the
mcg/dL
morning and evening.
(micrograms
• Instruct the patient to remain in bed or at rest for 1
per deciliter)
30-60 min hr immediately before the test
Cortisol (360- 20-600%
postinjection During the procedure
1000
• The test will last for about 3 hours
nmol/L)
• Synthetic ovine CRH (1 mcg per kg body weight or
(nanomoles
100 mcg total dose) is injected as an intravenous
per liter)
bolus over 30 seconds.
• Blood specimens for analysis of corticotropin and
➢ Significant Findings and Implications cortisol levels are collected at baseline and
specified intervals after CRH administration.
• CRH testing is also used to differentiate hypothalamic adrenal • Insert a cannula, which is a small plastic tube used
insufficiency in which patients Corticotropin and cortisol levels to take blood samples, into a vein in the patient’s
in primary, secondary, and tertiary adrenal insufficiency are as arm. This is where the injection of the hormone will
pass through.
follows:
After the procedure
a. Primary adrenal insufficiency • Some patients have mild, brief facial flushing
immediately after injection, but there are no other
• If CRH injection causes an ACTH response, but no cortisol side effects at this dose level.
response, the pituitary is functioning but the adrenal glands are • Inform that patient with diabetes can expect a
not. temporary rise in his/her blood glucose levels for a
• High baseline corticotropin levels that increase in response to few days after the test.
CRH; cortisol levels remain low before and after CRH • All patients with primary or secondary adrenal
• Patients with primary adrenal insufficiency have high ACTHs but insufficiency should receive exogenous steroid
replacement. Hydrocortisone I.V. or oral
do not produce cortisol.
prednisone is typically administered to simulate
b. Secondary (pituitary) adrenal insufficiency diurnal adrenal rhythm, with two-thirds of the dose
given in the morning and one-third in the
• If CRH injection does not generate ACTH response, the problem afternoon.
is the pituitary gland. • When a critically ill patient has signs and symptoms
• Low baseline corticotropin levels that do not respond to CRH; of adrenal insufficiency but his cortisol levels are
cortisol levels are not affected by CRH within the low-normal range, the practitioner may
order a trial treatment with exogenous
• Patients with secondary adrenal insufficiency have deficient
glucocorticoids.
cortisol responses absent ACTH responses.
• Absent ACTH response points to the pituitary as the cause
Medical/Surgical Management
c. Tertiary (hypothalamic) disease
1. Lifelong hormone replacement therapy
• CRH injection produces a delayed ACTH response, the problem
is the hypothalamus. • Treatment for Addison disease consists of lifelong hormone
• Low baseline corticotropin levels that show exaggerated, therapy with corticosteroids, specifically glucocorticoids and
prolonged responses to CRH; serum cortisol levels do not mineralocorticoids. To date, there is no therapy available to stop
exceed 20 mcg/dL the underlying immune destruction of the adrenal cortex.
• A delayed ACTH response points to the hypothalamus as the Generally, glucocorticoid or cortisol replacement includes oral
cause. prednisone or hydrocortisone. Other possible medicines are
prednisolone or dexamethasone, although these are less
➢ Nursing Care
commonly used. Prednisone can be taken once daily, whereas
Before the procedure hydrocortisone is divided into two or three doses per day. The
mineralocorticoid aldosterone is replaced with fludrocortisone
• Instruct the patient to refrain from smoking, avoid at a dose sufficient to keep the plasma renin level in the upper
alcohol use, avoid strenuous exercise for 12 hr limit of the normal range. The physician may also ask patients to
before the test. add extra salt to their daily diet, although if they are already
• Document any usual medication the patient takes. taking enough fludrocortisone medicine, this may not be
She will usually be able to take these after the test.
necessary. Patients in hot and humid weather, those who
undergo necessary. Patients in hot and humid weather, those
16
 who undergo vigorous exercises, and those experiencing
gastrointestinal upsets, such as diarrhea, must increase their salt
intake.
• Patients with Addison disease should be treated in conjunction
with an endocrinologist and be monitored on a regular basis for
appropriate hormone therapy. Glucocorticoid doses should be
titrated to the lowest tolerated dose that controls symptoms to
minimize the adverse effects of excess glucocorticoid. It is
important to instruct patients to learn the proper guidelines for
stress dosing of glucocorticoids, to have an injectable form of
glucocorticoid available, and to wear an adrenal insufficiency
medical alert identification.
• Men who have Addison disease do not need replacement with
androgens because their testes are able to produce adequate
testosterone levels; however, women can benefit from
androgen replacement because the adrenal glands are the main
source of androgen production in women.
• At certain times, medication dosages may need to be adjusted
to account for any additional stress on the body. Increasing the
dosage will help the body cope with the additional stress. The
endocrinologist will monitor the dosage and advise about any
changes.
• A patient’s physician may need to increase the dosage of the
medication if the patient will experience any of the following:
o An illness or infection – particularly if they have a high
temperature of 38C or above
o An accident, such as a car crash
o An operation, dental or medical procedure – such as a
tooth filling or endoscopy
o Strenuous exercise that is not usually part of the patient’s
daily life
Nursing Care
Before the Management
• Establish good rapport with the patient and their
significant others to promote collaboration in
planning and implementing the recommended
interventions to be done to or by the patient.
During the Management
• The nurse should facilitate comfort of the patient at
all times by using therapeutic communication when
addressing any questions or concerns the patient
and their significant others may have.
• Explain how proper adherence to lifelong steroid
therapy is necessary.
• Advise the patient to avoid stressful situations as
much as possible.
• Instruct the patient to wear a medical alert bracelet
and carry a wallet card so that In the event of
trauma or injury, appropriate therapy could be
initiated immediately.
• Notify the physician if the patient and their
significant others have questions about the dosage
of the patient’s medication that would need a more
detailed medical explanation.
2. Yearly or regular check-ups
• Approximately 50% of persons with Addison disease caused by
autoimmune adrenalitis develop other autoimmune disorders
during their lifetime, necessitating lifelong vigilance for
associated autoimmune conditions. With this, patients with
Addison’s disease must see their doctor or an endocrinology
specialist at least once a year. The doctor may recommend
annual screening for a number of autoimmune diseases.
• A patient’s treatment plan may also need to be reevaluated and
changed depending on their condition. For this reason, it is
important for them to see their doctor regularly.
Nursing Care
Before the Management
• Establish good rapport with the patient and their
significant others to promote collaboration in
planning and implementing the recommended
interventions to be done to or by the patient.
• Explain why regular check-ups are necessary to
accurately monitor the patient’s health status.
During the Management
• The nurse should facilitate comfort of the patient
at all times by using therapeutic communication
and by ensuring that the check- ups would be done
in a private room.
• The nurse may help in assessing vital signs,
especially BP and HR.
After the Management
• The nurse should ensure that patient education is
completed and that the nurse was able to address
any outstanding questions the patient and their
significant others may have.
• Notify the physician if the patient and their
significant others have questions that would need a
more detailed medical explanation.
3. Treating Addisonian crisis
• Treatment for an addisonian crisis is a medical emergency.
Coma, seizure, or death may occur due to overwhelming shock
if early treatment is not provided. In an adrenal crisis, an
intravenous or intramuscular injection of hydrocortisone (an
injectable corticosteroid) must be given immediately to replace
the lacking cortisol hormone in the body. Supportive treatment
of low blood pressure with intravenous fluids is usually
necessary. Fluid replacement, a mixture of salts and sugars
(sodium, glucose and dextrose), will be done to rehydrate the
patient. Hospitalization is required for adequate treatment and
monitoring. If infection is the cause of the crisis, antibiotic
therapy may be needed.
• People who have Addison's disease should be taught to
recognize signs of potential stress that may cause an acute
adrenal crisis. Most people with Addison's disease are taught to
give themselves an emergency injection of hydrocortisone or
increase their dose of oral prednisone in times of stress. It is
important for the individual with Addison's disease to always
carry a medical identification card that states the type of
medication and the proper dose needed in case of an
emergency.
Nursing Care
Before the management
• To avoid an Addisonian Crisis from happening,
17
 • Instruct the patient to wear a medical alert bracelet
and carry a wallet card so that In the event of
trauma or injury, appropriate therapy could be
initiated immediately.
• Instruct the patient and their significant others to
always have a kit at home that stores
hydrocortisone injection in case of feeling
• weak or when starting to vomit. Teach the patient
and significant others to administer this properly.
• Advise the patient to consult a doctor if symptoms
of this crisis are present. Symptoms include severe
weakness, confusion, lower back or leg pain, severe
abdominal pain, vomiting and diarrhea, leading to
dehydration, reduced consciousness or delirium,
low blood pressure, high potassium
(hyperkalemia), and low sodium (hyponatremia).
During the management
• Refer or admit the patient to an acute care setting.
• Assess vital signs, especially BP and HR.
• Administer parenteral fluids as prescribed.
Anticipate the need for an immediate infusion of
fluids for patients with abnormal vital signs.
• Administer replacement medications as prescribed
or indicated: oral cortisone (Cortone),
hydrocortisone (Cortef), prednisone, or
fludrocortisone (Florinef).
• Assess ECG rhythm, as available, for signs of
hyperkalemia.
After the management
• Encourage oral fluids as the patient tolerates to
help in maintaining a normal blood pressure level.
• The nurse should ensure that patient education is
completed and that the nurse was able to address
any outstanding questions the patient and their
significant others may have.
• Notify the physician if the patient and their
significant others have questions that would need a
more detailed medical explanation.
• Instruct the patient to immediately notify a
healthcare provider if they would experience
symptoms of addisonian crisis again.
NOTE: There are no surgical procedures for Addison’s
Disease as of the moment as all treatment for this
disease includes medication.
Pharmacology with Nursing Considerations
• Corticosteroids are a class of steroid hormones that are
produced and secreted by the adrenal glands in response to
pituitary adrenocorticotropic hormone, and regulated by
hypothalamic corticotropin releasing hormone. These hormones
are responsible for regulating major endocrine system functions,
including managing stress and controlling homeostasis. The main
corticosteroids produced by the adrenal cortex are cortisol
(glucocorticoids) and aldosterone (mineralocorticoids).
Aldosterone influences sodium and water balance, while cortisol
exerts its effect by preventing the release of inflammation
mediators.
• Pharmacologic treatment for Addison’s disease involves
corticosteroid (steroid) replacement therapy for life.
Corticosteroid medication is used to replace the hormones
cortisol and aldosterone that your body no longer produces. It's
usually taken in tablet form 2 or 3 times a day. In most cases, a
medication called hydrocortisone is used to replace the cortisol.
Other possible medicines are prednisolone or dexamethasone,
although these are less commonly used.
• Aldosterone is replaced with a medication called
fludrocortisone. These drugs are used for replacement therapy
in Addison’s disease.
• Fludrocortisone (Florinef)
o Synthetic adrenocortical steroid with very potent
mineralocorticoid activity. For use in Addison disease
and states of aldosterone deficiency.
• Hydrocortisone sodium succinate or phosphate (Cortef,
Hydrocortone)
o Drug of choice for steroid replacement in acute
adrenal crisis and for daily maintenance in patients
with Addison disease or secondary adrenocortical
insufficiency. Has both glucocorticoid and
mineralocorticoid properties. Biologic half-life is 8- 12
h. Easiest way to set up infusion is to have the
pharmacy mix 100 mg of hydrocortisone in 100 mL of
0.9 saline.
• Prednisone (Deltasone, Sterapred, Orasone)
o Used for glucocorticoid hormone replacement.
Longer acting than hydrocortisone, with a biologic
half-life of 18-36 h.
Fludrocortisone (Florinef)
Classification
Clinical: Glucocorticoid
Pharmacotherapeutic: Mineralocorticoid
Mechanism of Action
• Enhances sodium reabsorption, hydrogen and
potassium excretion, and water retention by the
distal renal tubules, much like aldosterone, an
endogenous mineralocorticoid.
• In large doses, fludrocortisone can inhibit
endogenous adrenocortical secretion, thymic
activity, and pituitary corticotropin excretion.
• It also can promote glycogen deposits in the liver
and induce a negative nitrogen balance when
protein intake is deficient.
Indications
• Primary and Secondary Chronic Adrenocortical
Insufficiency
• Salt-losing Adrenogenital Syndrome
Contraindications
• Hypersensitivity to fludrocortisone,
adrenocorticoids, or their components; systemic
fungal infections
Adverse Effects
• CNS: Dizziness, headache, mental changes, seizures
• CV: Arrhythmias, heart failure, hypertension,
peripheral edema
18
• EENT: Cataracts (with long-term use), increased
intraocular pressure
• Endocrine: Adrenal insufficiency, growth
suppression in children, hyperglycemia
• GI: Anorexia, nausea, vomiting
• GU: Menstrual irregularities
• HEME: Easy bruising
• MS: Arthralgia, muscle weakness, myalgia,
osteoporosis (with long-term use), tendon
contractures
• SKIN: Acne, diaphoresis, rash, urticaria
• Other: Hypokalemia, hypokalemic alkalosis,
impaired wound healing, weight gain
Nursing Responsibilities
• Monitor blood pressure, fluid status, and serum
electrolyte levels periodically during
fludrocortisone therapy. Watch for signs of heart
failure.
• Monitor for symptoms of overdose, such as
cardiomegaly, edema, excessive weight gain,
hypertension, and hypokalemia. ○ Instruct the
patient to take a missed dose of fludrocortisone as
soon as she remembers if it’s within 12 hours of
scheduled time.
• Warn against double-dosing. Advise her to notify
the prescriber if she misses more than one dose or
if nausea or vomiting prevents her from taking the
drug.
• Instruct patients to reduce dietary sodium and to
eat more potassium-rich foods during therapy.
• Advise the patient to notify prescriber about
stressful events, such as dental extractions,
emotional upset, illness, surgery, and trauma;
dosage increase may be required.
• Caution the patient not to stop taking the drug
abruptly but to taper dosage gradually, as
prescribed.
• Urge the patient to wear or carry medical
identification that documents corticosteroid use.
Hydrocortisone (Hydrocort, Alphosyl, Aquacort,
Cortef, Cortenema, and SoluCortef)
Classification
• Clinical: Glucocorticoid
• Pharmacotherapeutic: Adrenal corticosteroid
Mechanism of Action
• Acute Inhibits accumulation of inflammatory cells
at inflammation sites, phagocytosis, lysosomal
enzyme release, synthesis and/or release of
mediators of inflammation. Reverses increased
capillary permeability.
• Therapeutic Effect: Prevents/suppresses cell-
mediated immune reactions. Decreases/prevents
tissue response to inflammatory processes.
Indications
• Adrenal Insufficiency
• Anti-Inflammation, Immunosuppression
• Physiologic Replacement
• Adjunctive Treatment of Ulcerative Colitis
Contraindications
• Hypersensitivity to hydrocortisone. Fungal,
tuberculosis, viral skin lesions; serious infections,
IM administration in idiopathic thrombocytopenia
purpura.
Adverse Effects
• Long-term therapy: Hypocalcemia, hypokalemia,
muscle wasting, osteoporosis, spontaneous
fractures, amenorrhea, cataracts, glaucoma, peptic
ulcer, heart failure.
• Abrupt withdrawal after long-term therapy:
Nausea, fever, headache, sudden severe joint pain,
rebound inflammation, fatigue, weakness,
lethargy, dizziness, orthostatic hypotension.
Nursing Responsibilities
• Obtain baseline weight, BP, serum glucose,
cholesterol, electrolytes. Screen for infections
including fungal infections, TB, viral skin lesions.
• Assess for edema. Be alert to infection (reduced
immune response): sore throat, fever, vague
symptoms. Monitor daily patterns of bowel activity,
stool consistency.
• Instruct the patient to report fever, sore throat,
muscle aches, sudden weight gain, swelling, visual
disturbances, behavioral changes.
• Instruct patient to inform their dentist, other
physicians of cortisone therapy now or within the
past 12 months.
Prednisolone
Classification
• Clinical: Glucocorticoid
• Pharmacotherapeutic: Anti-inflammatory,
Immunosuppressant.
Mechanism of Action
• Inhibits accumulation of inflammatory cells at
inflammation sites, phagocytosis, lysosomal
enzyme release/synthesis, release of mediators of
inflammation.
• Therapeutic Effect: Prevents/suppresses cell-
mediated immune reactions. Decreases/prevents
tissue response to inflammatory processes.
Indications
• Adrenal Insufficiency
• Acute exacerbations of Multiple Sclerosis
• Treatment of Conjunctivitis, Corneal Injury
Contraindications
• Hypersensitivity to prednisolone. Acute superficial
herpes simplex keratitis, systemic fungal infections,
varicella, live or attenuated virus vaccines.
Adverse Effects
• Long-term therapy: Hypocalcemia, hypokalemia,
muscle wasting (esp. arms, legs), osteoporosis,
spontaneous fractures, amenorrhea, cataracts,
glaucoma, peptic ulcer, HF, immunosuppression.
• Abrupt withdrawal following long-term therapy:
Anorexia, nausea, fever, headache, severe/sudden
joint pain, rebound inflammation, fatigue,
weakness, lethargy, dizziness, orthostatic
hypotension. Sudden discontinuance may be fatal.
Nursing Responsibilities
19
• Question medical history as listed in Precautions. dizziness, orthostatic hypotension. Sudden
Obtain baselines for height, weight, B/P, serum discontinuance may be fatal.
glucose, electrolytes. Check results of initial tests Nursing Responsibilities
(tuberculosis [TB] skin test, X-rays, EKG). • Administer once-daily doses of prednisone in the
• Monitor B/P, weight, serum electrolytes, glucose, morning to match the body's normal cortisol
results of bone mineral density test, height, weight secretion schedule.
in children. Be alert to infection (sore throat, fever, • Because prednisone can produce many adverse
vague symptoms); assess oral cavity daily for signs reactions, assess regularly for signs and symptoms
of Candida infection. of such reactions as heart failure and hypertension.
• Monitor for symptoms of adrenal insufficiency, Also monitor fluid intake and output and daily
immunosuppression. weight.
• Monitor growth pattern in children. Prednisone
• Give once-daily doses in the morning to mirror the may retard bone growth.
body's normal cortisol secretion. • Be aware that prolonged use of prednisone may
• Instruct the patient to take oral prednisolone with cause hypothalamic-pituitary-adrenal suppression.
food to decrease stomach upset and to take a once- • Warning: Withdraw prednisone gradually, as
daily dose in the morning. ordered, if therapy lasts longer than 2 weeks.
• Emphasize the need to take the drug exactly as Stopping abruptly may cause acute adrenal
prescribed; taking too much increases the risk of insufficiency and, possibly, death.
serious adverse reactions. • Instruct patients to take prednisone with food to
• Instruct patients to report fever, sore throat, decrease GI distress and to take once-daily dose in
muscle aches, sudden weight gain, swelling, loss of the morning.
appetite, fatigue.
 • Emphasize the importance of taking the drug
• Patients should not abruptly discontinue without exactly as prescribed; taking more than prescribed
physician’s approval. Patients must avoid exposure increases risk of serious adverse reactions.
to chickenpox, measles.
 Long-term use may • Tell the patient the prescribed delayed-release
significantly increase risk of serious infections tablet form not to break, divide, or chew the tablet
because the delayed-release action is dependent
on an intact coating.
Prednisone (Deltasone, Sterapred, Orasone) • Advise patients to avoid people with contagious
Classification infections because the drug has an
• Clinical: Glucocorticoid immunosuppressant effect.
• Pharmacotherapeutic: Anti-Inflammatory,
Immunosuppressant.
Mechanism of Action Nursing Management
• Binds to intracellular glucocorticoid receptors and
suppresses inflammatory and immune responses Nursing Problem
by:
Possible Nursing Diagnoses:
o Inhibiting neutrophil and monocyte
accumulation at inflammation site and 1. Risk for Deficient Fluid Volume
suppressing their phagocytic and 2. Risk for Ineffective Tissue Perfusion
bactericidal activity
3. Risk for Decreased Cardiac Output
o Stabilizing lysosomal membranes
4. Imbalanced Nutrition: Less Than Body Requirements
o Suppressing antigen response of
5. Disturbed Body Image
macrophages and helper t cells
o Inhibiting synthesis of inflammatory
INTERVENTIONS RATIONALE
response mediators, such as cytokines,
This provides
interleukins, and prostaglandins.
documentation of weight
Indications
loss trends. Weight loss is
• Adrenal Insufficiency Monitor trends in weight.
a common
• Acute exacerbations of Multiple Sclerosis
manifestation of adrenal
• Treatment of Conjunctivitis, Corneal Injury
insufficiency.
Contraindications
Observe for petechiae. Patient bruises easily.
• Hypersensitivity to prednisone or its components,
The patient’s normal
systemic fungal infection
response to stress is not
Adverse Effects
functioning because he or
• Long-term therapy: Muscle wasting (esp. in arms, Minimize stressful
she cannot
legs), osteoporosis, spontaneous fractures, situations and
produce corticosteroids.
amenorrhea, cataracts, glaucoma, peptic ulcer, HF. promote a quiet
Stress can result in a life-
• Abrupt withdrawal following long-term therapy: environment.
threatening situation with
Anorexia, nausea, fever, headache, rebound
Addisonian
inflammation, fatigue, weakness, lethargy,
crisis.

20
 The patient in crisis • ADMINISTRATION OF HORMONES
Assist the patient with should be helped with all o Hormone therapy is a form of systemic therapy—a way
activities, as activities (turning, of administering drugs so they travel throughout the
needed. feeding, cleansing) to body, rather than being delivered directly to the
prevent overexertion. cancer—that works to add, block or remove hormones
Monitor vital signs with from the body to slow or stop the growth of cancer
frequent Sudden development of cells
monitoring of BP. Include profound hypotension
assessment for may indicate Addisonian Nursing Considerations
orthostatic hypotension. crisis.
Anticipate direct Auscultatory BP may be Nursing Implementation with Rationale
intra-arterial monitoring unreliable secondary to
of pressure for a vasoconstriction. • Monitor for thromboembolic disease. (Estrogen increases risk
continuing shock state. for thromboembolism.)
Keep a late-morning snack In case the patient • Monitor for abnormal uterine bleeding. (If an undiagnosed
available. becomes hypoglycemic. tumor is present, these drugs can increase its size and cause
The patient tires because uterine bleeding.)
of inadequate production • Monitor breast health. (Estrogens promote the growth of certain
of hepatic glucagon; the breast cancers.)
recommended diet • Monitor for vision changes. (These drugs may worsen myopia or
prevents fatigue, astigmatism and cause intolerance of contact lenses.)
Ask the dietician to
hypoglycemia, and
provide a high- • Encourage client not to smoke. (Smoking increases risk of
hyponatremia. The
protein, low- cardiovascular disease.)
patient with
carbohydrate, high-
primary Addison’s disease • Encourage client to avoid caffeine. (Estrogens and caffeine may
sodium lead to increased CNS stimulation.)
needs to increase salt
diet. • Monitor glucose levels. (Estrogens may increase blood glucose
intake 5 g if any activity
causes an levels.)
increase in diaphoresis • Monitor for seizure activity. (Estrogen-induced fluid retention
(activities in warm may increase risk of seizures.)
weather). • Monitor client’s understanding and proper self-administration.
Patients with adrenal (Improper administration may increase incidence of adverse
insufficiency are likely to effects.)
Monitor serum glucose experience hypoglycemia.
levels. It may require Evaluation
adjustment of insulin
dosage. • Evaluate the effectiveness of drug therapy by confirming that
Nursing Considerations client goals and expected outcomes have been met (see
“Planning”).
1. Physical Assessment o The client verbalizes relief of unpleasant symptoms of
FOCUS: the presence of symptoms of fluid imbalance and the menopause.
patient’s level of stress. o The client demonstrates an understanding of the
drug’s actions by accurately describing drug side
• VITAL SIGNS. The nurse should monitor the blood pressure and
effects and precautions.
pulse rate as the patient moves from a lying, sitting, and standing
o The client accurately states signs and symptoms to be
position to assess for inadequate fluid volume. A decrease in
reported to the healthcare provider.
systolic pressure (20 mm Hg or more) may indicate depletion of
fluid volume, especially if accompanied by symptoms. CORTICOSTEROIDS
• SKIN. The skin should be assessed for changes in color and
turgor, which could indicate chronic adrenal insufficiency and • A class of drug that lowers inflammation in the body. They also
hypovolemia. reduce immune system activity.
• OTHER SIGNS. The patient is assessed for change in weight, • Corticosteroids are steroid hormones that are either produced
muscle weakness, fatigue, and any illness or stress that may have by the body or are man-made.
precipitated the acute crisis. • Systemic corticosteroids refer to corticosteroids that are given
orally or by injection and distribute throughout the body. It does
2. Pharmacologic Treatment not include corticosteroids used in the eyes, ears, or nose, on the
skin or that are inhaled, although small amounts of these
1. Fludrocortisone (Florinef)
corticosteroids can be absorbed into the body.
2. Hydrocortisone (Hydrocort, AlphosylAquacort, Cortef,
o Naturally occurring corticosteroids, hydrocortisone
Cortenema, and SoluCortef)
(Cortef) and cortisone, are produced by the outer
3. Prednisolone
portion of the adrenal gland known as the cortex
4. Prednisone
21
 (hence the name, corticosteroid). Corticosteroids are • Client Education
classified as either: • Take her medicines exactly as prescribed.
• glucocorticoids (anti-inflammatory) which • Wear a medical alert identification and carry a medical
suppress inflammation and immunity and information card at all times.
assist in the breakdown of fats, • Keep track of patients weight, especially if he/she has not been
carbohydrates, and proteins, or as hungry or has been vomiting.
mineralocorticoids (salt retaining) that • Weigh patient himself or herself, at the same time of the day
regulate the balance of salt and water in the while wearing the same clothing.
body. • Keep track of her blood pressure.
• Synthetic corticosteroids mimic the actions of naturally o High blood pressure and swelling may mean that her
occurring corticosteroids and may be used to replace medicine needs to be adjusted.
corticosteroids in people with adrenal glands that are unable to o If she notices that she becomes light-headed when she
produce adequate amounts of corticosteroids, however, they first gets up in the morning, her blood pressure may be
more often are used in higher-than-replacement doses to treat low.
diseases of immunity, inflammation or salt and water balance. • Avoid strenuous activity in hot, humid weather.
o Examples: • Identify strategies for dealing with stress and avoiding adrenal
o bethamethasone, (Celestone) crisis.
o prednisone (Prednisone Intensol) • Notify primary providers about a disease before treatment or
o prednisolone (Orapred, Prelone) procedure.
• Keep extra medication handy.
Nursing consideration: • Prepare and carry a glucocorticoid injection kit.
• Common side effects: cause sodium (salt) and fluid to be • Stay in contact with their physician.
retained in the body and cause weight gain or swelling of the legs • Have annual checkups.
(edema), High blood pressure, Loss of potassium, headache, Complications
muscle weakness.
• The prolonged use of corticosteroids can cause obesity, growth Addisonian Crisis (Acute Adrenal Crisis)
retardation in children, and even lead to convulsions and
psychiatric disturbances. Reported psychiatric disturbances • If an individual has untreated Addison's disease, they may
include depression, euphoria, insomnia, mood swings, and develop an Addisonian crisis as a result of physical stress, such
personality changes. Psychotic behaviors also have been as an injury, infection or illness. An Addisonian crisis is a serious
reported. medical condition caused by the body’s inability to produce a
• Can increase in the rate of infections and reduce the sufficient amount of cortisol. Normally, the adrenal glands
effectiveness of vaccines and antibiotics. produce two to three times the usual amount of cortisol in
• The long term use of corticosteroids may cause osteoporosis response to physical stress. With adrenal insufficiency, the
which can result in bone fractures. inability to increase cortisol production with stress can lead to an
• Another condition which can result from the long term use of Addisonian crisis.
corticosteroids is adrenal necrosis of the hip joints, a very painful Signs and Symptoms of Addisonian Crisis
and serious condition that may require surgery.
• Corticosteroids should not be stopped suddenly after prolonged • Headache • Rapid heart rate
use as this can result in adrenal crisis because of the body's • Profound weakness • Joint, abdominal,
inability to secrete enough cortisol to make up for the • Fatigue flank pain
withdrawal. • Slow, sluggish • Unintentional weight
movement loss
3. Nutrition and Diet Therapy • Nausea • Rapid respiratory
• Low blood pressure rate
• Increase fluid intake and salt with excessive perspiration. • Dehydration • Unusual and
• Do not use salt substitutes. • High fever excessive sweating
• Ensure high-carbohydrate, high-protein diet with adequate • Shaking chills on face and/or palms
sodium intake. • Confusion or coma • Skin rash or lesions
• Encouraged patient to eat foods rich in calcium and Vitamin D • Darkening of the skin may be present
such as broccoli, soybeans, salmon, shrimp, yogurt, almond milk, • Loss of appetite
tofu, tuna, chicken breast, and eggs.
• Instructed patient to avoid caffeine or alcohol as this can
Laboratory and Diagnostic Test
interfere with the patient’s sleep cycle which can contribute to
anxiety and depression. • An Adrenocorticotropic Hormone (Cortrosyn) stimulation test
• Instructed patient to avoid packaged and processed foods as shows low cortisol.
much as possible because these are filled with artificial o The baseline cortisol level is low.
ingredients, preservatives, sugar and sodium. o Fasting blood sugar may be low.

22
 o Serum potassium is elevated (usually primary adrenal patients. Most cases
insufficiency). of primary
o Serum sodium is decreased (usually primary adrenal hyperaldosteronism
insufficiency). result from a benign
tumor of the adrenal
Treatment gland, and occur in
people between the
• In an adrenal crisis, an intravenous or intramuscular injection of ages of 30 and 50
hydrocortisone (an injectable corticosteroid) must be given years old.
immediately. Supportive treatment of low blood pressure with • The excess
intravenous fluids is usually necessary. Hospitalization is aldosterone secreted
required for adequate treatment and monitoring. If infection is in this condition
the cause of the crisis, antibiotic therapy may be needed. increases sodium
reabsorption and
Expectations (prognosis): potassium loss by the
kidneys. The result is
• Death may occur due to overwhelming shock if early treatment an electrolyte
is not provided. imbalance.
Risk factors
Complications:
Primary
• Shock Hyperaldosteronism
• Coma
• Seizures
and nephrotic
(kidney) syndrome. In
these disorders,
various mechanisms
from the individual
disease cause the
level of the hormone
to be elevated.
• Both primary and
secondary
hyperaldosteronism
can present with a
broad clinical range.
•
Secondary
Hyperaldosteronism

Hyperaldosteronism & Pheochromocytoma

Hyperaldosteronism “Conn’s Syndrome”

Definition

• One of the functions of the adrenal glands is to produce a

hormone called aldosterone that plays an active role in the blood
pressure. It does this by maintaining the balance of sodium,
potassium, and water in the blood. Excess production of
aldosterone is referred to as hyperaldosteronism.
• Hyperaldosteronism is an endocrine disorder that involves one
or both of the adrenal glands creating too much of a hormone
called aldosterone. This causes the body to lose too much
potassium and retain too much sodium, which increases water
retention, blood volume, and blood pressure.
• Hyperaldosteronism can initially present as mild or severe to
refractory hypertension but can often go undiagnosed.
Hyperaldosteronism can be of primary or secondary origin,
presenting similarly but differentiated by a set of lab values and
diagnostic studies. It is also called Conn’s Syndrome, and its
treatment is specific to the individual causes of
hyperaldosteronism

Types

Primary Secondary
Hyperaldosteronism Hyperaldosteronism
• Primary • Secondary
hyperaldosteronism hyperaldosteronism
used to be is generally related to
considered a rare hypertension (high
condition, but some blood pressure). It is
experts believe that it also related to
may be the cause of disorders such as
high blood pressure cardiac failure,
in 0.5% to 14% of cirrhosis of the liver,

23
 • Primary • Renin-producing Others might ✓ heart failure
hyperaldosteronism tumor have it due to: ✓ diuretic medications
is familial in up to • Renal artery stenosis ✓ a benign tumor
10% of patients. 1-2% • Edematous disorders on one of the
of cases have like left ventricular adrenal glands
glucocorticoid- heart failure ✓ adrenocortical
remediable • Pregnancy cancer, which is a
aldosteronism (GRA), • Cor pulmonale rare
which is treated by • Cirrhosis with ascites ✓ aldosterone-
medication. Genetic producing
testing should be cancerous tumor
done in patients with ✓ glucocorticoid-
confirmed onset of remediable
primary aldosteronism, a
hyperaldosteronism type of
< 20 years of age and aldosteronism
in patients with a that runs in
family history of families
stroke or primary ✓ other types of
aldosteronism < 40 inheritable issues
years of age. that affect the
• Additionally, the adrenal glands
following may be risk
factors to primary
hyperaldosteronism: Clinical Manifestations
• Moderate to severe
high blood pressure, • Patients often can present asymptomatically, but this varies with
especially if you need the severity of hyperaldosteronism. Symptoms are usually due
many medications to to moderate to severe high blood pressure or secondary to
control the blood hypokalemia. Patients with secondary hyperaldosteronism can
pressure present with different blood pressure measurements
• High blood pressure • High blood pressure can cause:
and a family history o Headaches
of primary o Dizziness
aldosteronism o Vision problems
• High blood pressure o Chest pain
and a family history
o Dyspnea.
of high blood
• Sometimes, hypokalemia may occur, If it does, it can cause:
pressure or stroke at
age 40 or younger o Headache
• High blood pressure o Excessive thirst
and a growth on one o A frequent need to urinate
of the adrenal glands o Neuromuscular symptoms such as fatigue, muscle
(found in an imaging weakness, muscle cramps, paresthesias, and cardiac
test done for another arrhythmias.
reason)
• High blood pressure Anatomy
and a low potassium
level
• High blood pressure
and obstructive sleep
apnea

Causes

Primary Secondary Hyperaldosteronism

Hyperaldosteronism
• Some people are • Several things can cause this,
born with including:
overactive ✓ a blockage or narrowing of the
adrenal glands. renal artery
✓ chronic liver disease
24
 • On an unenhanced (no contrast) CT, adenomas are usually well-
demarcated round or oval lesions, with homogeneous and
relatively low attenuation values. The addition of contrast helps
visualize vessels better, and thus, having a CT scan with and
without contrast is the best. If you are allergic to i.v. contrast,
you can have a non-contrast CT scan, which is not as good, but
better than no scan.

• The scan will tell which adrenal gland has the tumor in it (the
right or the left) and where in the adrenal gland it is located. It
will also show the size of the aldosterone-producing tumor and
where it is in relationship to the kidney, stomach, spleen, liver,
pancreas, intestines, and the major blood vessels such as the
vena cava and renal veins

• Normal findings: adrenal adenomas are usually well-demarcated

• There are two adrenal glands, which are located on top of each
of the kidneys. Each adrenal gland contains an outer adrenal
cortex. It’s responsible for producing certain steroid hormones,
including aldosterone and cortisol. Each gland also contains an
inner adrenal medulla, which produces several other hormones,
including adrenaline and noradrenaline.
• Aldosterone affects the body's ability to regulate blood pressure.
It sends the signal to organs, like the kidney and colon, that can
increase the amount of sodium the body sends into the
bloodstream or the amount of potassium released in the urine.
The hormone also causes the bloodstream to reabsorb water
with the sodium to increase blood volume. All of these actions
are integral to increasing and lowering blood vessels. Indirectly,
the hormone also helps maintain the blood's pH and electrolyte
levels.
Pathophysiology
round or oval lesions, with homogenous and relatively low
attenuation values.
• Significant findings: CT scan findings may be normal, or scans
may show nodular or multinodular glands. CT appears more
reliable at revealing tumors larger than 1 cm.
2. Invasive Procedures
Angiography (Adrenal Venous Blood Sampling)
• Is a kind of angiography wherein a radiologist draws blood
from both left and right adrenal veins and compares the
two samples. If only one side has elevated aldosterone,
there is a suspected growth on that adrenal gland.
o This test involves placing a tube in a vein in the
patient’s groin and threading it up to the adrenal
veins. Though essential for determining the
appropriate treatment, this test carries the risk of
bleeding or a blood clot in the vein.

o Adrenal venous sampling to assay aldosterone

serum via selective catheterization of both
adrenal veins, may still only be helpful in ~50% of
cases.

Normal and Abnormal Findings

Catecholamine Right adrenal Reference range

vein (range) in peripheral
Diagnostic Procedures blood
Epinephrine 3315 (389– 0–110
1. Non-invasive Procedures
(pg/ml) 118326)
CT Scan Norepinephrine 757 (156–11193) 70–750
(pg/ml)
• In patients with primary hyperaldosteronism, CT scan findings Dopamine (pg/ml) 19 (11–84) <30
may be normal, or scans may show nodular or multinodular Norepinephrine 0.3 (0.09–1.2) NA
glands. CT appears more reliable at revealing tumors larger than to epinephrine
1 cm. After a diagnosis of hyperaldosteronism has been ratiob
established clinically and biochemically, dedicated CT scanning
of the adrenal glands is performed using thin (3-mm) collimation.
Nonenhanced and enhanced CT scans are obtained. The mean 3. Laboratory Tests
attenuation level in adrenal adenomas is -2.2 HU. Blood Tests

25
• Captopril challenge test. This blood test measures the
aldosterone, renin, and other levels after you receive a dose of
the medication captopril, an ACE inhibitor.
o Normal findings: Plasma aldosterone concentration
(PAC) <15 ng/dl (416pmol.L) and PAC to plasma renin
activity (PRA) ratio less than 50
o Abnormal findings: PAC of >10 ng/dl
• Saline infusion test. This blood test measures the aldosterone,
renin, and other levels after you receive an IV sodium and saline
solution.
o Normal findings: PAC < 5 ng/dl
o Abnormal findings: PAC >10 ng/dl
• Salt-loading test. This measures the levels of aldosterone and
sodium in the urine after following a high-sodium diet for three
to five days.
o Normal findings: >39 nmol/24 hours
o Abnormal findings: >277 pmol/l
• The surgeon may remove only the tumor, one gland or both.
• Fludrocortisone suppression test. This is very similar to the salt-
loading test, but it includes taking fludrocortisone, an oral
steroid that mimics aldosterone.
o Normal findings: Upright plasma aldosterone less than
6 ng/d
o Abnormal findings: Upright plasma aldosterone higher
than 6 ng/dL
Nursing Care
• Adrenal vein sample. This involves taking a blood sample
directly from the veins of each adrenal gland and testing the
amount of aldosterone in it. If blood from one gland has
significantly more aldosterone, you may have a benign tumor on
one gland. If blood from each gland has similarly high levels of
aldosterone, both glands are likely overactive.
Medical – Surgical Management
1. Surgical Procedures
• Adrenalectomy is a surgery to remove one or both adrenal
glands.
o Problems with the adrenal glands are pretty rare.
Sometimes, though, an adrenal tumor that may or
may not produce excessive hormones can develop.
o For tumors that produce excessive hormones, a
surgeon must remove the gland and tumor so that
hormone levels can get back within normal ranges.
o For some of the tumors that are not producing
hormones, but are suspicious for cancer, likewise, the
tumor needs to be surgically removed.
Types of adrenalectomy:
o Open Surgery: Your surgeon may use open surgery if
the tumor is large or might be cancerous. The
surgeon makes an open large incision (cut) in the
abdomen to remove the gland(s).
o Laparoscopic adrenalectomy: More commonly, the
surgeon makes a few small incisions and performs a
minimally invasive procedure. This method uses a
laparoscope, a thin tube equipped with a tiny video
camera so the surgeon can see inside the body.
Robotic surgery uses the same incisions, but uses
wristed, rather than rigid instruments. Whether
laparoscopic or robotic, the procedure can either be
done by placing the incisions on the back (posterior
approach) or on the side (lateral approach). Both
procedures are equally successful, with the back
approach providing advantages of not entering the
abdomen. Back approach is also preferred in patients
with a history of prior upper abdominal incisions and
2-sided tumors. Due to the small working
space with the back approach, only tumors
smaller than 6 cm are approached through the back.
Surgery that removes one gland is a unilateral adrenalectomy.
A bilateral adrenalectomy removes both glands. People with a
diagnosis of cortisol excess (Cushing’s syndrome may take a
hydrocortisone supplement for about a year after surgery, until
the remaining gland starts making enough hormone on its own.
For other patients, testing is done after the surgery to decide if
the patients need to be on steroid replacement.
Preoperative Care
• Client Preparation
o A complete history and physical
examination is mandatory in the
evaluation of a patient with an adrenal
mass.
o A complete endocrinologic evaluation
should include measurement of serum
electrolytes, serum hormone levels, and
urine levels of steroid hormones and their
metabolites.
o Monitor the results of laboratory tests of
electrolytes and glucose levels.
Electrolyte and glucose imbalances are
corrected before the client has surgery.
o Perform an initial preoperative
assessment as per the institutional policy.
Consent for the procedure must be
signed and witnessed.
o The surgical site must be verified with the
patient and clearly marked with a surgical
marker by the attending surgeon before
the patient is transported to the OR.
o Educate the patient as to what to expect
during the intraoperative and
postoperative phases. Teach the client to
26
 turn, cough, and perform deep-breathing
exercises.
o Before the patient is brought to the OR,
adequate positioning supplies need to be
available and prepared including pillows,
axillary roll, arm support device, padding
materials, gel pad, and surgical tape.
o Use careful medical and surgical asepsis
when providing care and treatments.
Cortisol excess increases the risk of
infection.
o Antithrombotic stockings and knee- or
thigh-high sequential compression
devices are placed on the lower
extremities, to prevent venous stasis and
reduce the risk of deep vein thrombosis
and pulmonary embolism.
o Prophylactic I.V. antibiotics should be
administered within 60 minutes of the
initial skin incision.
o After the induction of general anesthesia,
the patient is endotracheally intubated
and an orogastric tube is placed to
decompress the stomach.
Intraoperative Care
• For the perioperative nurse, proper positioning is
one of the key responsibilities to protect the safety
and skin integrity of the patient under anesthesia.
• After positioning, the patient should be assessed
for proper spinal alignment, tissue perfusion, and
skin integrity.
• After the patient is draped and just before the
surgical incision is made, any member of the
surgical team may initiate the time-out.
• An experienced circulating nurse and scrub person
can often anticipate the surgeon's needs as they
closely follow the steps of the procedure.
• The scrub nurse will stand on the opposite side of
the primary surgeon to allow easy communication
and facilitate instrument exchanges.
• The circulating nurse monitors the level of the CO2
tank and has reserve tanks available.
• The circulating nurse must be prepared with
additional trocars or a hand-access device if
requested by the surgeon.
Postoperative Care
• The patient is usually extubated in the OR before
transport to the post-anesthesia care unit (PACU).
• The PACU RN must also monitor the patient
closely for signs of acute hemorrhage.
• Assesses the patient's level of pain and medicates
the patient for pain as ordered.
• Take and record vital signs, measure intake and
output, and monitor electrolytes on a frequent
schedule, especially during the first 48 hours after
surgery.
• Assess body temperature, WBC levels, and wound
drainage. Change dressings using sterile
technique.
2. Special Procedures (not applicable)
3. Nutrition & Diet Therapy
• In adults, a daily sodium intake of 10 g or more is recommended;
this amount can be reduced proportionately for children,
depending on their size.
• Regular monitoring of potassium is important when sodium
intake is increased in patients with suspected
hyperaldosteronism because this measure may unmask
hypokalemia.
• Medical management of patients with established
hyperaldosteronism should include salt restriction. This should
include not adding salt to cooking and not having salt on the
table.
• Ideally, patients should receive less than 2 g of sodium chloride
per day.
• Problems with compliance may occur because this degree of
restriction is often unpalatable to children.
• Start by choosing fresh, unprocessed foods to reduce the salt
intake.
• Try incorporating elements of the DASH diet, which is designed
for people with high blood pressure.
o The DASH diet doesn’t list specific foods to eat.
Instead, it recommends specific servings of different
food groups. The number of servings you can eat
depends on how many calories you consume.
o Or more simply stated, the DASH diet plan includes
eating more:
▪ Fruits and vegetables, low-fat or nonfat dairy
▪ Beans, and nuts
o And eating less:
▪ Fatty meats
▪ Full-fat dairy products
▪ Sugar-sweetened beverages
▪ Sweets, and sodium (salt)
o Sample Menu for a DASH diet:
(a) Monday
▪ Breakfast: 1 cup (90 grams) of oatmeal with
1 cup (240 ml) of skim milk, 1/2 cup (75
grams) of blueberries and 1/2 cup (120 ml)
of fresh orange juice.
▪ Snack: 1 medium apple and 1 cup (285
grams) of low-fat yogurt.
▪ Lunch: Tuna and mayonnaise sandwich
made with 2 slices of whole-grain bread, 1
tablespoon (15 grams) of mayonnaise, 1.5
cups (113 grams) of green salad and 3
ounces (80 grams) of canned tuna.
▪ Snack: 1 medium banana.
▪ Dinner: 3 ounces (85 grams) of lean chicken
breast cooked in 1 teaspoon (5 ml) of
vegetable oil with 1/2 cup (75 grams) each of
broccoli and carrots. Served with 1 cup (190
grams) of brown rice.
o In addition, many blood pressure medications work
better when combined with a healthy diet.
Pharmacology with Nursing Considerations
Spironolactone (Aldactone)
Classification: Mineralocorticoid receptor antagonist;
Potassium-sparing diuretic
27
Action: Indirectly inhibits Na+ reabsorption. The main Adverse Effects:
site of action is at the intercalated cells in the cortical • Headache
collecting duct. These cells have aldosterone receptors • Dizziness
where aldosterone binds and makes sodium-potassium • Diarrhea
pumps which go to the cell membrane and reabsorb • Stomach pain
sodium and excrete potassium. When spironolactone • Cough
binds with these receptors it antagonizes the • Excessive tiredness
aldosterone effects and thus inhibits Na+/ K+ pump. This • Flu-like symptoms
action causes natriuresis with loss of water and prevents • Breast enlargement or tenderness
excretion of potassium. • Abnormal vaginal bleeding
Indications: Nursing Considerations
• Hyperaldosteronism (Primary or secondary) • Arrange for pretreatment and periodic evaluation
• Heart failure of serum potassium and renal function
• Essential hypertension • Establish baseline patient weight to monitor drug
• Hypokalemia effect
• Edema (caused by liver or kidney disease • Avoid giving patient any food rich in potassium
• Monitor cardiovascular status with frequent BP
Contraindications:
determinations. Note that
• Liver disease
• BP lowering usually occurs within 2 wk with
• Chronic renal insufficiency
maximal antihypertensive effects achieved within 4
• Agents that use renin-angiotensin system (beta
wk.
blockers or ACE inhibitors)
• Monitor serum potassium levels more frequently
Adverse Effects:
when patients also receive an ACE inhibitor or an
• Male breast enlargement (gynecomastia)
angiotensin II receptor antagonist.
• Menstrual irregularities in women
• Establish appropriate safety precautions if patient
• Hyperkalemia
experiences adverse CNS effects
• Hyperchloremic metabolic acidosis
• Advise patient to Report weight change of more
• Kidney stones
than pounds in 1 day, severe dizziness, trembling,
Nursing Considerations:
numbness, muscle weakness or cramps,
• Dose should be given in early timings because of
palpitations
increased urination.
• Obtain complete health history (Electrolyte balance
& renal function). Amiloride (Midamor)
• Obtain vital signs with the baseline values
Classification: Potassium-sparing diuretic;
especially blood pressure.
Antihypertensive
• Assess medication history including alcohol and
Action: Exerts its potassium-sparing effect through the
nicotine consumption to avoid drug interaction.
inhibition of sodium reabsorption at the distal
• Determine possible drug allergies of patient.
convoluted tubule, cortical collecting tubule and
• Obtain blood and urine specimens for laboratory
collecting duct; this decreases the net negative potential
analysis.
of the tubular lumen and reduces both potassium and
• Observe for any change in consciousness, dizziness,
hydrogen secretion and their subsequent excretion.
fatigue, postural hypotension.
Indications:
• Monitor for fluid intake by measuring intake,
• Management of primary hyperaldosteronism
output and daily weight.
• Adjunctive treatment with thiazide diuretics or
• Monitor laboratory values especially potassium
other kaliuretic-diuretic agents in congestive heart
and sodium levels, BUN, Serum uric acid.
failure or hypertension
Contraindications:
• Hypersensitivity to amiloride
Eplerenone (Inspra)
• Hyperkalemia (K+ >5.5 mEq/L [5.5 mmol/L])
Classification: Antimineralocorticoid; Antihypertensive,
• Patients receiving other potassium-conserving
Aldosterone receptor blocker; Potassium-sparing
agents, such as spironolactone or triamterene.
diuretic
• Impaired renal function (Scr >1.5 mg/dL [132.6
Action: Binds to aldosterone receptors, blocking the
umol/L], or BUN >30 mg/dL [10.7 mmol/L])
binding of aldosterone, leading to increased loss of
diabetes/diabetic nephropathy
sodium and water and lowering of BP
Adverse Effects:
Indications:
• Hyperkalemia
• Treatment of hypertension
• Diarrhea
• Treatment of hyperaldosteronism
• Headache
Contraindications: • Nausea & vomiting
• Hypersensitivity to eplerenone • Abdominal pain
• Liver or kidney disease • Muscle cramps
• Type 2 diabetes • Encephalopathy
• Patients with hyperkalemia
28
 Nursing Considerations:
• Black Box Warning: Monitor serum potassium
levels carefully (Like other potassium-conserving
agents, amiloride may cause hyperkalemia (serum
potassium levels greater than 5.5 mEq/L), which, if
not corrected, is potentially fatal.)
• Monitor for signs and symptoms of hyperkalemia
and hyponatremia.
• Administer with food or milk to prevent GI upset
• Administer early in the day so increased urination
does not disturb sleep
• Monitor and record weight regularly to monitor
mobilization of edema fluid
• Avoid foods and salt substitutes high in potassium
• Provide frequent mouth care and sugarless
lozenges to suck
• Arrange for regular evaluation of serum
electrolytes
Nursing Management
Nursing Problems/Diagnosis
• Risk for Decreased Cardiac Output
o Scientific Basis: Secondary hyperaldosteronism in the
absence of hypertension occurs as a result of
homeostatic attempts to maintain the sodium
concentration or circulatory volume or to reduce the
potassium concentration. Clinical conditions in which
it may arise include diarrhea, excessive sweating, low
cardiac output states, and hypoalbuminemia due to
liver or renal disease or nephrotic syndrome.
• Altered Fluid and Electrolyte Imbalance
o Scientific Basis: Hyperaldosteronism is an endocrine
disorder that involves one or both of your adrenal
glands creating too much of a hormone called
aldosterone. This causes your body to lose too much
potassium and retain too much sodium, which
increases water retention, blood volume, and blood
pressure.
• Acute Pain
o Scientific Basis: Hyperaldosteronism is a disease in
which the adrenal gland(s) make too much
aldosterone which leads to hypertension and low
blood potassium levels. High blood pressure can
seriously affect the circulation causing pain in the legs
with walking, cold feet, and stroke.
• Fatigue
o Scientific Basis: One function of aldosterone is to
balance the sodium and potassium levels in the blood.
However, too much aldosterone may retain sodium
and lose potassium. The hypokalemia (low potassium
level) may cause fatigue, numbness, muscle cramps,
muscle weakness, and etc.
• Ineffective Breathing Pattern
o Scientific Basis: With hypertension, the right side of
the heart has difficulty pushing blood flow through the
lungs – and it’s not getting to the left side of the heart
and body. It puts strain on the right side of the heart,
which is not used to pushing against the high pressure.
Nursing Considerations
• Monitor the vital signs, especially the blood pressure every 4
hours. Observe for signs of decreasing peripheral tissue
perfusion (slow CRT, pallor, cyanosis, and cool, clammy skin).
• Monitor potassium and sodium levels. Watch out for
hyperkalemia.
• If renal function is impaired and an increase of potassium
amount in the body, look out for hyperkalemia.
• Answer questions the patient may have to help alleviate anxiety
about their condition.
• Monitor patient for signs & symptoms of adverse effects from
the medication.
• Monitor patient for signs & symptoms of infection after surgery.
• Ensure that the patient’s diet is low in sodium (since they have
too much sodium already) and high in potassium.
Client Education
• Educated with the common symptoms of primary
hyperaldosteronism and be aware of the common family history
findings to report to their physicians.
• Patients should understand the importance of compliance with
medical therapy as this is the only treatment besides surgical
intervention.
• A thorough explanation of the treatment options should be
given to the patient to allow them to be a part of the medical
team.
• Explain the appropriate diet for the patient and why it should be
done.
• Inform the client to exercise as consistent exercise, even just a
30-minute walk a few times a week, can help to reduce blood
pressure.
• Educate the client to reduce alcohol and caffeine as both can
increase blood pressure and some blood pressure medications
are less effective when taken with alcohol.
• Inform the client to quit smoking as smoking constricts blood
vessels which increases the heart rate and raises blood pressure.
Pheochromocytoma
Definition
• Disorders of the adrenal gland can involve the secretion of too
little or too much hormone, when too little hormone is secreted,
it may be because of a problem with the adrenal gland itself or it
may be due to a problem elsewhere in the body, such as the
pituitary gland or the hypothalamus. For example, a problem
with the pituitary gland could mean that the adrenal glands are
not being stimulated to secrete hormones. When too much
hormone is secreted (oversecretion), the disorder that results
depends on the hormone (Grossman, 2020).
• Pheochromocytoma is one example of an adrenal gland
disorder. It is a rare, catecholamine-secreting tumor derived
from chromaffin cells that is usually benign and originates from
the chromaffin cells of the adrenal medulla. The term
pheochromocytoma (in Greek, phios means dusky, chroma
29
 means color, and cytoma means tumor) refers to the color the (sporadically). Generally, the possible causes of developing a
tumor cells acquire when stained with chromium salts (Blake, pheochromocytoma are the following:
2020). This tumor is the cause of high blood pressure in 0.1% of
patients with hypertension, and is usually fatal if undetected and • Heredofamilial diseases/Genetic mutations. Approximately 25-
untreated. Although uncommon, it is one form of hypertension 35 percent of cases of pheochromocytomas may be familial,
that is usually cured by surgery. In 90% of patients (Porth, 2015), resulting from genetic disruptions or changes (mutations) to
the tumor arises in the medulla; in the remaining patients, it certain genes. These mutations are inherited as autosomal
occurs in the extra-adrenal chromaffin tissue located in or near dominant traits, the risk of passing the abnormal gene from
the aorta, ovaries, spleen or other organs. Ten percent of the affected parent to offspring is 50% for each pregnancy (NORD,
tumors are bilateral, and 10% are malignant. 2011).
• Hormones. Primarily adrenaline (epinephrine) and
Risk Factors noradrenaline (norepinephrine), that help control many body
functions, such as heart rate, blood pressure and blood sugar.
• What causes pheochromocytoma is still unknown, and no • Related tumors. While most of the chromaffin cells are located
avoidable risk factors have been found. According to the in the adrenal glands, small clusters of these cells are also in the
American Society of Clinical Oncology (ASCO), the following heart, head, neck, bladder, back wall of the abdomen and along
factors may raise a person's risk for these types of tumors: the spine. Chromaffin cell tumors, called paragangliomas, may
Inherited syndromes and gene changes. Between 25% and 35% result in the same effects on the body.
of pheochromocytomas and paragangliomas are linked to
hereditary syndromes. Changes to certain genes have also been Classifications
associated with the tumors when they are not connected to
known hereditary syndromes. Syndromes and gene changes that • According to the 2017 World Health Organization (WHO)
raise the risk of developing a pheochromocytoma or classification of endocrine tumors, pheochromocytomas (PCCs)
paraganglioma include: are tumors of the chromaffin cells that arise within the adrenal
o Multiple Endocrine Neoplasia type 2 (MEN2). medulla:
Approximately 50% of people with MEN2 develop a o Paragangliomas (PGLs) are neural crest-derived
pheochromocytoma. neuroendocrine tumors (NETs) that can originate at
o Von Hippel-Lindau syndrome (VHL). Approximately any level of extra-adrenal paraganglia (from the skull
10%-20% of people with VHL will develop a base to the pelvic floor).
pheochromocytoma. They often occur in both adrenal o PCCs and PGLs arising from sympathetic paraganglia
glands. are characterized by catecholamine production.
o Neurofibromatosis type 1 (NF1). Approximately 5% of o PGLs distributed along the parasympathetic chains of
people with NF1 are diagnosed with a the head and neck (NHPGL) tend to be silent or
pheochromocytoma or paraganglioma. pseudo-silent tumors.
o Succinate dehydrogenase (SDHx) syndromes.
Germline, or inherited, mutations in the SDH family of Clinical Manifestations
genes have also been associated with an increased risk
of pheochromocytoma and paraganglioma. The Signs and symptoms of pheochromocytomas often
Carney-Stratakis dyad, for example, is linked with include:
paragangliomas, gastrointestinal stromal tumor, renal • High blood pressure • Less common signs or
• Headache symptoms may
cell (kidney) carcinoma, and pituitary adenoma.
• Heavy sweating include:
o Other mutations. There are many other, less common
• Rapid heartbeat o Anxiety or
genetic mutations that may increase the risk of • Tremors sense of
pheochromocytoma or paraganglioma. • Paleness in the face doom
• Age. A pheochromocytoma can occur at any age, but the tumor • Shortness of breath o Constipation
is most common in people between ages 30 and 50. • Panic attack-type • Weight loss
• Gender. Men and women have an equal chance of developing a symptoms
pheochromocytoma. Complications
• Race/ethnicity. People of all races can be diagnosed with a
pheochromocytoma, but the tumor is less common in African • High blood pressure can damage multiple organs, particularly
Americans. tissues of the cardiovascular system, brain and kidneys. This
• Carney triad. This rare, non-hereditary condition can cause damage can cause a number of critical conditions, including:
paragangliomas, GISTs, and tumors in the cartilage of the lungs o Cardiomyopathy
to form. It almost exclusively affects women. o Myocarditis
o Intracerebral hemorrhage (ICH)
Causes o Pulmonary edema
o Stroke
• In most cases, the exact cause of pheochromocytoma is o Heart attack
unknown. Most cases occur randomly, for unknown reasons o Kidney failure

30
 o Optic neuritis
Pathophysiology
Health History and Physical Assessment
History
• Presence of RUQ pain following large meals , pain is described as
crampy and colicky and moderate in severity
• There are also complains of diarrhea
• Past Medical History: Diabetes Mellitus Type II, Hyperlipidemia,
Hypertension, Atrial fibrillation and diabetic neuropathy
• Family History of pheochromocytoma
• Tumors in other glands of the body
• Other hormonal disorders
• Genetic diseases including – Von Hippel-Lindau disease ,
Multiple endocrine neoplasia type 2 , Neurofibromatosis type 1
and Paraganglioma syndromes.
Physical Examination
• Five Hs: hypertension, headache, hyperhidrosis (excessive
sweating), hypermetabolism, and hyperglycemia.
• Elevated blood glucose and glucosuria
• Hypertension (Elevated BP)
• Headache
• Increased metabolic rate , diaphoresis, agitation, rapid
pulsations, palpitations and emotional outbursts
• Emotional instability
• Nausea and vomiting
• Acute attacks (profuse diaphoresis, dilated pupils , cold
extremities, severe hypertension which can precipitate stroke or
sudden blindness)
Diagnostic Procedures
1. Non-invasive Procedures
Computed Tomography (CT) Scan
• To evaluate pheochromocytoma tumors and masses within the
adrenal gland. It is very accurate at examining the adrenal glands
and other abdominal structures and can be used on any type of
adrenal tumor. CT scans can reveal adrenal pheochromocytomas
larger than 5–10 mm with sensitivity >95%.
Adrenal pheochromocytoma on the right side (white arrows): (a)
contrast-enhanced CT scans (arterial phase) in the axial plane, (b)
contrast- enhanced CT scan in the coronal plane.
• Significant Findings:
o The shape of a pheochromocytoma is usually spherical
and the edges are relatively smooth.
o The diverse morphological appearance of
pheochromocytomas may well mimic other adrenal
masses on CT and MRI scans. Differential diagnosis
should aim to distinguish a pheochromocytoma from
an adenoma, metastasis, or adrenal carcinoma.
• Nursing Interventions: (CT scan with IV contrast agent)
o Assess for any allergies to contrast agents, iodine, and
shellfish.
o Assess for pregnancy (if female)
o Instruct the patient to not to eat or drink for a period
amount of time especially if a contrast material will be
used.
o Encourage the patient to increase oral fluid intake if a
contrast is given.
Magnetic Resonance Imaging (MRI)
• Uses magnetic fields and radio waves to produce images of the
area being studied. MRI is not a first-choice imaging tool because
of its lower spatial resolution, lower logistical availability, higher
price, and stricter safety regulations. But it benefits from being
free of ionizing radiation and therefore suitable e.g., in cases of
31
 pregnant women or children or in patients with adverse 3. Laboratory Tests: Metanephrine and Catecholamine Testing:
reactions to an iodinated contrast medium.
High Pressure Liquid Chromatography (HPLC) with Electrochemical
Detection

• Test for detecting pheochromocytoma measures free

metanephrine (MN) in plasma
• Applying HPLC coupled to electrochemical detection with direct
current using a glassy carbon working electrode makes it
possible to detect even lowest amounts of catecholamines in
urine or plasma samples (Boettcher & Monks, 2020).
• Nursing Interventions:
o Assess for patients with metal implants (e.g. aneurysm Fractionated Plasma Free Metanephrine Level
clips, intraocular metallic fragment, pacemaker) and
all jewelry. • Standard venipuncture sample
o Assess for claustrophobia. • Drawn about 15-20 minutes after intravenous catheter insertion
(done in order to prevent elevation of catecholamine levels
M-iodobenzylguanidine (MIBG) scintigraphy resulting from the stress of the venipuncture insertion; uses
butterfly needle, scalp vein needle, or venous catheter)
• A scanning technology that can detect tiny amounts of an
• Supine position (NANETS guidelines states that seated patients
injected radioactive compound taken up by
may give higher false-positive rate)
pheochromocytomas or paragangliomas.
NORMAL PLASMA VALUES DIAGNOSTIC FOR
VALUES PHEOCHROMOCYTOMA
Epinephrine:
Epinephrine:
>400 pg/mL (2,180
100 pg/mL (590 pmol/L)
pmol/L)
Norepinephrine:
Norepinephrine:
<100 – 550 pg/mL (590 –
>2,000 pg/mL (11,800
3,240 pmol/L)
pmol/L)
*values that fall between normal levels and those
• Significant Findings: diagnostic of pheochromocytoma indicate the need for
o Pheochromocytomas appear on scintigrams as focal further testing*
increased concentrations of radioactivity in the • Factors that elevate catecholamine concentrations:
adrenal medulla but also in ectopic adrenergic tissue o Coffee
or metastases. Paragangliomas can easily be missed on o Tea
CT and MRI scans. o Tobacco
o Emotional and physical stress
Positron Emission Tomography (PET) o Use of many prescription and over-the-counter
medications (e.g. amphetamines, nose drops or
• A scanning technology that also can detect radioactive sprays, decongestant agents, bronchodilators)
compounds taken up by a tumor
• Nursing Interventions: Nursing Care:
o Routine medications may be taken, unless have been
instructed otherwise. Before:
o The patient will be asked not to eat anything 6 hours
• Written order for blood sample collection should be
before the exam. checked.
o After the procedure: Assess for any symptoms such as • Any prescription medications and over-the-counter
nasal congestion, itchy eyes, hives, rashes, sneezing or drugs and supplements taken by the patient shall
pain. be consulted whether to discontinue for some time
2. Invasive Procedures prior to the test or not.
• Adrenalectomy - is the surgical removal of one or both adrenal • Hand hygiene should be done and a clean
glands. It is usually advised for patients with tumors of the environment should be ensured prior to the
adrenal glands. collection.
• Bilateral Adrenalectomy - may be necessary if tumors are • Patient should be prepared psychologically and
present in both adrenal glands. physically and notify them about the purpose of the
• Laparascopic Approach - used for patients with solitary intra- collection.
• Patient should avoid the factors that elevate or
adrenal pheochromocytomas less than 8cm in diameter without
decrease the levels of catecholamine, MN, and
any malignancy.
VMA concentrations (e.g. coffee, tea, tobacco etc.).
• Nursing Care for Adrenalectomy, Bilateral Adrenalectomy and
Laparoscopic approach - at medical/surgical management
32
 • Inform the patient about the unpleasant sensations o Methylglucamine – present in radiocontrast media
that come with the venipuncture.
• Patient should be assessed before the collection for NORMAL VALUES
the history of skin allergy to alcohol, betadine, Total Catecholamines 14-110 mcg/24 hr
and/or adhesive tape. 3-6 yr: < 2.6 mg/24 hr 7-
• The site should also be examined to evaluate the Vanillylmandelic Acid
10 yr: < 3.2 mg/24 hr 11-
presence of local complications using observation 16 yr: < 5.2 mg/24 hr 17-
and palpation techniques. 83 yr: < 6.5 mg/24 hr
• Needed equipment should be prepared at the Males:
bedside. Normotensives:
• Site is prepared through disinfection with alcohol 3-8 years: 29-92 mcg/24
70% followed by betadine 10%, which is allowed hours
to remain at the insertion site for 1-3 mins. before 9-12 years: 59-188 mcg/24
collection for maximum effective action. hours 13-17 years: 69-221
• For Fractionated Plasma Free Metanephrine Level, mcg/24 hours
patient should be supine in position and at rest for > or =18 years: 44-261
30 minutes; insertion of needle may be done. 30 mcg/24 hours
minutes prior extraction. Reference values have not
During: been established for
• Strict antiseptic technique followed. patients that are <36
• Barrier precautions and care followed through months of age.
latex or non-latex gloves worn during collection Hypertensives: <400
• The needle bevel directed up during the collection Metanephrines mcg/24 hours
using 2 hands at 15-30 degrees angle. Females:
• For Fractionated Plasma Free Metanephrine Level, Normotensives:
patient should maintain a supine position. 3-8 years: 18-144 mcg/24
After: hours 9-12 years: 43-122
• Used supplies should be disposed immediately, mcg/24 hours 13-17 years:
organizing sharps and contaminated instruments 33-185 mcg/24 hours
in different containers. > or =18 years: 30-180
• Dressing should be applied thereafter. mcg/24 hours
• Site is assessed and evaluated at least every shift Reference values have not
for evidence of related complications. This is done been established for
through gentle palpation of the puncture site patients that are <36
through the intact dressing. months of age.
• Ensure patient’s comfort. Hypertensives: <400
• Make sure that the specimen collected will be sent mcg/24 hours
to the laboratory at once to ensure a timely and Males:
proper delivery. Normotensives:
24-hour Urine Collection 3-8 years: 34-169 mcg/24
hours
• For creatinine, total catecholamines, vanillylmandelic acid, and 9-12 years: 84-422 mcg/24
metanephrines hours 13-17 years: 91-456
• Measure creatinine in all collections of urine to ensure adequacy mcg/24 hours 18-29 years:
of the collection 103-390 mcg/24 hours 30-
• Collection container: Dark and acidified, kept cold to avoid 39 years: 111-419 mcg/24
degradation of the catecholamines hours 40-49 years: 119-
451 mcg/24 hours 50-59
• During or immediately after crisis, urine should be collected for
years: 128-484 mcg/24
example a 2- or 3-hour period of urine after a hypertension
hours 60-69 years: 138-
attack may be assayed for catecholamine content (Young et al., Normetanephrine
521 mcg/24 hours
2016). > or =70 years: 148-560
• Factors that may alter the results: mcg/24 hours
o Coffee Reference values have not
o Tea been established for
o Bananas patients that are <36
o Chocolates months of age.
o Vanilla Hypertensives: <900
o Aspirin mcg/24 hours
• Compounds that decrease 24-hour urine levels of MN: Females:
o Methyltyrosine – inhibits tyrosine hydroxylase, the Normotensives:
3-8 years: 29-145 mcg/24
rate-limiting enzyme in catecholamine synthesis
hours 9-12 years: 55-277
33
 mcg/24 hours 13-17 years: • In the next 24 hours, the patient collects the rest of
57-286 mcg/24 hours 18- the urine in the bottle provided.
29 years: 103-390 mcg/24 • Drink adequate fluids during the collection period.
hours 30-39 years: 111- • Amount for each intake and output of the patient
419 mcg/24 hours 40-49 shall be recorded on the corresponding sheets of
years: 119-451 mcg/24 his record.
hours • Store the container in a cool environment, may it
be in the refrigerator or ice cooler.
50-59 years: 128-484 • Exactly 24 hours after beginning the collection, the
mcg/24 hours 60-69 years: patient will be asked to void to complete the
138-521 mcg/24 hours specimen collection.
> or =70 years: 148-560 After:
mcg/24 hours • Perform hand hygiene after urine collection.
• Instruct the patient to continue to keep the
collection container refrigerated until transfer to
Reference values have not
the laboratory.
been established for
• The container containing the specimen should be
patients that are <36
sent to the laboratory once completed
months of age.
• Major physical stress may interfere with the assay and cause
false elevations of MN and NMN. Ethanol and multiple
Hypertensives: <900
prescription drugs, including the following, may also cause such
mcg/24 hours
results:
o Tricyclic Antidepressants (TCAs) Phenoxybenzamine
Interpretation: o Levodopa
o Beta blockers
• Increased metanephrine and normetanephrine levels are found o Labetalol
in patients with pheochromocytoma and tumors derived from o Amphetamines
neural crest cells. o Buspirone
• Total urine metanephrines 1300 mcg/24 hours and lower can be o Methyldopa
detected in nonpheochromocytoma hypertensive patients. o Chlorpromazine
• Further clinical investigation (eg, radiographic studies) is 4. Additional Laboratory Tests
warranted in patients whose total urinary metanephrine levels
are above 1300 mcg/24 hours (approximately 2 times the upper Clonidine Suppression Test
limit of normal). For patients with total urinary metanephrine
• May be performed if the results of plasma and urine tests of
levels below 1300 mcg/24 hours, further investigations may also
catecholamines are inconclusive
be indicated if either the normetanephrine or the metanephrine
• Clonidine (Catapres) – centrally acting antiadrenergic
fraction of the total metanephrines exceed their respective
medication that suppresses the release of neurogenically
upper limit for hypertensive patients. Finally, repeat testing or
mediated catecholamines
further investigations may occasionally be indicated in patients
• Guidelines from the North American NeuroEndocrine Tumor
with urinary metanephrine levels below the hypertensive cutoff,
Society (NANETS) recommend biochemical testing for
or even normal levels, if there is a very high clinical index of
pheochromocytoma in the ff. cases:
suspicion.
o Symptomatic patients
Nursing Care o Patients with adrenal incidentaloma
o Patients who have a hereditary risk for developing a
Before: pheochromocytoma or paraganglioma (extra-adrenal
• Explain the purpose and procedure of the said test pheochromocytoma)
to the patient.
• Show the patient the urine collection container, Normal Plasma
dark and acidified, for the said test. Catecholamine Response
• Appropriate labels, such as the patient’s name, to Clonidine
date of birth, and date and time of the last urine Minimum plasma
specimen collected, should be written. norepinephrine level: <
• Proper hand hygiene should be done prior to Norepinephrine 500 pg/𝑚𝑙!
collection. Norepinephrine decline
During: from baseline: > 50%
• Instruct the patient to urinate, flush down the urine Catecholamine
down the toilet upon waking up first thing in the (norepinephrine + < 500 pg/𝑚𝑙"
morning. Every 24 hour collection starts with an epinephrine)
empty bladder. • General laboratory features of pheochromocytoma include the
following:
34
 o Hyperglycemia • Assess if client is allergic to contrast dye or iodine
o Hypercalcemia (e.g shellfish)
o Erythrocytosis • Ask the client to remove jewelry prior to the
procedure and assess for metal implants like
Medical – Surgical Management pacemaker
• Inform client regarding the procedure, what to
Adrenalectomy expect, the purpose, and how long it takes.
• Ask the client if he/she has any concerns regarding
• Is the surgical removal of one or both adrenal glands. It is usually
the procedure
advised for patients with tumors of the adrenal glands. The • Arrange for the transport of the client to the
procedure can be performed using an open incision or radiology department and vice versa
laparoscopic technique. • Assist the client towards the radiology department
o In some cases, such as when the other adrenal gland After:
has been removed, your doctor might remove only the • Ask the client how he/she is doing
tumor, sparing some healthy tissue. • Obtain vital signs
o If a tumor is cancerous, the tumor and other cancerous • Instruct the client to flush the toilet twice after each
tissue will be removed. However, even if all of the use (to dilute radioactive material excreted in the
cancerous tissue isn't removed, surgery might limit urine).
hormone production and provide some blood pressure Peptide Receptor Radionuclide Therapy (PRRT)
control.
• Is a type of unsealed source radiotherapy, using
Nursing Care radiopharmaceutical which targets peptide receptors to deliver
localised treatment, typically for neuroendocrine tumours.
Before:
• A complete history and physical examination is Chemotherapy
mandatory in the evaluation of a patient with an
adrenal mass • Is a type of cancer treatment that uses one or more anti-cancer
• Monitor the results of laboratory tests of drugs as part of a standardized chemotherapy regimen.
electrolytes and glucose levels
Nursing Care
• Teach the client to turn, cough and perform deep
breathing exercises. Before:
During: • Review the chemotherapeutic drug prescription
• Proper positioning is one of the key responsibilities • Accurately identify the client
to protect the safety and skin integrity of the • Medications to be administered in conjunction with
patient under anesthesia. the chemotherapy
• Monitor vital signs. • Assess the client’s condition
After: • Prepare for potential complications
• Pain medication given as required (typically only • Assure accurate preparation of the agent
necessary for a few days). • Assess patient’s understanding of
• Patient is allowed and able to ambulate (move chemotherapeutic agents and administration
about) on the same day. procedures
• Liquid food intake is started the night of the During:
procedure • Patient should be protected from infections
• Solid food intake may begin on the first • Help the patient to identify period of more fatigue
postoperative day. and activeness
• The patient can leave on the second or third • Antiemetics should be administered one hr prior to
postoperative day. chemotherapy
After:
• Low fiber and residue diet should be recommended
MIBG
to patient as these food can cause diarrhea
• Radiation therapy combines MIBG, a compound that attaches to • Patient should be taught to maintain a record of
adrenal tumors, with a type of radioactive iodine. The treatment episodes of diarrhea and foods that cause diarrhea.
• Monitor hemoglobin levels, hematocrit, RBC count;
goal is to deliver radiation therapy to a specific site and kill
report dropping values
cancerous cells.
• Be prepared to administer a blood transfusion or
Nursing Care erythropoietin
Radiation Therapy
Before
• Obtained informed consent • Is a type of cancer treatment that uses beams of intense energy
• Assess if client is pregnant to kill cancer cells. Radiation therapy most often uses X-rays,
• Assess if client is claustrophobic but protons or other types of energy also can be used.

35
Nursing Care
Before:
• The nurse explains the procedure
• If implant is used the nurse informs patient and
family about restrictions placed on visitors
• Explain to the patient the nurse’s role before,
during and after the procedure.
During:
• Patient and family education
• Include restrictions and precautions
• Skin care
• Oral Care
• Protection of care providers
After:
• The nurse assesses the patient’s skin and
oropharyngeal mucosa regularly when radiation
therapy is directed to these areas, and also the
nutritional status and general well-being should be
assessed.
• If systemic symptoms, such as weakness and
fatigue, occur, the nurse explains that these
symptoms are a result of the treatment and do not
represent deterioration or progression of the
disease.
• Assigning the patient to a private room, posting
appropriate notices about radiation safety
precautions
Pharmacology with Nursing Considerations
Alpha-adrenergic blocker - phenoxybenzamine
(Dibenzyline)
Action: Inhibits the binding of norepinephrine to the
alpha-1 receptors, thereby promoting smooth muscle
cell, relaxation, reduced vascular tone, and decreased
peripheral resistance. The net result is control of blood
pressure.
Indication: Indicated in the treatment of
pheochromocytoma, to control episodes of
hypertension and sweating. If tachycardia is excessive, it
may be necessary to use a beta-blocking agent
concomitantly.
Contraindications:
• Phenoxybenzamine is contraindicated in patients
with a known hypersensitivity to the drug.
• Used cautiously in patients with compensated
congestive heart failure or coronary artery disease,
cerebrovascular disease, renal disease, and dental
disease.
• Relatively contraindicated in shock in which fluid
volume replacement is inadequate and respiratory
infection
• Administration to geriatric patients should be done
cautiously due to the greater risk of developing
phenoxybenzamine-induced hypothermia and/or
hypotension.
• Pregnant and lactation
Adverse Effects:
• Autonomic Nervous System: Postural hypotension
(orthostasis), tachycardia, retrograde ejaculation,
nasal congestion, miosis.
• Miscellaneous: Gastrointestinal irritation,
drowsiness, fatigue.
Nursing Considerations
• Monitor BP and note pulse quality, rate, and
rhythm in recumbent and standing positions during
periods of dosage adjustment. Observe the patient
closely for at least 4 doses administration from one
dosage increment to the next; hypotension and
tachycardia are most likely to occur in standing
position. The targets are 120/80 mm Hg (seated)
with a standing systolic pressure greater than 90
mmHg.
• Age and comorbid disease should be taken into
consideration when establishing and evaluating
targets.
• Drug has cumulative action, thus onset of
therapeutic effects may not occur until after 2 wk
of therapy, and full therapeutic effects may not be
apparent for several more weeks.
• Instruct the patient to make position changes
slowly, particularly from reclining to upright
posture, and dangle legs and exercise ankles and
feet for a few minutes before standing.
• Make the patient aware that light headedness,
dizziness, and palpitations usually disappear with
continued therapy but may reappear under
conditions that promote vasodilation, such as
strenuous exercise or ingestion of a large meal or
alcohol.
• Teach the patient that pupil constriction, nasal
stuffiness, and inhibition of ejaculation generally
decrease with continued therapy.
• Instruct the patient not to take OTC medications for
coughs, colds, or allergy without approval of the
physician. Many contain agents that cause BP
elevation.
• Some practitioners may prefer the use of a selective
alpha1-adrenergic blocker with fewer side effects,
such as prazosin (Minipress), terazosin (Hytrin), or
doxazosin (Cardura), when long-term therapy is
indicated.
Beta-adrenergic blockers
propranolol (Inderal, InnoPran), nadolol (Corgard),
timolol maleate (Blocadren), penbutolol sulfate
(Levatol), sotalol hydrochloride (Betapace), and
pindolol (Visken)
Action: Beta blockers primarily block β1 and β2
receptors and thereby the effects of norepinephrine and
epinephrine. By blocking the effects of norepinephrine
and epinephrine, beta blockers reduce heart rate;
reduce blood pressure by dilating blood vessels; and
may constrict air passages by stimulating the muscles
that surround the air passages.
Indications: Are used to treat high blood pressure,
chest pain (angina), abnormal heart rate (arrythmia),
congestive heart failure, and several other conditions.
They may also shrink certain types of vascular tumors,
such as hemangiomas
Contraindications:
36
• Symptomatic bradycardia
• Cardiogenic shock and hypotension
• Pheochromocytoma: administration of beta
blockers before alpha blockers → unopposed α-
adrenoceptor mediated vasoconstriction →
hypertensive crisis (except nonselective beta
blockers with α-antagonism, such as carvedilol and
labetalol)
• Decompensated heart failure
• Combination with calcium channel blockers
(diltiazem or verapamil): can precipitate AV block
• Sick sinus syndrome (without a pacemaker); heart
block greater than first-degree
• Relative contraindications: asthma, COPD,
psoriasis, Raynaud phenomenon, peripheral artery
occlusive disease, and Pregnancy (except labetalol,
which is used to treat pregnancy-induced
hypertension.
Adverse Effects:
• Cardiac: bradycardia, bradyarrhythmia (e.g., AV
block), ventricular tachyarrhythmia (torsades de
pointes), worsened heart failure (HF), worsened
vasospasm due to propranolol use, orthostatic
hypotension (esp. in elderly patients)
• CNS: fatigue/lethargy, sleep disorders, nightmares,
depression, hallucinations, seizures
• Cutaneous: psoriasis
Nursing Considerations:
• Monitor patient’s blood pressure
• Monitor client’s cardiac output and pulse rate,
rhythm regularly.
• Decrease in alertness may occur along with
weakness
• Monitor patient’s blood glucose levels
• Report any instance of pain or shortness of breath
• Do not stop these drugs abruptly after chronic
therapy but taper gradually over 2 weeks.
Calcium channel blocker
Amlodipine (Norvasc), diltiazem (Cardizem, Tiazac,
others), felodipine, isradipine, nicardipine, nifedipine
(Adalat CC, Procardia), nisoldipine (Sular) and
verapamil (Calan, Verelan)
Action: These drugs inhibit the movement of calcium
ions across myocardial and arterial muscle cell
membranes. As a result, action potential of these cells
are altered and cell contractions are blocked causing
decreased myocardial contractility, slow cardiac impulse
in conductive tissues, and arterial dilation and
relaxation.
Indication: Treatment of hypertension or in combination
with other antihypertensive agents with extended-
release preparations usually indicated for hypertension
in adults.
Contraindications:
• Allergy to calcium-channel blockers
• Heart block which can be exacerbated by
conduction-slowing effect of the drug
• Renal and hepatic impairment which can alter
metabolism and excretion of drugs thus increasing
the risk for toxicity
• Pregnancy and lactation which can cause potential
adverse effects to the fetus and should not be used
unless the benefit to the mother clearly outweighs
the risk to the fetus
Adverse Effects:
• CNS: headache, dizziness, light-headedness, fatigue
• CV: hypotension, bradycardia, peripheral edema,
heart block
• GI: nausea, hepatic injury
• EENT: rash, skin flushing
Nursing Considerations:
• Monitor patient response to therapy through
assessing cardiopulmonary status closely, including
pulse rate, blood pressure, heart rate, and rhythm.
• Obtain an ECG as ordered to evaluate heart rate
and rhythm
• Monitor respirations and auscultate lungs
• Monitor for presence of mentioned adverse effects
• Monitor for compliance to drug therapy regimen
• Monitor laboratory tests results, including liver and
renal function tests.
Catecholamine Synthesis Inhibitor
Metyrosine
Action: Inhibits tyrosine hydroxylase, which catalyzes
the first transformation in catecholamine biosynthesis.
Indication: For use the treatment of patients with
pheochromocytoma, for preoperative preparation of
patients for surgery, management of patients when
surgery is contraindicated, and chronic treatment of
patients with malignant pheochromocytoma.
Contraindications:
• Inhibits tyrosine hydroxylase, which catalyzes the
first transformation in catecholamine biosynthesis.
• For use in the treatment of patients with
pheochromocytoma, for preoperative preparation
of patients for surgery, management of patients
when surgery is contraindicated, and chronic
treatment of patients with malignant
pheochromocytoma.
• Parkinson's disease causes extrapyramidal effects
and should be used with caution in patients with
Parkinson's disease
• Driving or operating machinery can increase
depression and confusion, and impair mental
alertness. Moderate to severe sedation is possible
and has been reported in most patients taking
metyrosine. Patients should be advised to exercise
caution when driving or operating machinery until
the effects of metyrosine is known.
• Hepatic disease, renal disease for prolonged
periods of time in only a few patients, so the safety
of long-term administration has not been
established.
• Patients with hepatic disease or renal disease
should be treated with caution with prolonged
therapy
37
 • Dehydration contraindicates use of metyrosine. An
adequate fluid balance (daily urinary volume of 2 L
or more) should be maintained to minimize the risk
of developing metyrosine-induced crystalluria.
Fluid intake should be increased if crystalluria
occurs. If crystalluria persists, the dosage of
metyrosine may need to be reduced or the drug
discontinued.
Adverse Effects:
• CNS: fatigue, headache, psychic disturbances,
dizziness, drowsiness, lightheadedness
• GI: nausea, vomiting, diarrhea
• EENT: nasal stuffiness, xerostomia
• Renal: dysuria, crystalluria
• Others: galactorrhea, sexual dysfunction
Nursing Considerations:
• Hepatic Impairment with specific guidelines for
dosage adjustments in hepatic impairment are not
available; it appears that no dosage adjustments
are needed.
• Renal Impairment with specific guidelines for
dosage adjustments in renal impairment are not
available; it appears that no dosage adjustments
are needed.
• Administer orally without regard to meals.
• When used for preoperative preparation, the
optimally effective dose should be given for at least
5-7 days.
Nutrition and Diet Therapy
• Teach the patient to not smoke, drink caffeine-containing
beverages, or change position suddenly
o Hypertension is the hallmark of the disease and the
most common serious complication after surgery
• Provide a diet rich in calories, vitamins, and minerals. Eat
different foods from the following groups every day:
o Bread, cereal, rice and pasta.
o Vegetables.
o Fruits.
o Milk, yogurt, and cheese.
o Meat, poultry (chicken), fish, dry beans, eggs and nuts.
o Ask your caregiver how many servings of fats, oils and
sweets should be included in your diet.
o Adrenal pheochromocytoma can cause blood sugar
changes. A dietitian may work with you to help you
choose the best foods to control your blood sugar. You
may need to eat certain amounts of these foods at
specific times during the day. Ask your caregiver how
your favorite foods may fit into your diet.
Nursing Management
Nursing Problems/Diagnosis
• Risk for altered systemic tissue perfusion r/t fluctuations in CV
status
• Anxiety r/t increased circulating catecholamines
• Altered Nutrition r/t increased metabolic rate
Nursing Considerations
• Monitor vital signs: blood pressure, heart rate
• Monitor for hypertensive crisis: >180 systolic or >120
diastolic...if blood pressure is too high for a long period of time
this can cause damage to vital organs...kidneys, eyes, brain,
heart.
o Signs and symptoms of this: headache, vision changes,
neuro changes, seizures, shortness of breath
• Monitor for chest pain (risk for MI), neuro status (stroke), EKG
changes, hyperglycemia
• Provide a calm and cool environment....no overstimulation!
• Per MD order: Administer pre-opt (prior to adrenalectomy)
alpha-adrenergic blockers (Cardura, Minipress, Hyrtin): work by
blocking noradrenaline, reduces catecholamines. These
medications help decrease blood pressure and prevent a
hypertensive crisis during surgery.
o Alpha-adrenergic blockers can cause reflex
tachycardia (due to the decrease in blood pressure).
The heart rate increases in an attempt to increase the
blood pressure as a “reflex” response, and these
medications can cause orthostatic hypotension.
• Doctor may also prescribe to the patient a beta-adrenergic
blocker like Labetalol or Inderal to help with hypertension and
tachycardia
Client Education
• During the pre- and postoperative phases of care, the nurse
educates the patient about the importance of follow-up
monitoring to ensure that pheochromocytoma does not recur
undetected.
• For patient going for an adrenalectomy: educate about having to
take hormone replacement medications after surgery and taking
alpha-adrenergic prior to surgery (usually 2 weeks before
surgery)
o If a patient is having a bilateral adrenalectomy (both
glands removed ): will have to take glucocorticoids and
mineralocorticoid for life.
o If a patient is having a unilateral adrenalectomy (only
one gland removed): will have to take glucocorticoids
for approximately 2 years.
• After adrenalectomy, the use of corticosteroids may be needed.
Therefore, the nurse educates the patient about their purpose,
the medication schedule, and the risks of skipping doses or
stopping their administration abruptly
• The nurse educates the patient and family about how to
measure the patient’s blood pressure and when to notify the
primary provider about changes in blood pressure.
• In addition, the nurse provides verbal and written instructions
about the procedure for collecting 24-hour urine specimens to
monitor urine catecholamine levels
• Eat high calorie diet: burning fats at a rapid rate
• Avoid stimulant substances: energy drinks, caffeine products, or
smoking (due to vasoconstriction)
“Trying to manage diabetes is hard because if you don't, there are
consequences you'll have to deal with later in life.” – Bryan Adams
Diabetes Mellitus Type 1 and 2
38
Anatomy and Physiology
• The pancreas is a long,
slender organ, most of which is
located posterior to the bottom half
of the stomach.
• Although it is primarily an
exocrine gland, secreting a variety of
digestive enzymes, the pancreas also
has endocrine cells.
• Its pancreatic islets—clusters of cells formerly known as the
islets of Langerhans—secrete the hormones glucagon, insulin,
somatostatin, and pancreatic polypeptide (PP).
• Pancreas endocrine function involves the secretion of insulin
(produced by beta cells) and glucagon (produced by alpha cells)
within the pancreatic islets.
• These two hormones regulate the rate of glucose metabolism in
the body.
Cells and Secretions of the Pancreatic Islets
The pancreatic islets each contain four varieties of cells:
• The alpha cell produces the hormone glucagon and makes up
approximately 20 percent of each islet. Glucagon plays an
important role in blood glucose regulation; low blood glucose
levels stimulate its release.
• The beta cell produces the hormone insulin and makes up
approximately 75 percent of each islet. Elevated blood glucose
levels stimulate the release of insulin.
• The delta cell accounts for four percent of the islet cells and
secretes the peptide hormone somatostatin. Recall that
somatostatin is also released by the hypothalamus (as GHIH),
and the stomach and intestines also secrete it. An inhibiting
hormone, pancreatic somatostatin inhibits the release of both
glucagon and insulin.
• The PP cell accounts for about one percent of islet cells and
secretes the pancreatic polypeptide hormone. It is thought to
play a role in appetite, as well as in the regulation of pancreatic
exocrine and endocrine secretions. Pancreatic polypeptide
released following a meal may reduce further food consumption;
however, it is also released in response to fasting.
Regulation of Blood Glucose Levels by Insulin and Glucagon
• The concentration of glucose in the blood is tightly regulated
between 70 and 110 mg/dL.
• Insulin is released as blood glucose levels increase above this
level, which encourages body cells to remove glucose from the
blood.
• When blood glucose levels fall below this level, the hormone
glucagon is released, which allows body cells to release glucose
into the bloodstream.
Glucagon
• In response to decline in
blood glucose levels during periods of
fasting, prolonged labor, or exercise ,
the alpha cells of the pancreas secrete
the hormone glucagon, which has
several effects:
• Glucagon stimulates the liver
to convert its stores of glycogen back
into glucose. This response is known
as glycogenolysis. The glucose is then released into the
circulation for use by cells throughout the body.
• Glucagon stimulates the liver to take up amino acids from the
blood and convert them into glucose. This response is know as
gluconeogenesis.
• Glucagon stimulates lipolysis, the breakdown of stored
triglycerides into free fatty acids and glycerol. Some of the free
glycerol released into the bloodstream travels to the liver, which
converts the glycerol into glucose. This is also a form of
gluconeogenesis.
Homeostatic Regulation of Blood Glucose Levels
• Blood glucose concentration is tightly maintained between 70
mg/dL and 110 mg/dL.
• The only way to maintain such a narrow range is through
negative feedback.
• When blood sugar gets too high (such as after a meal), it is
lowered with insulin; when blood sugar gets too low (from too
long a break between meals), raise it with glucagon.
• In a nutshell, insulin attaches to insulin receptors on the capillary
walls, and is thus used to remove glucose from blood plasma;
insulin also helps with the storage of extra glucose through the
formation of glycogen and lipids.
• Glucagon, on the other hand, targets the liver cells, causing the
breakdown of glycogen, and thus releasing the glucose
monomers and adding them to the bloodstream (raising blood
glucose levels).
• Hypoglycemia – low blood sugar; Normal Level; Hyperglycemia –
high blood sugar
Insulin
39
 Type 1 Diabetes Mellitus

Definition

• Type 1 diabetes is a chronic illness characterized by the body’s

• Insulin's primary role is to promote glucose uptake into body
cells.
• Red blood cells, as well as brain, liver, kidney, and small intestine
lining cells, lack insulin receptors on their cell membranes and
therefore do not need insulin for glucose uptake.
• The presence of food in the intestine triggers the release of
gastrointestinal tract hormones such as glucose-dependent
insulinotropic peptide (previously known as gastric inhibitory
peptide).
• This is in turn the initial trigger for insulin production and
secretion by the beta cells of the pancreas.
• Once nutrient absorption occurs, the resulting surge in blood
glucose levels further stimulates insulin secretion.
• Insulin also reduces blood glucose levels by stimulating
glycolysis, the metabolism of glucose for generation of ATP.
• Moreover, it stimulates the liver to convert excess glucose into
glycogen for storage, and it inhibits enzymes involved in
glycogenolysis and gluconeogenesis.
• Finally, insulin promotes triglyceride and protein synthesis.
• The secretion of insulin is regulated through a negative feedback
mechanism.
• As blood glucose levels decrease, further insulin release is
inhibited.
inability to produce insulin due to the autoimmune destruction
of the beta cells in the pancreas. Although onset frequently
occurs in childhood, the disease can also develop in adults. Type
1 diabetes was previously called insulin- dependent diabetes or
juvenile diabetes.
• Type 1 diabetes occurs when some or all of the insulin-producing
cells in the pancreas are destroyed. This leaves the patient with
little or no insulin. Without insulin, sugar accumulates in the
bloodstream rather than entering the cells. As a result, the body
cannot use this glucose for energy. In addition, the high levels of
glucose that remain in the blood cause excessive urination and
dehydration, and damage tissues of the body.
Clinical Manifestations
• Type 1 diabetes signs and symptoms can appear relatively
suddenly and may include:
o Increased thirst
o Frequent urination
o Bed-wetting in children who previously didn't wet the
bed during the night
o Extreme hunger
o Unintended weight loss
o Irritability and other mood changes
o Fatigue and weakness
o Blurred vision
Risk Factors

Hormones of the Pancreas • Type 1 diabetes is thought to be caused by an immune reaction

Associated (the body attacks itself by mistake). This means that the
Chemical class Effect pancreas does not produce insulin Risk factors for type 1
hormones
Insulin (beta Reduces blood diabetes are not as clear as for prediabetes and type 2 diabetes.
Protein
cells) glucose levels Known risk factors include:
Glucagon (alpha Increases blood o Family history: Having a parent, brother, or sister with
Protein
cells) glucose levels type 1 diabetes
Inhibits insulin o Age: You can get type 1 diabetes at any age, but it’s
Somatostatin
Protein and glucagon more likely to develop when you’re a child, teen, or
(delta cells)
release young adult
Pancreatic o In the United States, whites are more likely to develop
polypeptide (PP Protein Role in appetite type 1 diabetes than African Americans and
cells)
Hispanic/Latino Americans

Laboratory and Diagnostic Procedures

Pathophysiology
Random Blood Glucose Test

• Definition: A random blood sugar test measures the levels of

glucose in the blood at any given point in the day.
• Purpose: RBS test is performed to confirm diabetes mellitus,
during the treatment and after the treatment of diabetes
mellitus.
• Procedure: This test is done by pricking a finger to draw a small
drop of blood which will then be wiped onto a test strip to be
measured using a glucometer. RBG Test can be performed

40
 anytime of the day. A blood glucose level with a measurement • Purpose: The glucose tolerance test identifies abnormalities in
of 200 mg/dL or higher indicates diabetes. the way your body handles glucose after a meal — often before
• Normal Findings: Normal range should be anywhere between 80 your fasting blood glucose level becomes abnormal.
mg/dl to 130 mg/dl prior to eating for healthy blood sugar levels • Procedure: This test measures how efficient the body handles a
in the body. standard amount of glucose. Blood is drawn before and two
• Significant Findings: People who have 140 mg/dl to 199 mg/dl hours after drinking a beverage that contains glucose. The doctor
as a result to their RBS test then they are pre diabetic and can will then compare the results to identify the glucose levels
develop diabetes type 2, while a person with a reading of 200 present in the plasma to see how well the body processed sugar.
mg/dl and above is most probably diabetic. Findings within 140-199 mg/dL of blood glucose is indicative of
prediabetes while diabetes measures 200mg/dL or higher.
Fasting Plasma Glucose (FPG) Test o The pathologist will give you a 75mL glucose drink then
• Definition: A blood sample will be taken after an overnight fast ask you to wait for 2 hours and then take the blood and
or measures plasma glucose levels after a fast of at least 8 hours. test glucose levels
• Purpose: This test is commonly used to screen for diabetes • Normal Findings: A normal blood glucose level is lower than 140
mellitus and prediabetes, in which absence of deficiency of mg/dL (7.8 mmol/L).
insulin allows persistently high glucose levels. • Significant Findings: A blood glucose level between 140 and 199
• Procedure: This test measures blood glucose level at a single mg/dL (7.8 and 11 mmol/L) is considered impaired glucose
point in time. It is best to take this test in the morning, after tolerance, or prediabetes. If you have prediabetes, you are at risk
fasting for at least 8 hours, to obtain more reliable results. To do of eventually developing type 2 diabetes. You are also at risk of
this test, a healthcare provider will draw blood from the patient. developing heart disease, even if you don't develop diabetes. A
The plasma will then be combined with other substances to blood glucose level of 200 mg/dL (11.1 mmol/L) or higher may
determine the amount of glucose present in the plasma, usually indicate diabetes.
measure in mg/dL. Blood glucose measurement of 100-125 • Summary of Results
mg/dL indicates prediabetes while 126 mg/dL indicates diabetes. Result Random Fasting A1C Test Glucose
Blood Blood Tolerance
Fasting Plasma Glucose
Glucose Sugar Test
(FPG)
Test Test
Normal < 100 mg/dL
Diabetes 200 126 6.5% or 200
Prediabetes 100 mg/dL to 125 mg/dL
mg/dL mg/dL above mg/dL or
Diabetes 12 mg/dL or higher
or above or above above
Prediabetes 140 100 to 5.7% to 140 to
Glycosylated Hemoglobin Test (HbA1C) mg/dL 125 6.4% 199
to 199 mg/dL mg/dL
• Definition: This test measures the average blood glucose control mg/dL
for the past 2-3 months. Normal N/A 99 4% to 140
• Purpose: An HbA1c test may be used to check for diabetes or mg/dL 5.7% mg/dL or
prediabetes in adults. People who have diabetes need this test or below below
regularly to see if their levels are staying within range.
• Procedure: This test measures the average blood glucose control Medical – Surgical Management
for the past 2-3 months. Compared to the FPG test, the HbA1C is
more convenient as no fasting is required for the patient. Results • Management of type 1 diabetes mellitus is aimed at controlling
indicate that an A1C of 5.7-6.4% means that one has and maintaining the patient’s blood glucose levels within the
prediabetes, and he/she is at high risk for the development of normal range. Good glycemic control in type 1 diabetes requires
diabetes. Diabetes is diagnosed when the results are at 6.5% or attention to diet, exercise, and insulin therapy.
higher.
• Normal Findings: Normal values typically range from 4% to 5.6% Insulin Administration
and indicate consistently near-normal blood glucose • To lower blood sugar, insulin shouldn’t be taken orally because
concentrations. stomach enzymes will break down the insulin which would
• Significant Findings: Results indicate that an A1C of 5.7-6.4% prevent its action. Insulin is life-saving as it prevents diabetic
means that none has prediabetes, and he/she is at high risk for ketoacidosis; in the long term, insulin administration and
the development of diabetes. Diabetes is diagnosed when the treatment prevents chronic complications from arising by
results are at 6.5% or higher. maintaining blood glucose levels within normal limits as
Oral Glucose Tolerance Test (OGTT) possible. Although all types of insulin produce the same effect,
the makeup of different types affects how fast or for how long
• Definition: This test measures blood glucose levels after the they work.
ingestion of a highly sugared beverage following a period of
fasting. Types of
Onset Duration Appearance
Insulin
41
 15 • Keep life support equipment and glucose readily
Rapid-acting 3-4 hours Clear
minutes available to deal with ketoacidosis or hypoglycemic
30-60 reactions.
Short-acting 5-8 hours
minutes • Unopened expiration dates of medications should
Intermediate- 14-16 be checked prior to use. Once vial or pen is opened,
1-2 hours Cloudy follow manufacturer’s instructions on when to
acting hours
24 hours discard. Dates can vary greatly from medication to
Long-acting 2 hours medication, by brand and type of insulin.
or longer
• Insulin can be administered through: During the Therapy
o Syringes - a fine needle injection or insulin pen is used • Insulin Administration
to administer insulin under the skin. These injections 1. Pinch the skin and put the needle in at a 45o angle.
are made of plastic and should be discarded after one 2. If the skin tissues are thicker, one may be able to
inject straight up and down (90 angle). Check with
use.
a healthcare provider before doing this.
o Insulin pump - is a wearable device programmed to
3. Push the needle all the way into the skin. Let go of
dispense specific amounts of rapid-acting insulin the pinched skin. Inject the insulin slowly and
automatically. A tube connects a reservoir of insulin to steadily until it is all in.
a catheter that’s inserted under the skin of the 4. Leave the syringe in place for 5 seconds after
abdomen. injecting.
o Insulin pen - a device that makes injecting insulin 5. Pull the needle out at the same angle it went in.
easier and more convenient for you compared to using
a syringe.

After the Therapy

• Arrange for proper disposal of syringes.
• Instruct patient to use the same type and brand of
syringe; use the same type and brand of insulin to
avoid dosage errors
• Insulin injection sites:
• Instruct patient to store the drug in the refrigerator
o Upper outer arms
or in a cool place out of direct sunlight; do not
o Abdomen
freeze insulin. If frozen, insulin should be discarded.
o Buttocks • Instruct patient to wear a medical alert tag or ID
o Upper outer thighs stating that he/she has diabetes and is taking
• Materials needed: insulin so that emergency medical personnel will
o Insulin take proper care of you.
o Needles • Instruct to avoid alcohol as this may cause serious
o Syringe/Insulin pen reactions to occur.
o Alcohol swab • Instruct patient to report fever, sore throat,
o Disposable container vomiting, hypoglycemic or hyperglycemic
reactions, rash.
Nursing Responsibilities

Before the Therapy Blood Sugar Monitoring

• Assess for contraindications or cautions such as
history of allergy or pregnancy so that appropriate • Monitoring blood glucose levels is significant in patients with
monitoring and dose adjustments can be type 1 DM as this helps manage one’s condition and prevent
completed. complications. Blood glucose can be measured at home by using
• Check insulin if appearance is altered. If so, discard a portable electronic device called a blood sugar meter.
and use a new vial or pen (with a normal • Materials needed:
appearance) to ensure potency. o Glucose meter
• Choose where to give the injection. Keep a chart of o Alcohol swab
places/parts where insulin was administered, so o Test strip
that it won’t be injected in the same place all the
o Needle (lancet)
time.
o Lancet device
• Assess the skin for bruises, tenderness, swelling,
o Sterile gauze
firm, numbness, or lumps. Do not proceed to inject
if the following are noted. • Steps in monitoring for blood sugar:
1. Wash hands with soap and warm water, then dry.

42
 2. Prepare the lancing device by inserting a fresh lancet.
Lancets that are used more than once are not as sharp as a
new lancet and can cause more pain and injury to the skin.
3. Prepare the blood glucose meter and test strip (the exact
instructions for this depend upon the type of glucose meter
used).
4. Use the lancing device to obtain a small drop of blood from
the edge of the finger. If blood sugar is rising/falling rapidly,
it's more accurate to use the fingertip, as testing at
alternate sites may give significantly different results in
these situations.
5. Wipe the first drop of blood with a sterile gauze.
6. Apply the blood drop to the test strip in the blood glucose
meter. The results will be displayed on the meter after
several seconds.
7. Dispose of the used lancet in a container designed for
sharps (not in household trash).
Nursing Responsibilities
Before
• Collect together all the equipment including: test
meter, test strips, finger pricking device/lancet,
clean gauze and the patient’s records.
• Explain the procedure to the patient and gain
verbal consent
• Ensure the code strip matches the meter code.
• Assess sites for skin puncture.
• Perform hand hygiene.
During
• Rotate sites to prevent skin damage.
• A new test strip should be used each time the
procedure is undertaken and the machine should
be calibrated at regular intervals.
• If there is difficulty in getting a drop of blood from
the fingertip, instruct to rinse fingers with warm
water and shake the hand below your waist. This
can help get the blood flowing.
• Instruct patient to avoid squeezing finger as this
may affect the results.
After
• Make sure to dispose of the materials used for
every test. Keep them in a sharps bin.
• Instruct the patient to keep a journal or log of the
blood sugar levels he/she took. Hence, time, date,
blood glucose result, medication and dose should
be included. Additional notes should include what
he/she ate, exercise (if he/she did), or difficulties
with illness or stress
Medical Management
Continuous Glucose Monitoring
• Continuous glucose monitoring (CGM) is a way to monitor your
blood sugar levels every 5 to 15 minutes, 24 hours a day.
• CGM systems use a glucose sensor to measure the level of
glucose in the fluid under the skin.
• The sensor is attached to a transmitter placed on your skin.
• It will then transmit results to a small recording device or to a
smartphone or other smart device.
• In some cases, it transmits the information directly to an insulin
pump.
• It must be removed and placed on a different part of the body
approximately once every 7 to 14 days.
Artificial Pancreas (closed-loop control)
• Artificial pancreas is an “all-on-one” diabetes management
system designed to release insulin in response to the changing
blood glucose levels in a similar way to a human pancreas. The
artificial pancreas consists of a glucose sensor, a control
algorithm, and an insulin infusion device.
Lifestyle Modifications
• Exercise: Patients with type 1 diabetes are recommended to take
regular aerobic exercises, such as swimming or walking for at
least 150 minutes a week. Physical activity lowers blood sugar,
hence, it is important to check blood glucose levels before
starting a new activity.
• Diet: There is no standardized dietary advice suitable for all
individuals with diabetes. However, it is important to focus on a
diet that is nutritious, low-fat, high-fiber foods such as fruits,
vegetables, and whole grains.
Surgical Management
Pancreas Transplant
• This is a surgical procedure that allows implant of healthy
pancreas from a deceased donor to a patient with diabetes.
Pancreas transplants give the person a chance to stop taking
insulin injections. It offers a potential cure for this condition but
it is typically reserved for those with serious complications of
diabetes because the side effects of a pancreas transplant can be
significant.
Pharmacology with Nursing Interventions
Regular Insulin
Classification: Hormone
Action: Insulin is a hormone secreted by pancreatic
beta-cells of the islets of Langerhans. It initiates its
action by binding to a glycoprotein receptor on the
surface of the cell. This receptor consists of an alpha-
subunit, which binds the hormone, and a beta-subunit,
which is an insulin-stimulated, tyrosine-specific protein
kinase.
Indications: indicated to improve glycemic control in
diabetes mellitus types 1 & 2; management of diabetic
ketoacidosis, hyperkalemia, and marked resistance.
Contraindications: hepatic disease, renal failure, renal
impairment, hypersensitivity to drug.
Adverse Effects: hypoglycemia (symptoms: sweating,
dizziness, palpitation, tremor, hunger, restlessness,
tingling, lightheadedness, headache, irritability);
ketoacidosis; local reactions and fat hypertrophy at
injection site.
Nursing Considerations:
• Assess for contraindications or cautions (e.g.
history of allergy, pregnancy, etc.) so that
43
 appropriate monitoring and dose adjustments can
be completed.
• Assess skin lesions; orientation and reflexes; blood
pressure, pulse, respiration and adventitious
breath sounds which could indicate a response to
high or low glucose levels and potential risk factors
in giving insulin.
• Inspect skin areas that will be used for injection;
note any areas that are bruised, thickened, or
scarred, which could interfere with insulin
absorption and alter anticipated response to insulin
therapy.
• Obtain blood glucose levels as ordered to monitor
response to insulin.
• Rotate injection sites to avoid damage to muscles
and to prevent subcutaneous atrophy.
• Store insulin in a cool place away from direct
sunlight to ensure effectiveness. Pre-drawn
syringes are stable for 1 week if refrigerated.
Antihypertensive Medications
Angiotensin converting enzyme (ACE) inhibitors
Medications include benazepril (Lotensin), captopril,
enalapril (Vasotec), fosinopril and lisinopril (Prinivil,
Zestril)
Classification: angiotensin-converting enzyme (ACE)
inhibitors
Action: blocks angiotensin II formation and inhibiting
bradykinin metabolism, causing vasodilation as well as a
decrease in blood volume, which leads to lower blood
pressure and decreased oxygen demand from the heart
Indications: hypertension, congestive heart failure, left
ventricular dysfunction, renal disease Contraindications:
hypersensitivity reactions, hypotension, heart block, sick
sinus syndrome
Adverse Effects: cardiac arrhythmias, reflex tachycardia,
GI irritation, ulcers, liver injury
Nursing Considerations:
• Administer on empty stomach 1 hour before or 2
hours after meals to ensure proper absorption of
drug.
• Give the parental form of enalapril only if oral form
is not feasible.
• Consult the patient's physician to reduce the dose,
most especially if renal failure is present.
• Monitor patient for any situation that may light to
a drop in fluid volume (e.g. excessive sweating,
diarrhea, dehydration) to detect and treat
hypotension as early as possible.
Angiotensin II receptor blockers
Medications include candesartan (Atacand),
irbesartan (Avapro),
olmesartan (Benicar) and losartan (Cozaar)
Classification: angiotensin receptor blockers (ARBs)
Action: block the action of angiotensin II by preventing
angiotensin II from binding to angiotensin II receptors on
the muscles surrounding blood vessels, resulting in
vasodilation.
Indication: hypertension, congestive heart failure, renal
disease
Contraindications: allergy to the drug, lactation
Adverse Effects: upper respiratory tract symptoms
(cough), dry skin, headaches, abdominal pain, weakness
Nursing Considerations:
• The patient must be watched for adverse effects,
such as hypertension.
• Monitor the patient's respiratory function
throughout therapy, as well as his pulse.
Cholesterol-lowering Medications
Statins
Medications include atorvastatin (Lipitor), fluvastatin
(Lescol),
Luvastatin (Mevacor, Altoprev), pravastatin
(pravachol)
Classification: HMG CoA reductase inhibitors
Action: Statins decrease cholesterol output by blocking
the HMG CoA reductase enzyme that the liver uses to
make cholesterol
Indication: patients with primary
hypercholesterolaemia, patient with existing heart
disease, people with an LDL level of 190 mg/dL or higher.
Contraindications: active hepatic disease, pregnancy
and breastfeeding.
Adverse Effects: constipation, nausea, headaches, cold-
like symptoms, sore muscles (with or without muscle
injury), increased blood glucose levels, reversible
memory issues.
Nursing Considerations:
• Instruct patients to avoid intake of grapefruit
products as these increase the side effects.
• Instruct the patient to limit the amount of alcohol
intake when taking statin because it increases the
risk of liver damage.
• Monitor liver function tests prior to initiation of
therapy and as clinically indicated. If symptoms of
serious liver injury, hyperbilirubinemia, or jaundice
occur discontinue atorvastatin/ezetimibe and do
not restart.
Bile Acid Sequestrants
Medications include cholestyramine (Questran,
Prevalite, Locholest), colestipol (Colestid)
Classification: Bile Acid Sequestrants
Action: These drugs bind to bile acids in the intestinal
lumen & prevent their normal reabsorption. The resin
itself (cholestryamine) is not absorbed from the GI tract.
Indication: patients having an isolated increase in LDL
Contraindications: patients with homozygous familial
hypercholesterolemia, patients with
hypertrigylceridemia (>250 mg/dL), hypersensitivity to
medication, patients with liver or gallbladder problems.
Adverse Effects: constipation, abdominal pain, bloating,
vomiting, diarrhea, weight loss, excessive passage of gas,
heartburn, gallstones.
44
 Nursing Considerations:
• Inform patient that bile acid sequestrants reduce
the absorption of vitamin A, D, E, and K. Long-term
use may cause a deficiency of vitamin A, D, E, and
K.
• Instruct patient to tell his/her provider about all
medicines, supplements, vitamins, and herbs
he/she is taking or will take. Certain medicines may
interact with bile acid sequestrants.
Nursing Management
Nursing Problems
• Imbalanced Nutrition: Less than Body Requirements
• Risk for Unstable Blood Glucose
• Risk for Impaired skin integrity
• Risk for Infection
• Deficient Knowledge
• Risk for Ineffective Therapeutic Regimen Management
Nursing Considerations
• Assess for signs of hyperglycemia.
• Assess blood glucose levels before meals and at bedtime
• Explore patient’s health beliefs about physical exercise and
review exercise program recommendations with the patient.
• Determine the blood glucose levels of the patient before
exercising
• Assess the patient’s current knowledge and understanding
about the prescribed diet.
• Review meal plan with the client that focuses on the
recommended distribution of calories from carbohydrates, fats,
proteins, and other sources.
• Teach patient how to perform home glucose monitoring
• Instruct patient on the proper injection of insulin.
• Instruct patient on the proper storage of insulin
• Instruct patient that insulin vial that is in use should be kept at
room temperature.
• Educate patient on the correct rotation of injection sites when
administering insulin.
• Stress the importance of achieving blood glucose control.
• Explain the importance of weight loss to obese patients with
diabetes.
• Explain the importance of having consistent meal content or
timing.
• Refer the patient to support groups, diet and nutrition education
and counseling.
• Educate the patient about the health benefits and importance of
exercise in the management of Diabetes.
• Provide instructions to patients using self-monitoring blood
glucose (SMBG).
• Report BP of more than 160 mm Hg (systolic). Administer
hypertensive medications as prescribed.
Type 2 Diabetes Mellitus
Definition
• Type 2 diabetes is a chronic disease. It is characterized by high
levels of sugar in the blood. Type 2 diabetes is also called adult-
onset diabetes because it used to start almost always in middle-
and late- adulthood. However, more and more children and
teens are developing this condition.
• Type 2 diabetes is much more common than type 1 diabetes,
and is a different disease, but it shares with type 1 diabetes the
high blood sugar levels and the complications of high blood
sugar.
• Type 2 diabetes occurs when your body's cells resist the normal
effect of insulin, which is to drive glucose in the blood into the
inside of the cells. This condition is called insulin resistance. As a
result, glucose starts to build up in the blood. In people with
insulin resistance, the pancreas "sees" the blood glucose level
rising.
• The pancreas responds by making extra insulin to maintain a
normal blood sugar. Over time, the body's insulin resistance gets
worse. In response the pancreas makes more and more insulin.
Finally, the pancreas gets "exhausted"; it cannot keep up with
the demand for more and more insulin. As a result, blood glucose
levels start to rise.
Signs and Symptoms
• Increased thirst
• Frequent urination
• Increased hunger
• Unintended weight loss
• Fatigue
• Blurred vision
• Slow-healing sores
• Frequent infections
Risk Factors
• Diabetogenic Lifestyle (excessive caloric intake, inadequate
caloric expenditure, obesity)
• Patients taking glucocorticoids or when the patients have
conditions that antagonize the actions of insulin (e.g. Cushing
syndrome, acromegaly, pheochromocytoma)
• Age greater than 45 years (though, as noted above, type 2
diabetes mellitus is occurring with increasing frequency in young
individuals)
• Weight greater than 120% of desirable body weight
• Family history of type 2 diabetes in a first-degree relative
• Hispanic, Native American, African American, Asian American, or
Pacific Islander descent
• History of previous impaired glucose tolerance (IGT) or impaired
fasting glucose (IFG)
• Hypertension (>140/90 mmHg) or Dyslipidemia (HDL cholesterol
level <40 mg/dL or triglyceride level >150 mg/dL)
• History of gestational diabetes mellitus or of delivering a baby
with a birth weight of over 9 lb
• Polycystic ovarian syndrome ( which results in insulin resistance).
Complications
• Five times more likely to get heart disease or have a stroke. At
high risk of blocked blood vessels (atherosclerosis) and chest
pain (angina)
45
• High blood sugar can damage the tiny blood vessels in the back • Aerobic exercise. Choose an aerobic exercise that you enjoy,
of the eyes (retinopathy). If this isn’t treated, it can cause such as walking, swimming, biking or running. Adults should aim
blindness. for 30 minutes or more of moderate aerobic exercise on most
• Blood doesn’t circulate as well, so wounds heal slower and can days of the week, or at least 150 minutes a week.
become infected.
• Resistance exercise. Resistance exercise increases your
Laboratory and Diagnostic Procedures strength, balance and ability to perform activities of daily living
more easily. Resistance training includes weightlifting, yoga and
• Random Blood Sugar Test: A random blood sugar test checks the calisthenics.
blood glucose at a random time of day. Regardless of when the
patient last ate, a level of 200 mg/dL (11.1 mmol/L) or higher • Limit inactivity. Breaking up long bouts of inactivity, such as
suggests diabetes, especially if the patient also has signs and sitting at the computer, can help control blood sugar levels.
symptoms of diabetes, such as frequent urination and extreme
thirst. • Adults living with type 2 diabetes should aim for two to three
sessions of resistance exercise each week.
• Fasting Blood Sugar Test: A blood sample is taken after an
overnight fast. Results are interpreted as follows: • Children should engage in activities that build strength and
flexibility at least three days a week. This can include resistance
NORMAL Less than 100 mg/dL (5.6 exercises, sports and climbing on playground equipment.
mmol/L)
PREDIABETES 100 - 125 mg/dL (5.6 - 6.9 Weight Loss: Weight loss results in better control of blood sugar
mmol/L) levels, cholesterol, triglycerides and blood pressure. If overweight,
DIABETES 126 mg/dL (7mmol/L) or begin to see improvements in these factors after losing as little as 5%
higher on two separate of the body weight. However, the more weight being lost, the greater
tests the benefit to health and disease management.

Monitoring blood sugar: Monitoring is usually done with a small, at-

• A1C Test: The A1C test is a blood test that provides information home device called a blood glucose meter, which measures the
about the average levels of blood glucose, also called blood amount of sugar in a drop of your blood.
sugar, over the past 3 months.
• Oral Glucose Tolerance Test: This test is less commonly used • Keep a record of measurements to share with your health care
than the others, except during pregnancy. The patient needs to team.
fast overnight and then drink a sugary liquid at the doctor’s • You may need to check it once a day and before or after exercise.
office. Blood sugar levels are tested periodically for the next two • If you take insulin, you may need to do this multiple times a day.
hours. Results are interpreted as follows: • Continuous glucose monitoring is an electronic system that
records glucose levels every few minutes from a sensor placed
NORMAL Less than 140 mg/dL (7.8 under your skin. Information can be transmitted to a mobile
mmol/L device such as your phone, and the system can send alerts when
PREDIABETES 140 to 199 mg/dL (7.8 levels are too high or too low.
mmol/L to 11.0 mmol/L)
suggest DIABETES 200 mg/dL (11.1 mmol/L Diabetes Medication: If you can't maintain your target blood sugar
or higher after 2 HOURS level with diet and exercise, your doctor may prescribe diabetes
medications that help lower insulin levels or insulin therapy.

Medical – Surgical Management
Medical Management
Diet: It is important to center diet around:
• A regular schedule for meals and healthy snacks
• Smaller portion sizes
• More high-fiber foods, such as fruits, nonstarchy vegetables and
whole grains
• Fewer refined grains, starchy vegetables and sweets
• Modest servings of low-fat dairy, low-fat meats and fish
• Healthy cooking oils, such as olive oil or canola oil
• Fewer calories
Physical Activity: Exercise is important for losing weight or
maintaining a healthy weight. It also helps with regulating blood sugar
levels.
• Drug treatments for type 2 diabetes include the following:
o Metformin
o Sulfonylureas
o Glinides
o Thiazolidinediones
o DPP4 Inhibitors
o GLP-1 receptor agonists
o SGLT2 inhibitors
o Blood pressure and cholesterol- lowering medications,
as well as low-dose aspirin, to help prevent heart and
blood vessel disease.
Insulin Therapy: Different types of insulin vary on how quickly they
begin to work and how long they have an effect. Insulin type, dosage
and schedule may change depending on how stable your blood sugar
levels are. Side effects of insulin include the risk of low blood sugar
(hypoglycemia), diabetic ketoacidosis and high triglycerides.

46
• Long-acting insulin, for example, is designed to work overnight • semaglutide
or throughout the day to keep blood sugar levels stable. (Rybelsus, Ozempic)
• Short-acting insulin might be used at mealtime. SGLT2 Inhibitors • canagliflozin
(Invokana),
Surgical Management • dapagliflozin
(Farxiga) and
Bariatric Surgery. Weight-loss surgery can help treat type 2 diabetes • empagliflozin
by controlling the level of sugar in the blood. Majority of patients lose (Jardiance)
50 to 80% of the excess weight during the 18-24 months after surgery.

• Laparoscopic Roux-en-Y Gastric Bypass: This procedure involves Medications for Insulin Therapy
creating a small stomach pouch. The intestine is connected to
the new pouch and rerouted. The pouch is connected directly to Short-acting insulin • regular insulin
the lower part of the small intestine. Food bypasses the lower (Humulin and
stomach, the first part of the small intestine (duodenum) and Novolin)
some of the second part (jejunum). Rapid-acting insulins • insulin aspart
(NovoLog, FlexPen,
• Laparoscopic Sleeve Gastrectomy (LSG): LSG reduces the size of Fiasp)
the stomach and limits food intake. LSG is technically easier to • insulin glulisine
perform than gastric bypass and is a good surgical option in many (Apidra)
patients. Patients who are at risk for undergoing anesthesia, or • insulin lispro
(Humalog)
who have a heart or lung problem and should not undergo a long
• Intermediate-acting
surgery, may also benefit from this surgery.
insulin
• Duodenal Switch (DS): DS is another procedure that results in • insulin isophane
calories not being absorbed well. DS is a combination of LSG and (Humulin N, Novolin
N)
a large bypass procedure. The procedure creates a smaller
Long-acting insulins • insulin degludec
stomach that is connected to the farthest part of the small
(Tresiba)
intestine. The duodenum, jejunum and part of the proximal
• insulin detemir
ileum are bypassed and then connected to a point near the (Levemir)
ileocecal valve. The surgery is effective, but also riskier than • insulin glargine
other procedures. It is generally only for people who have BMI (Lantus)
higher than 50. • insulin glargine
(Toujeo)
• Laparoscopic Adjustable Gastric Banding: An inflatable band is Combination insulins • NovoLog Mix 70/30
placed around the upper part of the stomach. The band is (insulin aspart
adjusted by injecting saline into a subcutaneous port. • protamine-insulin
aspart)
Pharmacology • Humalog Mix 75/25
(insulin lispro
Alpha-Glucosidase • acarbose (Precose)
• protamine-insulin
Inhibitors • miglitol (Glyset)
lispro)
Biguanides Metformin (Glucophage
• Humalog Mix 50/50
Metformin Hydrochloride
(insulin lispro
ER, Glumetza, Riomet,
protamine-insulin
Fortamet)
lispro)
Sulfolynureas • glimepiride (Amaryl)
• Humulin 70/30
• glimepiride-
(human insulin NPH-
pioglitazone
human insulin
(Duetact)
regular)
• glimepiride-
• Novolin 70/30
rosiglitazone
(human insulin NPH-
(Avandaryl)
human insulin
• Gliclazide
regular)
• glipizide (Glucotrol)
• Ryzodeg (insulin
DPP-4 Inhibitors • sitagliptin (Januvia), degludec-insulin
• saxagliptin (Onglyza) aspart)
• linagliptin (Tradjenta)
GLP-1 Receptor Agonists • exenatide (Byetta,
Bydureon),
• liraglutide (Saxenda, General Nursing Considerations for Anti-Diabetic Medications
Victoza)

47
• Assess for contraindications or cautions (e.g. history of allergy to
the drugs, pregnancy and lactation status, severe renal or
hepatic dysfunction, etc.) which are contraindications in the use
of these agents.
• Perform a complete physical assessment to establish baseline
status before beginning therapy and to evaluate effectiveness
and any potential adverse effects during therapy.
• Assess orientation and reflexes; baseline pulse and blood
pressure; adventitious breath sounds; abdominal sounds and
function, to monitor effects of altered glucose levels.
• Assess body systems for changes suggesting possible
complications associated with poor blood glucose control.
• Investigate nutritional intake, noting any problems with intake
and adherence to prescribed diet, to help prevent adverse
reactions to drug therapy.
• Assess activity level, including amount and degree of exercise,
which can alter serum glucose levels and dosage needs for these
drugs.
• Monitor blood glucose levels as ordered to evaluate
effectiveness of drug and glycemic control.
• Monitor results of laboratory tests, including urinalysis, for
evidence of glycosuria, and renal and liver function tests, to
determine the need for possible dose adjustment and evaluate
for signs of toxicity.
• Administer the drug as prescribed in the appropriate
relationship to meals to ensure therapeutic effectiveness.
• Ensure that patient has dietary and exercise regimen and using
good hygiene practices to improve the effectiveness of the
insulin and decrease adverse effects of the disease.
• Monitor nutritional status to provide nutritional consultation as
needed.
• Monitor response carefully; blood glucose monitoring is the
most effective way to evaluate dose. Obtain blood glucose levels
as ordered to monitor drug effectiveness.
• Monitor patients during times of trauma, pregnancy, or severe
stress, and arrange to switch to insulin coverage as needed.
• Provide comfort measures to help patient cope with drug
effects.
• Provide patient education about drug effects and warning signs
to report to enhance patient knowledge and to promote
compliance.
• Monitor patient response to therapy (stabilization of blood
glucose levels).
• Monitor for adverse effects (hypoglycemia and gastrointestinal
distress).
• Evaluate patient understanding on drug therapy by asking
patient to name the drug, its indication, and adverse effects to
watch for.
• Monitor patient compliance to drug therapy.
Nursing Management
Nursing Problems
• Risk for Unstable Blood Glucose
• Deficient Knowledge
• Risk for Infection
• Risk for Disturbed Sensory Perception
• Powerlessness
• Risk for Ineffective Therapeutic Regimen Management
• Risk for Injury
• Imbalanced Nutrition: Less Than Body Requirements
• Risk for Deficient Fluid Volume
Nursing Considerations
• Screening, prevention, and early detection of type 2 diabetes
o Describe the risk factors for Type 2 Diabetes.
o Explain the importance of prevention or delay of onset
of type 2 diabetes in individuals at risk Explain the role
that exercise plays in the prevention of, or delay in
progression to type 2 diabetes.
o Explain the importance of weight control and the role
that diet plays in the prevention of, or delay in
progression to type 2 diabetes.
• Promoting self care
o Support the patient and help develop their own self-
care with guidance from a registered nurse.
o Observe and report for any concerns that you may
have about a patient that would affect their ability to
self-care.
o Encourage patient to use their personalized care plans.
• Mental Health
o Have an understanding and awareness of how mental
health issues, such as depression and anxiety, can
affect people with diabetes.
o Report any changes that you notice in the patient’s
normal mental health, to a registered nurse or doctor.
This could include changes in medications adherence,
mood, and appearance and also anxiety.
• Nutrition
o Identify food and drinks high in sugar content.
o Follow the nutritional plan and report any related
problems.
o Measure and record the waist circumference, height,
and weight of your patient accurately.
o Report if meals are not eaten, especially
carbohydrates, if the patient is using insulin or blood
glucose lowering therapies.
• Urine Monitoring
o Perform the test according to the manufacturer’s
instructions and local guidelines.
o Document and report the results following local
guidelines and procedures.
• Blood Glucose Monitoring
o Perform the test according to manufacturer's’
instructions and local guidelines.
o Document and report the result according to local
guidelines and procedures.
o Recognize and follow local quality assurance
procedure, including disposal of sharps.
o Recognize hypoglycemia and be able to administer
glucose.
o Understand the normal range of glycemia and report
any readings outside this range to the appropriate
person.
• Oral Therapies
48
 o Describe the effect an oral antihyperglycemic agent • Weight loss • Weight loss
has on blood glucose levels • Fatigue • Fatigue
o Demonstrate an understanding of the on- going nature • Fruity smelling • Blurred vision
of the therapy breath • Slow healing sores or
o Report any identified problems appropriately • Irritability frequent infections
o Recognize the signs of hypoglycemia and administer • Blurred vision
• Slow healing sores or
glucose
frequent infections
• Injectable therapies
Diabetes prevention
o Describe the effect of insulin on blood glucose levels.
There is NO WAY to Most cases of type 2
o Be aware of local sharps disposal policy.
prevent type 1 diabetes diabetes can be prevented
o Show and understanding of the on-going nature of the Diabetes treatment
therapy. • Insulin injections • Healthy eating and
o Administer insulin competently where supported by • Blood sugar checks meal planning
local policy. • Healthy eating and • Increased physical
o Report identified problems appropriately. meal planning activity
o All nursing staff who handle prescribe or administer
insulin should undertake a training course e.g. NHS
Diabetes - safe use of insulin e- learning. “With all of the holiday cheer in the air, it's easy to overlook the
• Hypoglycemia ingredients in the foods. Ingredients such as salt, sugar, and fat - all of
o State the normal blood glucose range. which leads to diseases such as high blood pressure, diabetes,
o Describe the mild and severe signs and symptoms of strokes, heart disease, and cancer.” — Lee Haney
hypoglycemia.
o Demonstrate competent use of blood glucose
monitoring equipment to confirm hypoglycemia.
o Offer appropriate treatment as per local guidelines.
o Know where treatment for hypoglycemia is stored. Acute Complications of Diabetes Mellitus
o Reassure and comfort the person with diabetes and
Objectives
their carer.
1. Identify and Define the Acute Complications of DM
o Document and report a hypoglycemia event to a
2. Understand its Pathophysiology
registered nurse.
3. Know the different Laboratory and Diagnostic tests needed
o Recognize that older people may not demonstrate
4. Determine the Medical/Pharmacologic/Surgical Management
clear signs and symptoms of hypoglycemia.
5. Provide appropriate Nursing
o If the person with diabetes is unresponsive, ensure
HYPOGLYCEMIA
their airway is clear and call emergency services.
Where the level of sugar (glucose) in your blood drops too low (<70
• Hyperglycemia
mg/dL)
o State the normal blood glucose range
o Describe the signs and symptoms of hyperglycemia
Causes:
o Perform blood and ketone tests according to local
• Incorrect Insulin Administration
guidelines
• Insufficient exogenous carbohydrate intake
o Correctly document the results and report those out
• Increased utilization of carbohydrate /depletion of hepatic
of the accepted range to the appropriate person
glycogen stores
o Recognize that older people may be asymptomatic of
hyperglycemia • Increased insulin sensitivity
• Medications
Diabetes Type 1 vs Type 2 • Critical Illness (Hepatic, Renal or Cardiac Failure)
• Hormone Deficiency
Type 1 Type 2 ✓ Cortisol
Insulin production
✓ Glucagon
The body does not make The body cannot use
✓ Epinephrine
enough insulin = INSULIN insulin properly = INSULIN
DEPENDENT RESISTANT
Age at diagnosis
Usually ages 0 to 40 Usually ages 40+ (mostly
(mostly young children or adults but occurring in
teens) children and teens who
are overweight and obese)
Symptoms of diabetes
• Decreased thirst & • Increased thirst &
urination urination

49
 Pharmacologic Treatment

Glucose Supplements
• used to raise the patient's serum glucose

dextrose (d-Glucose)
• monosaccharide that is absorbed from the intestine and
distributed, stored, and used by tissues
• Parenterally injected
• Effective in small doses
• Concentrated dextrose infusions provide higher amounts of
glucose and increased caloric intake with minimum fluid
volume
Signs and symptoms of hypoglycemia
• Anxiety
Glucose Supplements: Nursing Considerations
• Irritability
• Educate the patient on drug interactions with magnesium
• Trembling
• Pallor chloride, magnesium citrate, magnesium hydroxide,
• Palpitations magnesium oxide, and magnesium sulfate.
• Increasing Systolic BP • Educate the patient on adverse effects such as:
• Tachycardia o Hyperosmolarity
• Sweating o Edema
• Hunger o venous thrombosis
• Blurry Vision o Tachypnea
• Confusion o Fever
• Can’t concentrate o Hyperosmolar syndrome
• Weakness o Hypervolemia
o Phlebitis
Laboratory and Diagnostic Tests o Diarrhea
A diagnosis of hypoglycemia is not based only on symptoms. o Polydipsia
o Pulmonary edema
Whipple’s Triad o Cerebral hemorrhage
• low blood glucose level o Mental confusion
• Symptoms of hypoglycemia at the time of the low glucose level o Unconsciousness
• Symptoms of relief with treatment of hypoglycemia o Cerebral ischemia
o Hypophosphatemia
o Hypomagnesemia
o Hyperglycemia
o Injection site extravasation
o Tissue necrosis.

• Use caution in DM or carbohydrate intolerance; reduce the

rate of infusion to reduce the possibilities of causing
hyperglycemia and glycosuria.
• Give 5% or 10% dextrose to avoid reactive hypoglycemia when
highly concentrated dextrose infusion is abruptly withdrawn.
• An unexpected rise in blood glucose level in a stable patient
may be an early symptom of infection; monitor for signs and
symptoms of infection and laboratory parameters.
• Rebound hypoglycemia may occur following abrupt
Capillary Blood Glucose (CBG) Test withdrawal.
• the use of a glucose meter for testing the concentration of • Hypertonic solutions (>10%) may cause thrombosis when
glucose in the blood infused through peripheral veins; best to infuse through a
central venous catheter.
VALUES • Monitor changes in fluid balance, electrolyte concentrations,
<70 mg/dL Hypoglycemia and acid-base balance during prolonged use.
20 – 40 mg/dL Seizures may occur • Monitor glucose levels and for possible hyperglycemia when
<20 mg/dL Severe hypoglycemia treating pediatric patients.

50
• Dextrose injection contains aluminum that may be toxic;
patients with impaired renal function, and preterm infants, at
higher risk; limit aluminum to <4 mcg/kg/day.
• Parenteral nutrition associated with liver disease; increased risk
in patients who receive parenteral nutrition for extended
periods of time, especially preterm infants; monitor liver
function tests, if abnormalities occur consider discontinuation
or dosage reduction.
• Monitor blood glucose and administer insulin as needed.
Glucose Elevating Agents
• act in the pancreas or the peripheral tissues to increase blood
glucose levels
• MOA: Elevates blood glucose levels by inhibiting glycogen
synthesis and enhancing gluconeogenesis
• Glucagon also increases hydrolysis of glycogen to glucose
(glycogenolysis) in the liver
• Indications: when IV administration of dextrose is problematic
• EMS protocol in patients with altered mental status
• ready-to-use subcutaneous (SC) solution in prefilled syringes or
an autoinjector
Glucose Elevating Agents: Nursing Considerations
• Inform patients of the symptoms of
hypoglycemia and how to treat it.
• Inform patients that generalized allergic
reactions have been reported with glucagon
treatment including generalized rash, and in
some cases anaphylactic shock with breathing
difficulties, and hypotension. Advise patients to
monitor and report any signs or symptoms of a
hypersensitivity reaction.
• Advise patients to avoid driving or operating
machinery until ingesting a meal
• Inform patients with DM that treatment with
Glucagon for Injection may increase their risk of
hyperglycemia.
• Inform patients with cardiac disease that treatment with
Glucagon for injection may increase their risk of a transient
increase in blood pressure and heart rate.
• Treatment is effective in treating hypoglycemia only if
sufficient hepatic glycogen present; patients in states of
starvation, with adrenal insufficiency or chronic hypoglycemia
may not have adequate levels of hepatic glycogen for therapy
to be effective; patients with these conditions should be
treated with glucose.
• Caution should be observed when used as an adjunct in
endoscopic or radiographic procedures to inhibit
gastrointestinal motility in patients with known cardiac
disease.
• Do not administer to patients suspected of having insulinoma.
• Patients taking beta-blockers may have a greater increase in
both pulse and blood pressure, an increase of which will be
temporary because of glucagon’s short half-life.
• When used with indomethacin, glucagon may lose its ability to
raise blood glucose or may even produce hypoglycemia.
• Coadministration with an anticholinergic drug is not
recommended due to increased gastrointestinal side effects.
• Glucagon may increase the anticoagulant effect of warfarin.
• Insulin reacts antagonistically towards glucagon. Use with
caution when used as a diagnostic aid in diabetes patients
Intranasal Glucagon
• MOA: activates hepatic glucagon receptors, which stimulate
cyclic adenosine monophosphate (cAMP) synthesis
• Indication: severe hypoglycemic reactions in adults and
children (aged 4 years or older) with diabetes
• Allergic reactions reported including anaphylactic shock with
breathing difficulties and hypotension.
• Contraindicated with pheochromocytoma; glucagon may
stimulate catecholamine release from the tumor; if blood
pressure (BP) increases dramatically and undiagnosed
pheochromocytoma is suspected, administer phentolamine 5-
10 mg IV to lower BP.
• Effective for hypoglycemia only if sufficient hepatic glycogen is
present; patients in states of starvation, with adrenal
insufficiency, or chronic hypoglycemia may not have adequate
levels of hepatic glycogen for glucagon to be effective; treat
these patients with glucose.
• Patients taking beta-blockers may have transiently increased
pulse and BP when administered glucagon.
• In patients taking indomethacin, glucagon may lose its ability to
raise blood glucose or may even produce hypoglycemia.
• Glucagon may increase anticoagulant effect of warfarin.
Inhibitors of Insulin Secretion
• increase glucose levels by reducing peripheral glucose
metabolism
diazoxide (Proglycem)
• direct inhibitor of insulin secretion
• increases hepatic glucose output by inhibiting pancreatic insulin
release
• decreases cellular glucose uptake
• Indications:
o help improve symptoms of hypoglycemia caused by
increased insulin secretion in patients awaiting
surgery.
o those with unresectable disease and may be
indicated in some cases of insulinoma or overdosage
with oral (PO) hypoglycemic agents.
• Hyperglycemic effect starts within 1 hour, lasting a maximum of
8 hours if the patient's renal function is normal.
• Patients with refractory hypoglycemia may require high
dosages
diazoxide (Proglycem): nursing Considerations
• Administer with food.
• Observe for signs of adverse effects.
• Monitor glucose levels carefully.
• Monitor blood pressure (preferably continuously).
51
• Continuous cardiorespiratory monitoring. Observe arrhythmias.
• Monitor fluid balance carefully.
• Weigh daily.
• Use caution in coronary or cerebral insufficiency, DM,
extravasation, heart failure (may increase fluid retention),
cardiovascular insufficiency, gout, hypotension, hypokalemia,
liver disease, renal dysfunction.
• Ketoacidosis and nonketotic hyperosmolar coma reported in
patients treated with recommended doses usually during
intercurrent illness; prompt recognition and treatment
essential and prolonged surveillance following the acute
episode necessary because of long drug half-life of
approximately 30 hours.
• Effects of diazoxide on the hematopoietic system and the level
of serum uric acid kept in mind; the latter should be considered
particularly in patients with hyperuricemia or a history of gout.
• Antihypertensive effect of other drugs may be enhanced by
diazoxide; should keep this in mind when administering it
concomitantly with antihypertensive agents.
• Because of protein binding, administration of diazoxide with
coumarin or its derivatives may require reduction in dosage of
anticoagulants
ocreotide (Sandostatin)
• acts primarily on somatostatin
receptor subtypes II and V
• inhibits growth hormone secretion and
has a multitude of other endocrine and
nonendocrine effects, including
inhibition of glucagon, vasoactive
intestinal peptides (VIP), and
gastrointestinal peptides.
ocreotide (Sandostatin): nursing considerations
• Monitor lab tests: Periodic blood glucose, liver function tests,
and serum electrolytes.
• Monitor for hypoglycemia and hyperglycemia because
octreotide may alter the balance between insulin, glucagon,
and growth hormone.
• Monitor fluid and electrolyte balance, as octreotide stimulates
fluid and electrolyte absorption from GI tract.
• Dietary fat absorption may be altered in some clients. Monitor
fecal fat and serum carotene to aid in the assessment of
possible drug-induced aggravation of fat malabsorption.
• Use caution in patients with hepatic impairment; patients with
established cirrhosis may necessitate dosage adjustment.
• Use caution in patients with renal impairment; patients
receiving dialysis may necessitate dosage adjustment.
• Monitor for pancreatitis; may alter fat absorption in some
patients.
• Monitor for cholelithiasis; may impair gallbladder function.
• Monitor Vitamin B12 levels; may decrease levels.
• Monitor for hypothyroidism; octreotide suppresses secretion
of TSH).
• Use caution when giving drug to patients with cardiovascular
disease.
• Use caution in patients with heart failure or concomitant
medications that may alter heart rate or rhythm; arrhythmia,
conduction abnormalities, and bradycardia reported in
acromegalic and carcinoid syndrome patients
• Somatostatin analogs may affect glucose regulation; severe
hypoglycemia may occur in type 1 diabetes patients;
hyperglycemia may occur in type 2 diabetes or patients without
diabetes; therapy may worsen hypoglycemia in patients with
insulinomas; use with caution.
• Dosage adjustments may be necessary in the elderly.
• Females of childbearing age should use adequate
contraception because the treatment may restore fertility.
• In patients maintained on total parenteral nutrition (TPN),
monitoring for elevations in zinc levels recommended.
• May reduce excessive fluid loss in patients with conditions
that cause fluid losses.
• Coadministration with cyclosporine may decrease blood levels
of cyclosporine and result in transplant rejection.
Antineoplastic Agents
• Inhibit cell growth and proliferation
streptozocin (Zanosar)
• high affinity for neuroendocrine cells, inhibits
cell proliferation, and is cytolytic
• indicated in the treatment of metastatic
islet cell carcinoma of the pancreas
streptozocin (Zanosar): Nursing considerations
• Monitor lab tests: Perform CBC at least weekly, and liver
function tests prior to each course of therapy.
• Ensure that repeat courses of streptozocin treatment are not
given until the patient's liver, kidney, and hematologic
functions are within acceptable limits.
• Report evidence of drug-induced declining kidney function
promptly; changes are dose related and cumulative.
• Be alert to early laboratory evidence of kidney dysfunction:
Hypophosphatemia, mild proteinuria, and changes in I&O ratio
and pattern.
• Mild adverse renal effects may be reversible following
discontinuation of streptozocin, but nephrotoxicity may be
irreversible, severe, or fatal.
• Be alert to symptoms of sepsis and superinfections (leukopenia)
or increased tendency to bleed (thrombocytopenia). Monitor
S/Sx of Superinfection
• Monitor and record temperature pattern to promptly recognize
impending sepsis.
streptozocin (Zanosar): Blackbox warnings
• The drug should be
administered under the
supervision of an experienced
cancer chemotherapy physician
in a facility equipped to monitor
drug tolerance and to protect
and maintain a patient compromised by drug toxicity.
• Renal toxicity is dose-related and cumulative and may be
severe or fatal.
52
• Nausea and vomiting may be severe and treatment limiting at
times.
• Liver dysfunction, diarrhea, and hematologic changes reported.
• Parenteral streptozocin is mutagenic and found to be
tumorigenic in some rodents.
• The physician must weigh risks versus benefits to the patient.
Medical Management
WORKING WITH A DIETICIAN: MEAL PLAN ADJUSTMENTS
• Plate Method
• Calorie Counting
• maintains consistency in carbohydrates at meaLS
CONTINUOUS OF MONITORING OF BLOOD USGAR LEVELS
• Knowing your blood glucose level throughout the day—when
you get up, before meals, after meals, etc.—can help you avoid
going low.
• LIMITING CONSUMPTION OF ALCOHOLIC BEVERAGES
Alcohol can affect the way your body metabolizes glucose, so if
you're already prone to hypoglycemia, you should cut back on
how much alcohol you drink.
EMERGENCY GLUCOSE: CARRY GLUCOSE TABLETS/HARD CANDY
• Recheck blood sugar 15 minutes after eating the tablets or
candy
• If it has not returned to normal, you will need to give yourself
glucose again.
• If you are having trouble raising your blood sugar to normal,
you should contact your doctor.
SURGICAL MANAGEMENT
PANCREATECTOMY
• Cells in the pancreas produce insulin, so some types of
pancreatic tumor can cause the pancreas to make too much
insulin. In these rare cases, part of the pancreas can be
removed to reduce the amount of insulin produced.
NURSING MANAGEMENT
Acute Confusion
• may be related to inadequate glucose for cellular brain function
and effects of endogenous hormone activity, possibly
evidenced by increased restlessness, misperceptions, or
fluctuation in cognition/ level of consciousness.
Risk for Unstable Blood Glucose Level
• possibly evidenced by risk factors of dietary intake, lack of
adherence to diabetes management, inadequate blood glucose
monitoring, medication management.
Deficient Knowledge regarding pathophysiology of condition,
therapy, and self-care needs
• may be related to lack of information or recall,
misinterpretations, possibly evidenced by development of
hypoglycemia and statements of questions, misconceptions
GENERAL NURSING CONSIDERATIONS
• Obtain a complete patient history including the last alcohol
intake and medications.
• Educate the patient on the importance of monitoring his/her
blood sugar level as often as directed by his/her physician.
✓ For conscious patients with blood glucose levels below
60mg/dl give at least 10-15g of fast-acting simple
carbohydrates
✓ For unconscious patients and patients unable to
swallow administer dextrose 50% 50ml bolus per IV as
prescribed
• Refer the patient to a dietician for diet modifications.
• Advise the patient to avoid sugary foods and eat frequent
small meals during the day.
• Advise the patient to check his/her blood sugar 15 minutes
after he/she has eaten food with sugar in it.
• Educate the patient about the importance of bringing candy or
any fast-acting carbohydrate such as sugar-free soft drink and
glucose tablets/gel
• Educate the patient that alcohol drinking may cause low levels
of blood glucose
• Inform the patient that insulin treatment can cause low
blood sugar, and so can a type of diabetes medication
(i.e.,sulfonylureas)
• Advise the patient not to drive when he/she is
experiencing symptoms of hypoglycemia
• Keep a sugar source in the car at all times for emergencies
• Educate him/her ways he/she can prevent hypoglycemia which
include:
• Following his/her meal plan
• Eating at least three evenly spaced meals each day with
between-meal snacks as prescribed
• Planning meals no more than 4 to 5 hours apart
• Exercising 30 minutes to 1 hour after meals. Check sugars
before and after exercise, and discuss with his/her doctor
what types of changes can be made
• Double-checking
insulin and dose of
diabetes medicine
before taking it
• If drinking alcohol, be
moderate and monitor
blood sugar levels
• Knowing when the medicine is at its peak level.
• Testing blood sugar as often as directed by his/her doctor.
• Carrying an identification bracelet that says he/she has
diabetes.
DIABETIC KETOACIDOSIS
• A life-threatening problem that affects people with diabetes
• Insufficient/ No insulin in the body
• Liver releases its glucose stores
• Body starts breaking down fat instead
• Ketones as a by-product
• Main Characteristics
1. Hyperglycemia
2. Ketosis
3. Acidosis
53

Causes
• Untreated/ Undetected Diabetes
• Insufficient/ Absent Insulin due to: illness/ infection, stress,
medications (corticosteroids or thiazide diuretics)
• Not eating or skipping meals
• Not taking insulin medication
Risk Factors
• Have type 1 diabetes
• Have had some form of trauma, either emotional or physical
• Stress
• Have an infection with high fever
• Have had a heart attack or stroke
• Smokes
• Have a drug or alcohol addiction
Complications
• Low levels of potassium (hypokalemia)
• Swelling inside the brain (cerebral edema)
• Fluid inside your lungs (pulmonary edema)
• Damage to your kidney or other organs from your fluid loss
A. Health History and Physical Assessment
Signs and Symptoms
• Symptoms occur suddenly
• Warning sign: BS >300 mg/dl
• Hyperglycemia: may vary between 300-800 mg/dl
• Ketosis
• Metabolic acidosis: low pH level( 6.8-7.3)
• Polyuria
• Polydipsia
• Dehydration: dry mucous membranes, face flushed, decreased
skin turgor, tachycardia, hypotension, blurred vision, weakness,
headache
• N/V, abdominal pain
• Kussmaul breathing
• Acetone breath
• Ketones in urine
• Fatigue
• Confusion
• Weight loss
Diagnostic Findings
• Blood glucose levels may vary between 300 and 800 mg/dl
(depending on the degree of dehydration).
• The severity of DKA depends on the Low serum bicarbonate
level( 0-15mEq/L) and low pH level( 6.8-7.3).
• A low partial pressure of carbon dioxide (PCO2 10-30mmHg)
reflects respiratory compensation or Kussmaul respirations.
• Accumulation of ketone bodies is reflected in blood and urine
ketone measurements.
• Electrolytes depletion depends on the degree of dehydration.
• Increased levels of creatinine, BUN and hematocrit may have
increased levels depending on the degree of dehydration.
• An anion gap (AG) is a measure of acid-base balance. During
metabolic acidosis, there is a high anion gap value (>10mEq/L),
meaning the body’s blood is more acidic than normal
B. Diagnostic Test and Nursing Implications
Metabolic function studies
• Measurement of A1C, BUN, creatinine, serum glucose,
electrolytes, pH, serum ketones, calculation of anion gap
and osmolar gap
a. Before:
• Define and explain the test
• State the specific purpose of the test
• Instruct the patient to fast for at least 8 hours prior to
the blood draw.
• Discuss test preparation, procedure, and posttest care
b. During:
▪ Ensure that the patient has complied with dietary
restrictions and other pre testing preparations.
▪ Phlebotomist performs venipuncture.
C. After:
• After blood extraction, the client is instructed to apply
gentle pressure over a clean dressing.
54
• The blood sample is then sent to the laboratory, where it
would be analyzed as the healthcare practitioner has
ordered.
• Instruct the patient to resume usual diet, as directed by
the HCP.
Complete Blood Count
• Even in the absence of infection, the CBC shows an
increased white blood cell (WBC) count.
Before:
• Define and explain the test
• State the specific purpose of the test
• Discuss test preparation, procedure, and posttest care
During:
• The phlebotomist identifies a vein in the crook of the
elbow and applies a tourniquet above the site to make
the vein look more apparent. Aseptic technique is done
before venipuncture.
• During venipuncture, the phlebotomist inserts a needle
through the skin into a vein.
• The amount of blood needed for the test is withdrawn
through the needle into a special tube or tubes. The
procedure usually takes less than 3 minutes.
After:
o After blood extraction, the client is instructed to apply
gentle pressure over a clean dressing to help the blood
clot and prevent swelling and hematoma.
o The blood sample is then sent to the laboratory, where it
would be analyzed as the healthcare practitioner has
ordered.
Urine analysis/ Urine dipstick test
• Glucose and ketones are usually present.
Before:
• Define and explain the test
• State the specific purpose of the test
• Discuss test preparation, procedure, and posttest care
During:
• Instruct the steps on how to appropriately collect a
clean-catch or midstream specimen as ordered.
After:
• Transport the urine specimen to the laboratory promptly.
Electrocardiography
• Patients suffering from diabetic ketoacidosis (DKA) may
exhibit electrocardiographic (EKG) changes. Common
abnormalities observed on EKG include tall peaking T
waves, prolonged QT interval and widening of QRS
complex
Before:
• Define and explain the test
• State the specific purpose of the test
• Discuss test preparation, procedure, and posttest care
During:
• Ensure the patient has removed all external metallic
objects from the area to be examined prior to the
procedure.
• Instruct the patient to void prior to the procedure and to
change into the gown, robe, and foot coverings provided.
• Instruct the patient to remain still throughout the
procedure because movement produces unreliable
results.
• Record baseline values.
• Place the patient in a supine position.
• Prepare the skin surface with alcohol and remove excess
hair. Shaving may be necessary. Dry skin sites.
• Apply the electrodes in the proper position.
• The machine is set and turned on after the electrodes,
grounding, connections, paper supply, computer, and
data storage device are checked.
• If the patient has any chest discomfort or pain during the
procedure, mark the ECG strip indicating that
occurrence.
After:
• A report of the examination will be sent to the
requesting HCP, who will discuss the results with the
patient.
• When the procedure is complete, remove the electrodes
and clean the skin where the electrode pads were
applied.
Fasting Blood Glucose
• High glucose levels may be observed
Before
• Define and explain the test
• State the specific purpose of the test
• Instruct the patient to fast for at least 12 hr before
specimen collection.
• Discuss test preparation, procedure, and posttest care
During
• Ensure that the patient has complied with dietary
restrictions and other pre testing preparations.
• Phlebotomist performs venipuncture.
55
After
• After blood extraction, the client is instructed to apply
gentle pressure over a clean dressing.
• The blood sample is then sent to the laboratory, where it
would be analyzed as the healthcare practitioner has
ordered.
• Instruct the patient to resume usual diet, as directed by
the HCP.
Glycosylated Hemoglobin
• > 6.5% may indicate diabetes)
Before:
o Define and explain the test
o State the specific purpose of the test
o Discuss test preparation, procedure, and posttest care
During:
• Phlebotomist performs venipuncture.
After:
o After blood extraction, the client is instructed to apply
gentle pressure over a clean dressing.
o The blood sample is then sent to the laboratory, where it
would be analyzed as the healthcare practitioner has
ordered.
C. Medical Management
• Management of DKA is aimed at correcting dehydration,
electrolyte loss and acidosis before correcting the
hyperglycemia with insulin.
Rehydration
• Fluid replacement of as much as 6 to 10 L Iv fluid may be
needed, it also enhances the excretion of glucose by the
kidneys.
• When blood glucose level reaches 300mg/dL or less, the
IV solution may be changed to dextrose 5% in water
(D5W) to prevent a precipitous decline in the blood
glucose level.
• Frequent monitoring of V/S, I&O, and lung assessment
• Monitor for signs of fluid overload
Restoring Electrolyes
• Serum potassium level must be monitored frequently.
• Insulin administration enhances the movement of
potassium from the extracellular fluid into the cells.
• Frequent monitoring of ECGs and laboratory
measurements are necessary.
• Potassium replacement is withheld only if hyperkalemia
is present or if the patient is not urinating
Reversing Acidosis
• The acidosis with DKA is reversed with insulin
administration, which inhibits fat breakdown, thereby
ending ketone production and acid buildup.
• Insulin is usually infused IV at a slow, continuous rate.
• Hourly blood glucose must be measured.
• Regular insulin is the only type of insulin approved for IV
use, and may be added to IV solutions.
• Insulin must be infused continuously until subcutaneous
administration can be resumed.
• The rate or the concentration of dextrose infusion may
be increased to prevent hypoglycemia.
• Blood glucose levels are corrected before acidosis, IV
insulin administration is continued until 12 to 24 hours,
until the serum bicarbonate level increases, and until the
patient can eat.
Regular Insulin (Humulin-R)
• C - Hormones
• A - Insulin helps control blood glucose levels by signaling
the liver and muscle and fat cells to take in glucose from
the blood.
• I - Diabetes mellitus, Hyperglycemia, Diabetic
Ketoacidosis
• C - hypoglycemia
• A - Insulin resistance, lipodystrophy, hypersensitivity
reaction, lightheadedness, sweating, palpitation, tremor,
hunger, restlessness, tingling of the hands and feet
• N - Medication is subcutaneously administered 20-30
minutes before a meal
D. Pharmacology with Nursing Considerations
• Check the patient's most recent blood glucose level,
dietary intake and sign and symptoms of hyperglycemia
or hypoglycemia.
• Perform hand hygiene before administering the drug.
• Check expiry date before administration.
• Clean the injection site with an alcohol swab before
administration
• Educate the patient about the signs and symptoms, and
management of hypoglycemia.
• Administer insulin at room temperature and rotate sites
to avoid lipodystrophy.
• Only regular, short-acting insulin may be given
intravenously, if it is incorporated in the patient’s IV bag,
always label the bag and indicate the amount of insulin
incorporated.
E. Nursing management
56
1. Nursing Problems
• Deficient fluid volume related to electrolyte loss
• Risk for infection related to weakened immune system
secondary to Diabetes
• Imbalanced nutrition, less than body requirements
• Unstable Blood Glucose level related to hyperglycemia
• Fatigue related to unable to meet energy needs
• Deficient knowledge regarding individual care needs and
treatment related to missed insulin dose
2. Nursing Considerations
• Priority on patient education: In case of hypoglycemic
episode (<70 mg/dl; S/S such as feeling dizzy and weak):
drink a cup of fruit juice or chew on a hard candy
• Patient teaching on how to use a blood glucose meter
device.
• In keeping blood sugar in control: change diet according
to HCP’s advice, cessation of smoking, and regular
exercise
• In preventing further health problems: take medications
as prescribed, have a complete eye exam, regularly check
skin integrity, monitor blood pressure, blood sugar, and
weight, have a yearly blood cholesterol test, identify
measures that could alleviate stress
HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC SYNDROME
• It is a metabolic disorder of type 2 diabetes resulting
from a relative insulin deficiency initiated by an illness
that raises the demand for insulin.
• HHS occurs when a person’s blood glucose (sugar) levels
are too high for a long period, leading to severe
dehydration (extreme thirst) and confusion.
• Hyperglycemic Nonketotic Syndrome is also known by
many other names, including:
✓ Diabetic HHS.
✓ Diabetic hyperosmolar syndrome.
✓ Hyperglycemic hyperosmolar nonketotic coma (HHNK).
✓ Hyperosmolar coma.
✓ Hyperosmolar hyperglycemic state.
✓ Nonketotic hyperosmolar syndrome (NKHS).
Symptoms
It can take days or weeks to develop. Possible signs and
symptoms include:
✓ Blood sugar level of
600 milligrams per
deciliter (mg/dL)
Excessive thirst
✓ Dry mouth
✓ Increased urination
✓ Warm, dry skin
✓ Fever
✓ Drowsiness
✓ Confusion
✓ Hallucinations
✓ Vision loss
✓ Convulsions
✓ Coma
Risk Factors
• Have type 2 diabetes. If you don't monitor your blood
sugar or you don't yet know you have type 2 diabetes,
your risk is higher.
• Are older than age 65.
• Have another chronic health condition, such as heart
disease or kidney disease.
• Have an infection, such as pneumonia, a urinary tract
infection or a virus, which causes blood sugar levels to
rise.
• Take certain medications. Some drugs — such as
corticosteroids (prednisone), diuretics
(hydrochlorothiazide and chlorthalidone) and certain
inhalers such as terbutaline.
Anatomy and Physiology
• The endocrine system is made up of glands that produce
and secrete hormones, chemical substances produced in
the body that regulate the activity of cells or organs.
These hormones regulate the body's growth,
metabolism, and sexual development and function.
• The pancreas is a tubuloalveolar gland and has exocrine
and endocrine tissues. secretes hormones for the
regulation of blood glucose concentration, including
insulin, glucagon and somatostatin.
• Pancreatic duct - Culminate the food that enters the
stomach by releasing pancreatic juice.
- The pancreatic duct joins the common bile duct
to form the ampulla of Vater which is located at
the first portion of the small intestine, called the
duodenum.
• Islet cells (islets of Langerhans) - create and release
important hormones directly into the bloodstream.
Hormones released:
- Insulin: which acts to lower blood sugar
- Glucagon: which acts to raise blood sugar
57
Maintaining proper blood sugar levels is crucial to the • Insulin Administration.
functioning of key organs including the brain, liver, and
Treatment typically involves starting intravenous (IV) fluids
kidneys. The central section of the pancreas is called the neck
(saline solution delivered through a needle into a vein) to
or body. The thin end is called the tail and extends to the left
rehydrate the body quickly. It also may require IV insulin to
side.
bring down blood sugar levels.

• Potassium and sometimes sodium phosphate

replenishment may also be required to support cell
function.
• If you are hospitalized due to HHNS, you may be kept
overnight for observation. The main goal of treatment of
this condition is to identify the underlying factors,
whether that's an infection, a certain medication, or poor
blood sugar management.

“Insulin is not a cure for diabetes; it is a treatment. It enables

the diabetic to burn sufficient carbohydrates so that proteins
and fats may be added to the diet in sufficient quantities to
provide energy for the economic burdens of life.” - FREDERICK
BANTING

Diagnostic Procedures

Range of laboratory tests, including blood glucose,

electrolytes, BUN, complete blood count, serum osmolality,
and arterial blood gas analysis.

• The blood glucose level is usually 600 to 1200 mg/dL

• BUN and serum creatinine levels are markedly increased
• Osmolality exceeds 320 mOsm/kg
• pH level greater than 7.30
• mild or absent ketosis

Mental Status Examination - mental status changes, focal

neurologic deficits, and hallucinations

Medical Management

• Fluid Replacement
• Correction of Electrolyte Imbalances

58
Long Term Complications of Diabetes Mellitus
Macrovascular Complications
CORONARY ARTERY DISEASE (CAD)
Coronary artery disease (CAD), also known as coronary heart disease
or ischemic heart disease, is one of the most common heart diseases.
It is caused by plaque buildup in the wall of the arteries (called
atherosclerosis) that supply blood to the heart, making the arteries
that supply blood to the heart muscle become hardened and
narrowed. As it grows, less blood can flow through the arteries. As a
result, the heart muscle can't get the blood or oxygen it needs. This
can later on lead to chest pain (angina) or a heart attack. Most heart
attacks happen when a blood clot suddenly cuts off the hearts' blood
supply, causing permanent heart damage.
Symptoms:
• Heart attack = first sign
• Chest pain or discomfort (angina)
• Weakness, light-headedness, nausea (feeling sick to your
stomach), or a cold sweat
• Pain or discomfort in the arms or shoulder
• Shortness of breath
Risk Factors:
• Being overweight
• Lack of physical inactivity
• Smoking tobacco
• Family history of heart disease (esp a member having this
disease at an early age, 50 or younger)
Anatomy and Pathophysiology
• Left main coronary artery (LMCA). The left main coronary artery
supplies blood to the left side of the heart muscle (the left
ventricle and left atrium). The left main coronary divides into
branches:
• The left anterior descending artery branches off the left coronary
artery and supplies blood to the front of the left side of the heart.
• The circumflex artery branches off the left coronary artery and
encircles the heart muscle. This artery supplies blood to the
outer side and back of the heart.
• Right coronary artery (RCA). The right coronary artery supplies
blood to the right ventricle, the right atrium, and the SA
(sinoatrial) and AV (atrioventricular) nodes, which regulate the
heart rhythm. The right coronary artery divides into smaller
branches, including the right posterior descending artery and the
acute marginal artery. Together with the left anterior
descending artery, the right coronary artery helps supply blood
to the middle or septum of the heart.
• If the coronary artery functions normally, it ensures adequate
oxygenation of the myocardium at all levels of cardiac activity.
Constriction and dilation of the coronary arteries, governed
primarily by local regulatory mechanisms, regulate the amount
of blood flow to the myocardium in a manner that matches the
amount of oxygen delivered to the myocardium with the
myocardial demand for oxygen.
Diagnostic Procedure
Electrocardiogram (ECG)
An ECG can often reveal evidence of a previous heart attack or one
that's in progress.
Echocardiogram
During an echocardiogram, your doctor can determine whether all
parts of the heart wall are contributing normally to your heart's
pumping activity. Parts that move weakly may have been damaged
during a heart attack or be receiving too little oxygen. This may be a
sign of coronary artery disease or other conditions.
Exercise stress test
If your signs and symptoms occur most often during exercise, your
doctor may ask you to walk on a treadmill or ride a stationary bike
during an ECG.
Nuclear stress test
59
It measures blood flow to your heart muscle at rest and during stress.
A tracer is injected into your bloodstream, and special cameras can
detect areas in your heart that receive less blood flow.
Cardiac catheterization and angiogram
During cardiac catheterization, a doctor gently inserts a catheter into
an artery or vein in your groin, neck or arm and up to your heart. X-
rays are used to guide the catheter to the correct position.
Sometimes, dye is injected through the catheter. The dye helps blood
vessels show up better on the images and outlines any blockages. If
you have a blockage that requires treatment, a balloon can be pushed
through the catheter and inflated to improve the blood flow in your
coronary arteries. A mesh tube (stent) is typically used to keep the
dilated artery open.
Cardiac CT scan
A CT scan of the heart can help your doctor see calcium deposits in
your arteries that can narrow the arteries. If a substantial amount of
calcium is discovered, coronary artery disease may be likely.
Medical Surgical Management
Angioplasty and stent placement (percutaneous coronary
revascularization)
Your doctor inserts a long, thin tube (catheter) into the narrowed part
of your artery. A wire with a deflated balloon is passed through the
catheter to the narrowed area. The balloon is then inflated,
compressing the deposits against your artery walls. A stent is often
left in the artery to help keep the artery open. Most stents slowly
release medication to help keep the arteries open.
Coronary artery bypass surgery
A surgeon creates a graft to bypass blocked coronary arteries using a
vessel from another part of your body. This allows blood to flow
around the blocked or narrowed coronary artery. Because this
requires open-heart surgery, it's most often reserved for people who
have multiple narrowed coronary arteries.
Stenting
Stenting uses a device called a stent to restore blood flow in the
coronary artery. A stent is a tiny, expandable, mesh-like tube made of
a metal such as stainless steel or cobalt alloy. Like in an angioplasty
procedure, a stent mounted onto a tiny balloon is opened inside of an
artery to push back plaque and to restore blood flow.
MICS CABG
The beating heart procedure described above can be performed
through a small rib incision rather than through a median sternotomy.
Pharmacology with Nursing Considerations
Cholesterol-modifying medications
These medications reduce (or modify) the primary material that
deposits on the coronary arteries. As a result, cholesterol levels —
especially low-density lipoprotein (LDL, or the "bad") cholesterol —
decrease. Your doctor can choose from a range of medications,
including statins, niacin, fibrates and bile acid sequestrants
Aspirin
This can reduce the tendency of your blood to clot, which may help
prevent obstruction of your coronary arteries. If you've had a heart
attack, aspirin can help prevent future attacks. But aspirin can be
dangerous if you have a bleeding disorder or you're already taking
another blood thinner, so ask your doctor before taking it.
Beta blockers
These drugs slow your heart rate and decrease your blood pressure,
which decreases your heart's demand for oxygen. If you've had a
heart attack, beta blockers reduce the risk of future attacks.
Calcium channel blockers
These drugs may be used with beta blockers if beta blockers alone
aren't effective or instead of beta blockers if you're not able to take
them. These drugs can help improve symptoms of chest pain.
Ranolazine
This medication may help people with chest pain (angina). It may be
prescribed with a beta blocker or instead of a beta blocker if you can't
take it.
Nitroglycerin
Nitroglycerin tablets, sprays and patches can control chest pain by
temporarily dilating your coronary arteries and reducing your heart's
demand for blood.
Angiotensin-converting enzyme (ACE) inhibitors and angiotensin II
receptor blockers (ARBs)
These similar drugs decrease blood pressure and may help prevent
progression of coronary artery disease.
Nursing management
Nursing Problems
• Altered tissue perfusion (myocardial) related to narrowing of the
coronary artery(ies) associated with atherosclerosis, spasm,
and/or thrombosis
• Acute pain
• Risk for decreased cardiac output
• Anxiety
• Deficient knowledge (Learning Need) regarding condition,
treatment plan, self-care, and discharge needs
Nursing Considerations
• Monitor vital signs especially blood pressure, apical heart rate,
and respirations every 5 minutes during an anginal attack.
• Maintain continuous ECG monitoring or obtain a 12-lead ECG, as
directed, monitor for arrhythmias and ST elevation.
• Place the patient in a comfortable position and administer
oxygen, if prescribed, to enhance myocardial oxygen supply.
• Instruct the patient to notify the nurse immediately when chest
pain occurs.
• Reinforce the importance of notifying nursing staff whenever
angina pain is experienced.
• Encourage supine position for dizziness caused by antianginals.
60
• Maintain a quiet, comfortable environment. Restrict visitors as • are over age 50 (old age)
necessary. • are overweight
• Provide light meals. Have the patient rest 1 hour after meals. • have abnormal cholesterol
• Provide supplemental oxygen as indicated. • have a heart disease
• have a diabetes
Nursing Considerations • a family history of high cholesterol, high blood pressure
• Identify specific activities or precipitating events the patient may • have a high blood pressure
engage if any: frequency, duration, intensity, and location of pain
occurs. Lifestyle choices that can increase risk of developing PVD include:
• Be alert to adverse reactions related to abrupt discontinuation • not engaging in physical exercise
of beta-adrenergic blocker and calcium channel blocker therapy. • poor eating habits
These drug must be tapered to prevent a “rebound • smoking
phenomenon”; tachycardia, increase in chest pain, and • drug use
hypertension
• Observe for associated symptoms: dyspnea, nausea and Symptoms
vomiting, dizziness, palpitations, desire to micturate.
• Evaluate reports of pain in jaw, neck, shoulder, arm, or hand Claudication.
(typically on left side • It is the most common symptoms of PVD and PAD. It is a lower
PERIPHERAL VASCULAR DISEASE limb muscle pain that you may notice when you are walking
is a blood circulation disorder that causes the blood vessels outside faster or for long distances. It usually goes away after some rest.
of your heart and brain to narrow, block, or spasm. This can happen It occurs when there’s not enough blood flow to the muscles
in your arteries or veins. PVD typically causes pain and fatigue, often you’re using.
in your legs, and especially during exercise. The pain usually improves
with rest. It can also affect the vessels that supply blood and oxygen Skin and Nails
to your: • Thin, brittle, shiny skin on the legs and feet
• Arms • Decreased skin temperature in the extremities
• Stomach and intestines • Thickened, opaque toenails
• Kidneys • Hair loss on the legs

CAUSES Peripheral
• Atherosclerosis (major cause) • Ulcerations may be present at pressure points such as heels or
• Thromboembolism ankles
• Buerger’s disease • Paleness when legs are elevated (elevation pallor)
• Raynaud’s phenomenon • Reddish-blue discoloration of the extremities
• Functional PVD - there’s no physical damage to your blood • Peripheral pulses may be diminished or absent
vessels’ structure. Instead, your vessels widen and narrow in • Unequal pulses between extremities
response to other factors like brain signals and temperature • Bruits may be auscultated with a stethoscope
changes. The narrowing causes blood flow to decrease. Most • Pain while walking, resolves with rest
common causes of functional PVD are:
• Emotional stress Complications
• Cold temperatures • Amputation (loss of limb)
• Operating vibrating machinery or tools • Poor wound healing
• Drugs • Restricted mobility due to pain or discomfort
• Organic PVD - involves changes in blood vessel structure like • Severe pain in the affected extremity
inflammation, plaques, and tissue damage. The primary causes • Stroke (3 times more likely in people with PVD)
are: • Heart attack
o Smoking • Death
o High blood pressure
o Diabetes Anatomy and Physiology
o High cholesterol
o Additional causes includes: The Vascular System
o Extreme injuries Vascular System, also called the circulatory system, is made up of the
o Muscles or ligaments with abnormal structures vessels that carry blood and lymph through the body. The arteries and
o Blood vessel inflammation veins carry blood throughout the body, delivering oxygen and
o Infection nutrients to the body tissues and taking away tissue waste matter.
The lymph vessels carry lymphatic fluid (a clear, colorless fluid
Risk Factors containing water and blood cells). The lymphatic system helps protect
At a higher risk for PVD if you:
61
and maintain the fluid environment of the body by filtering and • aorta : largest artery in the body, in which it extends from the
draining lymph away from each region of the body. left ventricle down the left side of the body. It divides into four
(4) major regions:
Classes of blood vessels: o Ascending aorta
• Arteries and arterioles (the arterial system) o Aortic arch
• Arteries are described as ‘branching’ or bifurcating’ vessels, as o Thoracic aorta
great arteries (such as aorta) branch off into smaller arteries and o Abdominal aorta
arterioles.
• Veins and venules (the venous system) b. Venous System
• Veins are described as ‘converging’ or ‘joining’ vessels, as • The veins are thin, elastic vessels that act as a reservoir of blood.
venules and veins join to return blood to the heart through the • Transport low-pressure blood back to the heart.
largest veins (such as the superior and inferior venae cavae). • Have a large lumen, as well as valves that ensure a one-way flow
• Capillaries (the smallest bloods vessels, linking arterioles and of blood to the heart.
venules through networks within organs and tissues)
• Capillaries are in intimate contact with the tissues, providing C. Capillaries
nutrients and removing waste products through their thin walls • The capillaries connect arterioles to venules.
at a cellular level. • The arteries divide into arterioles, which in turn divide into
capillaries.
• These feed blood back into the venules, which connect to larger
veins and ultimately to the superior or inferior vena cava. There
are three main types of capillaries:
✓ Continuous
✓ Fenestrated
✓ Sinusoidal
• They act as a semipermeable membrane allowing the diffusion
of gases and transfer of nutrients and waste products.

Three Types of Capillaries

Type Features Example of
location
Continuous Uninterrupted lining of Skin
capillary endothelial cells with tight Muscles
junctions between cells,
limiting passage of solutes
Fenestrated Similar to continuous capillary Intestine
Capillary but some endothelial cells have Kidneys
pores (or fenestrations);
Structure of blood vessels: usually found at filtration sites
Blood vessels, except the smallest ones, are made up of three layers: Sinusoidal Modified, leaky capillaries with Liver
• Tunica interna (innermost layer) is a single layer of squamous capillary large fenestrations and less Bone
(flat) epithelial cells called the endothelium. tight junctions, allowing large marrow
• Tunica media (middle layer) takes up most of the arterial vessel molecules and cells to pass Some
wall and is composed of smooth muscle fibres and elastin. endocrine
• This is where an activated sympathetic nervous system can tissues
stimulate the smooth muscle fibres to contract: →
vasoconstriction; decrease in blood flow Fluid movement between capillaries and tissues
• Inhibition of nerve fibers → relaxation of tunica media muscle Fluid movement through the capillary walls is governed by
fibers → vasodilation ; increase of blood flow. hydrostatic pressure and oncotic pressure.
• Tunica externa or adventitia (outer layer) consists mainly of ✓ Blood in a capillary exerts pressure on the wall of the vessel
connective tissue fibres that protect the blood vessels and attach because of the pressure exerted upstream by the blood coming
them to any surrounding tissues. from the arteriole.
✓ The blood pressure (BP) generates hydrostatic pressure, which
Anatomy of Vasculature expels fluid from the pores of the capillary into the interstitial
A. .Arterial System compartment.
• Arteries supply the body with oxygenated blood – with the ✓ Hydrostatic pressure is highest at the arterial end, and lowest at
exception of the pulmonary arteries from the heart; Blood the venous end, of the capillary.
travels from the arteries to the arterioles and on to the ✓ The other influencing force is oncotic pressure, which is
capillaries, where gaseous exchange takes place. underpinned by the principle of osmosis;

62
✓ the passive movement of water through a semipermeable top of the foot over the first metatarsal and medial
membrane from a region of low solute concentration to one of cuneiform.
high solute concentration, with the aim of achieving equilibrium.
Major veins:

✓ Superior Vena Cava - arises from the union of the left and right
brachiocephalic veins which returns blood from the head, neck,
thorax, and upper limbs to the right atrium of the heart.
✓ Inferior Vena Cava – returns blood from the abdomen, pelvis
and lower limbs to the right atrium.

How diabetes can lead to PVD or PAD

✓ Diabetes can hurt your arteries and if it is not controlled well,

Physiological regulation of BP
BP, which is crucial to maintain the perfusion of organs, is influenced
by:
✓ The total volume of blood in the body;
✓ Cardiac output – the amount of blood pumped out by the
heart in one minute;
✓ Peripheral vascular resistance (PVR), resistance to the flow
of blood in the arterial system, which is influenced by
factors including vessel length, lumen diameter, and blood
viscosity.
blood sugar levels will be high which makes the artery walls
rough and produces a waxy substance in the blood called
plaque (contains cholesterol) that builds up on the artery walls.
This makes it harder for blood to flow through the arteries. This
limits blood flow to the arms and legs and causes tissue
damage. The feet are most at risk of tissue damage. If tissue
damage is very bad, then toes, feet, or even legs may need to
be removed (amputated).

BP can be affected by a change in cardiac output or PVR. An important

measure is the mean arterial pressure (MAP), which is the pressure
that propels blood towards tissues with each cardiac cycle and
generates perfusion pressure to the organs.

Systemic Circulation
Major peripheral arteries:
✓ Superficial temporal artery – is where the temporal pulse
could be palpated located in front of the ear.
✓ Common Carotid artery – is located lateral to the larynx,
where the carotid pulse could be palpated and should not
be palpated together as doing so many interrupt blood flow
to the brain.
✓ Brachial artery – is where the brachial pulse could be
palpated located on a medial portion of antecubital space
and commonly used for assessing blood pressure. Diagnostic Procedures
✓ Radial artery – is commonly used for assessing pulse rate
and for withdrawing an arterial blood specimen. Where the Assessment
radial pulse could be palpated located on the thumb side of
✓ Pain or loss of sensory nerves secondary to ischemia
the wrist.
✓ Paresthesias and loss of position sense
✓ Femoral artery – arises from the abdominal aorta, which is
✓ Polar or coldness
commonly used for entry side for cardiac catheterization to
✓ Paralysis
gain access to the coronary arteries. Where the femoral
✓ Pallor due to empty superficial vessels (can progress to
pulse could be palpated located on the inguinal area.
mottled, cyanotic, and cadaverous cold leg)
✓ Popliteal artery – is where the popliteal pulse could be
✓ Pulselessness
palpated located at the back of the knee.
✓ Intermittent claudication – calf muscle pain occurring when
✓ Posterior tibial artery – is where the posterior tibial pulse
muscle is forced to contract without adequate blood supply
could be palpated located behind the medial malleolus.
(e.g. after walking). The calf muscle pain is alleviated with rest.
✓ Dorsalis pedis artery – arises from the abdominal aorta,
✓ Resting pain, which is pain at rest when limited blood flow
where the dorsalis pedis pulse could be palpated located on
cannot meet very low tissue requirements.

63
✓ Trophic changes in skin and nails such as dryness, scaling, and
thinning of skin; decreased or absent hair growth, brittle and
thickened nails and gangrenous changes marking death and
decay of tissues.
Laboratory and Diagnostic Study findings
✓ Doppler ultrasound flow studies reveal that extremity blood
pressure measurements in the legs are lower than in the arms.
✓ Angiography may confirm the diagnosis and shows vascular
obstructions or aneurysms and the presence of collateral
circulation
✓ Digital subtraction angiography visualizes vascular obstructions,
aneurysms, narrowing of vessels and atherosclerotic plaque.
Diagnostic Procedure
Edinburgh Claudication Questionnaire
✓ This is a test used by many medical professionals to diagnose
peripheral artery disease. It is a series of 6 questions and a pain
diagram. It is accurate at diagnosing PAD in people with
symptoms up to about 90% of the time.
Ankle/Brachial Index (ABI)
✓ This is one of the most widely used tests for a person who has
symptoms suggesting intermittent claudication -- pain
associated with PVD that comes and goes as a result of
narrowed blood vessels.
✓ This test compares the blood pressure in the arm (brachial)
with the blood pressure in the legs.
✓ In a person with healthy blood vessels, the pressure should be
higher in the legs than in the arms.
✓ An ABI a.
✓ Blood pressures in your arms and legs will be taken before and
after exercise (walking on a treadmill, usually until you have
symptoms).
✓ A significant drop in leg blood pressures and ABIs after exercise
suggests PVD.
✓ Alternative tests are available if you are unable to walk on a
treadmill.
✓ If the leg pulse can't be felt, the use of a portable Doppler flow
probe will quickly reveal the absence or presence of an arterial
flow.
Angiography or Arteriography
✓ A type of X-ray. Angiography has for many years been
considered the best test available and has been used to guide
further treatment and surgery. However, imaging techniques,
such as ultrasonography and MRI, are preferred more and more
because they are less invasive and work just as well.
✓ Uses a dye injected into the arteries to highlight blockages and
narrowing of arteries. If you have diabetes or have kidney
damage, the dye could cause further damage to your kidneys
and, rarely, cause acute kidney (renal) failure, requiring dialysis.
✓ Certain treatments for blocked arteries, such as angioplasty,
can be performed at the same time as the test. A specialist
called an interventional radiologist or an invasive cardiologist
can perform these treatments.
✓ With ultrasonography or MRI, angioplasty cannot be done at
the same time.
Ultrasonography
✓ Uses sound waves to find abnormalities.
✓ A handheld device that emits ultrasound waves is placed on the
skin over the part of the body being tested. It is noninvasive
and painless.
✓ You cannot hear or see the waves; they "bounce" off structures
under your skin and give an accurate picture. Any abnormalities
in the vessels or obstruction of blood flow can be seen.
Magnetic Resonance Imaging (MRI)
✓ A type of imaging study. Rather than radiation, MRI uses a
magnetic field to obtain an image of internal structures. It gives
a very accurate and detailed image of blood vessels. This
technique is also noninvasive.
Medical Surgical Management
Percutaneous balloon angioplasty
✓ A technique for enlarging an artery that is blocked or narrowed
without surgery.
✓ A diagnostic angiogram is done first to locate the blockage or
narrowing and determine the severity. That's because minor
blockages, for instance, can often be treated with medicine. If
the obstruction is significant, especially in a larger artery,
angioplasty may be reasonable.
✓ The angioplasty is performed through a thin tube called a
catheter inserted with a needle into the affected artery. It has a
tiny balloon attached to the end. The balloon is inflated,
pushing aside the plaque and widening the artery so that it no
longer restricts blood flow.
✓ The balloon is then deflated and removed from the artery.
Atherectomy
✓ Removal of an atherosclerotic plaque. A tiny cutting blade is
inserted into the artery to cut the plaque away.
Surgery
✓ When the obstructive lesions are long and involve most of the
vessel, surgery may be the best alternative. The most widely
used operation for a blocked or damaged artery is called a
bypass. This is similar to the artery bypass operation done on
the heart.
✓ A piece of vein, harvested from another part of your body, or a
piece of synthetic artery is used to bypass or detour the
obstructed segment of disease, therefore restoring blood flow
to the downstream or distal portion of the artery.
✓ Surgery is required less often today, as better preventative anti-
atherosclerotic medications and techniques have become
available for treating blocked or damaged arteries. With
modern treatments, surgery is required only for very severe
atherosclerosis that's unresponsive to medications and
angioplasty.
Pharmacology with Nursing Considerations
Antidiabetic
Insulin
64
✓ Medications: insulin analog or lispro (Humalog), insulin aspart o headaches
(Novolog), insulin glargine (Lantus, Toujeo), insulin glulisine o rashes
(Apidra), insulin detemir (Levemir), regular insulin (Novolin R), o itchy skin
NPH insulin (Novolin N), inhaled insulin (Afreeza) o hair loss
✓ Classification: Antidiabetic ✓ Nursing Consideration:
✓ Action: insulin is a hormone that promotes the storage of the o assess patient for hypersensitivity, acute liver disease,
body's fuel, facilitates the transport of various metabolites and
pregnancy
ions across cell membrane and stimulates the synthesis of
o conduct thorough physical assessment before
glycogen from glucose, fats from lipids, and of protein from
amino acids beginning drug therapy to establish baseline data
✓ Indication: diabetic conditions o establish safety precaution to protect patient from
✓ Contraindication: no contraindication because it is used as a injury (e.g., raising side rails, adequate lighting,
replacement hormone padding the sides of the bed)
✓ Adverse Effect: o maintain antidotes to promptly treat drug overdose
o hypoglycemia o educate patient about contraindications and adverse
o ketoacidosis effects of the medication
o insulin injection: local reaction at injection sites such
as lipodystrophy (a lump or small dent)
Lipid Lowering Agents
o inhaled insulin: cough, throat pain, irritation
✓ Nursing Consideration: Bile Acid Sequestrants
o assess for contraindications or cautions (e.g. history
of allergy, etc.) ✓ Medications: cholestrytamine, colestipol (colestid),
o inspect skin areas that will be used for injection; note colesevelam (welchol)
for areas that are bruised, thickened, or scarred ✓ Classification: Bile Acid Sequestrants
o rotate injection site ✓ Action: bind with bile acids in the intestine to form a complex
o obtain CBG before administering insulin that is excreted in the feces.
o educate patient about the insulin regarding its action, ✓ Indication: primary hypercholesterolemia
indication, adverse effect, and contraindication ✓ Contraindication:
o monitor the results of laboratory test, including o allergy to bile acid sequestrants
urinalysis o complete biliary obstruction
o abnormal intestinal function
Anticoagulant o pregnancy and lactation
✓ Medications: warfarin (Coumadin), heparin, apixaban (Eliquis), ✓ Adverse Effect:
dabigatran (Pradaxa), edoxaban (Savaysa), enoxaparin o headache
(Levenox), rivaroxaban (Xarelto) o anxiety
✓ Classification: Anticoagulants o fatigue
✓ Action: inhibit the specific clotting factors and interfere with o drowsiness
clotting cascade. and thereby prevent clots o nausea
✓ Indication: used if patients are at risk of developing blood clots o constipation that may progress to fecal impaction
that could potentially block a blood vessel and disrupt the flow o aggravation of hemorrhoids
of blood in the body o increase bleeding
✓ Contraindication: o vitamin A and D deficiencies
o bleeding abnormality (e.g. thrombocytopenia, o muscle aches and pains
platelet defect, peptic ulcer disease) ✓ Nursing Consideration:
o CNS lesion (e.g. stroke, surgery, trauma) o do not administer powdered agents in dry form;
o spinal anesthesia or lumbar puncture colestipol may be mixed with carbonated beverage.
o malignant hypertension Stir and swallow all of the dose
o acute live problems o inform patient to swallow the tablets whole
o advanced retinopathy o give prescribed drugs before meals
o WARFARIN (pregnancy) o arrange bowel program
✓ Adverse Effect: o provide comfort measure
o excessive bleeding (blood in urine, severe bruising,
prolonged nosebleed, bleeding gums, vomiting or HMG-CoA Reductase Inhibitors
coughing of blood)
o sudden severe back pain ✓ Medications: fluvastatin (Lescol), lovastatin (Mevacor),
o difficulty breathing or chest pain pravastatin (Pravachol), rosuvastatin (Crestor), atorvastatin
o diarrhea or constipation (Lipitor), simvastatin (Zocor)
o indigestion ✓ Classification: HMG-CoA Reductase Inhibitors
o dizziness
65
✓ Action: block HMG-CoA reductase from completing the Promote vasodilation
formation of cellular cholesterol
✓ Indication: increase cholesterol and LDL levels; to slow • Provide insulating warmth with gloves, socks and other
progression of CAD in patients; to prevent first myocardial outerwear as appropriate.
infarction in patients • Keep room temperatures comfortably warm.
✓ Contraindication: • Instruct the client to warm himself with warm drinks or baths.
o allergy to statins or to fungal by products or • Never apply a direct heat source to the extremities. Limited
compounds blood flow combined occurs with normal circulation.
o active liver disease or a history of a alcoholic liver • Teach the client about the vasoconstrictive effects of nicotine
disease and caffeine, emotional stress, and chilling, discuss ways to
o pregnancy and lactation avoid or minimize these risk factors.
o caution in patients with impaired endocrine functions • Teach the client to avoid constricting clothes, such as garters,
✓ Adverse Effect: knee-high stockings and belts.
o flatulence • If overreplacement of glucocorticoid is indicated, inform the
o abdomen pain client about the purpose of therapy and possible adverse
o cramps effects such as cushingoid appearance, weight gain, acne,
o nausea hirsutism, peptic ulcer, diabetes mellitus, osteoporosis,
o vomiting infection, muscular weakness, mood swings, cataracts and
o constipation hypertension.
o headache Promote activity and mobility
o dizziness
o blurred vision ✓ For a client with decreased arterial function but without
o insomnia activity-limiting tissue damage, encourage a program of
o fatigue balanced exercise and rest to promote development of
o cataract development collateral circulation.
o increased concentration of liver enzymes
o acute liver failure Provide care for a client undergoing angiography or percutaneous
✓ Nursing Consideration: transluminal angioplasty
o give at bedtime (atorvastatin can be given/taken at ✓ Before the procedure, provide information related to the
anytime during the day) procedure, validate that the informed consent has been
o monitor cholesterol and LDL levels obtained, mark peripheral pulses, obtain diagnostic data as
o eye examinations ordered and withhold food and fluids as prescribed.
o liver function tests ✓ After the procedure, maintain bed rest as prescribed, keeping
o lifestyle changes necessary the involved extremity extended, monitor vital signs and assess
o use of barrier contraceptives peripheral pulses and circulation every 15 minutes for 2 hours
o cholesterol lowering diet and exercise program and then every hour for 4 hours.
o withhold lovastatin, atorvastatin, or fluvastatin in any ✓ Assess for bleeding, hematoma, or edema at the catheter
acute or serious medical conditions insertion site, encourage oral fluid and monitor urine output.
Nursing Management
Provide care for a client undergoing an autogenous saphenous vein
Nursing Problems or a synthetic bypass gas

✓ Ineffective peripheral tissue perfusion related to impaired
arterial circulation.
✓ Pain related to decreased oxygen supply to tissues.
✓ Risk for impaired skin integrity related to compromised tissue
perfusion.
✓ Fear and anxiety related to actual or potential lifestyle changes.
Nursing Consideration
✓ Prepare the client for surgery and mark the site of the
peripheral pulses
✓ Monitor the client carefully after the procedure (especially for
the first 24 hours) for signs of graft occlusion as manifested by
decreased arterial perfusion.
✓ Anticipate and take steps to prevent complications of any
surgical procedure involving general anesthesia, particularly
respiratory problems and infection.

✓ Provide proper positioning
✓ Place the client’s legs in a dependent position in relation to the
heart to improve peripheral blood flow
✓ Avoid raising the client’s feet above heart level unless
specifically prescribed by the health care providers
✓ Keep the client in a neutral, flat, supine position if in doubt
about the nature of his peripheral vascular problems.
Provide care for a client who has received an axillofemoral or
axillobifemoral bypass graft or an endarterectomy (i.e. removal of
atheromatous plaque)
✓ Avoid positioning the client on the side of the graft or incision
after the procedure
✓ Warn the client not to wear tight clothing which can lead to
graft occlusion

66
✓ Instruct the client on signs and symptoms of infection to report Veins
to the health care provider.
• Capillaries → veins
Provide care for client undergoing an amputation • Carry deoxygenated blood to the heart
• Thinner than arteries, less elastic, fewer smooth muscle cells
Promote and teach skin and foot care • Veins increase in diameter and thickness while decrease in
CEREBROVASCULAR ACCIDENT (CVA) number as they progress toward the heart
o Venules: slightly larger diameter than those of
Anatomy and Physiology capillaries
• Composed of endothelium resting on connective tissue
Blood Vessels and Circulation o Small Veins: slightly larger diameter than those of
Functions: venules
✓ Carries blood o Medium-size veins collect blood from small veins and
✓ Exchanges nutrients, waste products and gases with tissues deliver it to large veins
✓ Transports Substances o Large veins have valves, which allow one-way flow
✓ Helps regulate Blood Pressure ▪ Folds in the tunica intima which form flaps
✓ Directs blood flow to the tissues ▪ More valves in veins of lower limbs than
✓ Allows regulation of blood glucose upper limbs
▪ Must compete/counteract with effects of
General Features of Blood Vessel Structure gravity

3 Blood Vessels:
1) Arteries 3 TUNICS OF BLOOD VESSELS
• Carry oxygen-rich blood away from heart
2) Elastic • Tunica Intima – innermost; basement membrane; composed of
• Largest in diameter, thickest walls Endothelium
• Aorta, pulmonary trunk • Tunica Media – middle layer; smooth muscles arranged
3) Muscular circularly
• Medium to Small; thick in diameter • Tunica Adventitia – outer portion; made of connective tissue
• Can control blood flow to body regions
• Distributing Arteries → medium-sized arteries
• Smooth muscle tissue enables these vessels to control blood
flow to different body regions
• Vasoconstriction: contraction of smooth muscle; decreases
blood vessel diameter and blood flow
• Vasodilation: relaxation of smooth muscle; increases blood
vessel diameter and blood flow

Arterioles
• Transport blood from small arteries to capillaries

Capillaries
• Arterioles → capillaries
- Exchange between blood and tissue fluid
• Thinner than arteries → slower blood flow
• Consist only of endothelium
• Blood flows from arterioles to capillaries (branch to form
networks)
• Precapillary Sphincters: smooth muscle cells that regulate
blood flow through capillaries
• Red blood cells flow through most capillaries in single file and
are frequently folded as they pass through smaller capillaries
- While passing through, blood gives up O2 and
nutrients to the tissue spaces and takes up CO2 and
other by-products of metabolism
• Capillary networks are more abundant in the lungs and highly
metabolic tissues like liver, kidneys, and skeletal/cardiac muscle
than other tissue types
BLOOD VESSELS OF THE SYSTEMIC
CIRCULATION ARTERIES
AORTA – where all arteries of the systemic circulation branch
directly or indirectly
3 PARTS:
1. ASCENDING AORTA passes superiorly from LV; where R and L
coronary arteries arise from its base
2. AORTIC ARCH – aorta arches posteriorly and to the left 3 major
arteries that carry blood to the head and upper
limbs: BRACHIOCEPHALIC ARTERY, LEFT COMMON CAROTID ARTERY,
LEFT SUBCLAVIAN ARTERY
3. DESCENDING AORTA – longest part

67
 • THORACIC AORTA: extends through the thorax and
diaphragm
• ABDOMINAL AORTA – extends through the diaphragm
• ARTERIAL ANE – powerpoint slide cuts off here
Physiology of Circulation
• The function of the circulatory system is to maintain adequate
blood flow to all body tissues. Adequate blood flow is required
to provide nutrients and O2 to the tissues and to remove the
waste products of metabolism from the tissues.
Blood Pressure
• This is a measure of the force blood exerts against the blood
vessel walls. In arteries, blood pressure values go through a
cycle that depends on the rhythmic contractions of the heart.
The pressure of the blood flow in the body is produced by the
hydrostatic pressure of the fluid (blood) against the walls of the
blood vessels. Fluid will move from areas of high to low
hydrostatic pressures. In the arteries, the hydrostatic pressure
near the heart is very high and blood flows to the arterioles
where the rate of flow is slowed by the narrow openings of the
arterioles. During systole, when new blood is entering the
arteries, the artery walls stretch to accommodate the increase
of pressure of the extra blood; during diastole, the walls return
to normal because of their elastic properties.
• Many other factors can affect blood pressure, such as
hormones, stress, exercise, eating, sitting, and standing. Blood
flow through the body is regulated by the size of blood vessels,
by the action of smooth muscle, by one-way valves, and by the
fluid pressure of the blood itself.
Capillary Exchange and Regulation of Interstitial Fluid Volume
• Capillary exchange occurs through or between endothelial cells.
Diffusion, which includes osmosis, and filtration are the primary
means of capillary exchange. The major forces responsible for
moving fluid through the capillary wall are blood pressure and
osmosis. Blood pressure forces fluid out of the capillary, and
osmosis moves fluid into the capillary. Fluid moves by osmosis
from the interstitial space into the capillary because blood has a
greater osmotic pressure than does interstitial fluid.
• Blood has a greater osmotic pressure because of the large
concentration of plasma proteins that are unable to cross the
capillary wall. The concentration of proteins in the interstitial
space is much lower than that in the blood. The capillary wall
acts as a selectively permeable membrane, which prevents
proteins from moving from the capillary into the interstitial
space but allows fluid to move across the capillary wall.
Control
of Blood Flow in Tissues
Local Control
• Local control of blood flow is achieved by the periodic
relaxation and contraction of the precapillary sphincters. When
the sphincters relax, blood flow through the capillaries
increases. When the sphincters contract, blood flow through
the capillaries decreases. The precapillary sphincters are
controlled by the metabolic needs of the tissues. For example,
blood flow increases when by-products of metabolism buildup
in tissue spaces, allowing for faster removal of these
substances. During exercise, the metabolic needs of skeletal
muscle increase dramatically, and the by-products of
metabolism are produced more rapidly. The precapillary
sphincters relax, increasing blood flow through the capillaries.
Other factors that control blood flow through the capillaries are
the tissue concentrations of O2 and nutrients, such as glucose,
amino acids, and fatty acids.
• Blood flow increases when O2 levels decrease or, to a lesser
degree, when glucose, amino acids, fatty acids, and other
nutrients decrease. An increase in CO2 or a decrease in pH also
causes the precapillary sphincters to relax, thereby increasing
blood flow.
How Diabetes may lead to CVA or stroke:
• Diabetes is a well-established risk factor for stroke. It can cause
pathologic changes in blood vessels at various locations and can
lead to stroke if cerebral vessels are directly affected. People
with diabetes have a pancreas that doesn't make enough
insulin, or that the cells in the muscles, liver, and fat don't use
insulin the right way; or that it doesn't produce any at all. They
thus end up with too much glucose or sugar in their blood. This
extra sugar in the blood can cause increased deposits of fat or
blood clots on the blood vessel walls. These clots and deposits
can restrict or completely block vessels in the neck or brain.
This eventually decreases or cuts off blood supply entirely and
prevents oxygen from reaching the brain. When this happens a
stroke can occur.
Concept Map
• A cerebrovascular accident (CVA), or stroke, is defined as the
sudden occurrence of a focal, non-convulsive neurologic deficit.
is a syndrome characterized by the rapid onset (minutes to
hours) of neurologic symptoms such as hemiparesis, sensory
abnormalities, and aphasia. It happens when there is a loss of
68
 blood flow to part of the brain. Your brain cells cannot get the
oxygen and nutrients they need from blood, and they start to
die within a few minutes. This can cause lasting brain damage,
long-term disability, or even death.
CAUSES
• A cerebrovascular accident is the rapidly developing loss of
brain function(s) due to disturbance in the blood supply to the
brain, caused by a blocked or burst blood vessel. This can be
due to ischemia (lack of glucose and oxygen supply) caused by
thrombosis or embolism or due to a hemorrhage. As a result,
the affected area of the brain is unable to function, leading to
inability to move one or more limbs on one side of the body,
inability to understand or formulate speech, or inability to see
one side of the visual field.
RISK FACTORS
COMPLICATIONS
The most common complications of stroke are:
• Brain edema — swelling of the brain after a stroke.
• Pneumonia — causes breathing problems, a complication of
many major illnesses. Pneumonia occurs as a result of not being
able to move as a result of the stroke. Swallowing problems
after stroke can sometimes result in things ‘going down the
wrong pipe’, leading to aspiration pneumonia.
• Urinary tract infection (UTI) and/or bladder control. UTI can
occur as a result of having a foley catheter placed to collect
urine when the stroke survivor cannot control bladder function.
• Seizures — abnormal electrical activity in the brain causing
convulsions. These are common in larger strokes.
• Deep venous thrombosis (DVT) — blood clots form in veins of
the legs because of immobility from stroke.

• Modifiable Factors
• Smoking
• Obesity
• Hypertension
• High cholesterol level
• Excessive alcohol consumption
• Drug addiction
• High dose of estrogen OC
• Diabetes mellitus
• Atrial fibrillation
• Type A personality
• Sedentary Lifestyle
• Non-modifiable Factors
• Age CONCEPT MAP
• Family History of CVA
• Family History of DM
• Sex (Male)
• Race

SYMPTOMS

• Consider stroke in any patient presenting with acute neurologic

deficit or any alteration in level of consciousness. Common
signs and symptoms of stroke include the abrupt onset of any
of the following:
o Hemiparesis, monoparesis, or (rarely) quadriparesis
o Hemisensory deficits
o Monocular or binocular visual loss
o Visual field deficits
o Diplopia
o Dysarthria
o Facial droop
o Ataxia
o Vertigo (rarely in isolation)
o Aphasia
o Sudden decrease in the level of consciousness

Although such symptoms can occur alone, they are more likely to
occur in combination.

69

DIAGNOSTIC PROCEDURES
The first step in assessing a stroke patient is to determine whether
the patient is experiencing an ischemic or hemorrhagic stroke so
that the correct treatment can begin.
Computed tomography (CT) of the head
• The first and most important test after a stroke.
• A series of X-rays of the brain that can detect a stroke from a
blood clot or bleeding.
• Useful diagnostic test for hemorrhagic strokes because blood
can easily be seen, however, damage from an ischemic stroke
may not be revealed on a CT scan for several hours or days and
the individual arteries in the brain cannot be seen.
• To improve the detection and characterization of stroke, CT
angiography (CTA) may be performed. A contrast material may
be injected intravenously and images are obtained of the
cerebral blood vessels. Images that detect blood flow, called CT
perfusion (CTP), may be obtained at the same time.
• The combination of CT, CTA and CTP can help physicians decide
on the best therapy for a patient experiencing a stroke.
MRI of the head
• Uses a powerful magnetic field, radio frequency pulses and a
computer to produce detailed pictures of organs, soft tissues,
bone and virtually all other internal body structures.
• Also used to image the cerebral vessels, a procedure called MR
angiography (MRA). Images of blood flow are produced with a
procedure called MR perfusion (MRP).
• Physicians use MRI of the head to assess brain damage from a
stroke and help predict recovery.
• To help determine the type, location, and cause of a stroke and
to rule out other disorders, physicians may use:
Blood tests
• To check how fast blood can clot, whether blood sugar is too
high or low, and whether there is an infection.
Electrocardiogram (ECG, EKG)
• Checks the hearts' electrical activity, which can help determine
whether heart problems caused the stroke.
Carotid ultrasound/Doppler ultrasound
• To check for narrowing and blockages in the body's two carotid
arteries, which are located on each side of the neck and carry
blood from the heart to the brain.
• Doppler ultrasound produces detailed pictures of these blood
vessels and information on blood flow.
Cerebral angiography
• The gold standard test used to visualize the blood vessels which
supply the brain.
• Performed with one of three imaging technologies—x-rays, CT
or MRI, and in some cases a contrast material, to produce
pictures of major blood vessels in the brain.
• Helps to identify blockages that cause ischemic stroke.
• Also identifies aneurysms and arteriovenous malformations,
which cause hemorrhagic stroke.
MEDICAL SURGICAL MANAGEMENT
Emergency IV medication. Therapy with drugs that can break up a
clot has to be given within 4.5 hours from when symptoms first
started if given intravenously. The sooner these drugs are given, the
better. Quick treatment not only improves your chances of survival
but also may reduce complications. An IV injection of recombinant
tissue plasminogen activator (tPA) — also called alteplase (Activase)
— is the gold standard treatment for ischemic stroke. An injection of
tPA is usually given through a vein in the arm with the first three
hours. Sometimes, tPA can be given up to 4.5 hours after stroke
symptoms started. This drug restores blood flow by dissolving the
blood clot causing your stroke. By quickly removing the cause of the
stroke, it may help people recover more fully from a stroke. Your
doctor will consider certain risks, such as potential bleeding in the
brain, to determine if tPA is appropriate for you.
Emergency endovascular procedures. Doctors sometimes treat
ischemic strokes directly inside the blocked blood vessel.
Endovascular therapy has been shown to significantly improve
outcomes and reduce long-term disability after ischemic stroke.
These procedures must be performed as soon as possible:
• Medications delivered directly to the brain. Doctors insert a
long, thin tube (catheter) through an artery in your groin and
thread it to your brain to deliver tPA directly where the stroke
is happening. The time window for this treatment is somewhat
longer than for injected tPA, but is still limited.
• Removing the clot with a stent retriever. Doctors can use a
device attached to a catheter to directly remove the clot from
the blocked blood vessel in your brain. This procedure is
particularly beneficial for people with large clots that can't be
completely dissolved with tPA. This procedure is often
performed in combination with injected tPA.
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The time window when these procedures can be considered has
been expanding due to newer imaging technology. Doctors may
order perfusion imaging tests (done with CT or MRI) to help
determine how likely it is that someone can benefit from
endovascular therapy
PHARMACOLOGY WITH NURSING CONSIDERATIONS
ANTIDIABETIC MEDICATIONS
Insulin
• Sample Medications:
✓ Insulin lispro (Humalog), Apidra (Insulin glulisine) [Rapid Acting]
✓ Humulin R (Regular insulin), Actrapid [Short Acting]
✓ Glargine (Lantus), Detemir (Levemir), Toujeo (Glargine Insulin)
[Long Acting]
✓ Humulin® NPH [Intermediate Acting]
✓ Humulin® 30/70 (30% short, 70% intermediate Humulin NPH),
NovoMix® 30 (30% rapid, 70% intermediate Protaphane),
Humalog® Mix 50 (50% rapid, 50% intermediate Humulin NPH)
[Mixed Insulin]
• Action: Lowers blood glucose by stimulating glucose uptake in
skeletal muscle and fat, inhibiting hepatic glucose production.
Other actions of insulin: inhibition of lipolysis and proteolysis,
enhanced proteisynthesis. Therapeutic Effects: Control of
hyperglycemia in diabetic patients.
• Indication
o management of type 1 diabetes mellitus
o may also be used in type 2 diabetes mellitus when
diet and/or oral medications fail to adequately
control blood sugar
• Contraindications
o Hypoglycemia
o Precautions: Infection, stress, or changes in diet may
alter requirement
• Adverse Effects
o Endo: Hypoglycemia
o Local: lipodystrophy, pruritus, erythema, swelling
o Misc: Allergic reactions, including Anaphylaxis
• Nursing Considerations
• Check type, species, source, dose, and expiration date with
another licensed nurse. Do not interchange insulins without a
physician's order. Use only insulin syringes to draw up a dose.
Use only 100 unit syringes to draw up insulin lispro dose.
• Explain to patients that medication controls hyperglycemia but
does not cure diabetes. Therapy is long-term
• Review signs of hypoglycemia and hyperglycemia with patients.
If hypoglycemia occurs, advise the patient to take a glass of
orange juice or 2–3 tsp of sugar, honey, or corn syrup dissolved
in water (glucose, not table sugar, if taking miglitol), and notify
the health care professional. Advise patient about symptoms of
hyperglycemia (confusion, drowsiness; flushed, dry skin,
dehydration, blurred vision, fatigue)
• Encourage patients to follow prescribed diet, medication, and
exercise regimen to prevent hypoglycemic or hyperglycemic
episodes
• Instruct patients in proper testing of serum glucose and
ketones
• Advise patient to notify health care professional if nausea,
vomiting, or fever develops; if unable to eat usual diet; or if
blood glucose levels are not controlled
LIPID LOWERING AGENTS
HMG-CoA Reductase Inhibitors
• Sample Medications: Atorvastatin, Pravastatin, Simvastatin,
Rosuvastatin
• Action: Inhibit an enzyme, 3-hydroxy-3-methylglutaryl-
coenzyme A (HMG-CoA) reductase, which is responsible for
catalyzing an early step in the synthesis of cholesterol.
Therapeutic Effects: Lowers total and LDL cholesterol and
triglycerides. Slightly increase HDL. Slows the progression of
coronary atherosclerosis with resultant decrease in CHD-
related events
• Indication:
- Adjunctive management of primary
hypercholesterolemia and mixed dyslipidemias.
- Atorvastatin: Primary prevention of cardiovascular
disease (increased risk of MI or stroke) in patients
with multiple risk factors for coronary heart disease
CHD or type 2 diabetes mellitus (also prisk of angina
or revascularization procedures in patients with
multiple risk factors for CHD).
• Contraindications
- Hypersensitivity; Active liver disease or unexplained
persistent increase in AST or ALT levels
- OB: Avoid use during pregnancy (may cause fetal
harm); Lactation: Avoid breast feeding if treatment is
necessary
- Use Cautiously in: History of liver disease; Alcoholism
- Pedia: Children 8 yr (safety and effectiveness not
established)
• Adverse Effects
- CNS: amnesia, confusion, dizziness, headache,
insomnia, memory loss, weakness
- CV: chest pain, peripheral edema
- EENT: rhinitis; lovastatin, blurred vision
- Resp: bronchitis
- GI: abdominal cramps, constipation, diarrhea, flatus,
heartburn, altered taste, drug-induced hepatitis,
dyspepsia, elevated liver enzymes, nausea,
pancreatitis.
- GU: erectile dysfunction
- Derm: rashes, pruritus
- Endo: hyperglycemia
- MS: RHABDOMYOLYSIS, arthralgia, arthritis, immune-
mediated necrotizing myopathy, myalgia, myopathy
(increase with simvastatin 80 mg/day dose)
- Misc: hypersensitivity reactions.
• Nursing Considerations
• Obtain a dietary history, especially with regard to fat
consumption
• Lab Test Considerations: Evaluate serum cholesterol and
triglyceride levels before initiating, after 4– 6 wk of therapy,
and periodically thereafter
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• Monitor liver function tests, including AST and ALT, before
initiating therapy and if signs of liver injury (fatigue, anorexia,
right upper abdominal discomfort, dark urine, or jaundice)
occur. May also cause an increase in alkaline phosphatase and
bilirubin levels
• Monitor for signs and symptoms of immune-mediated
necrotizing myopathy (IMNM) (proximal muscle weakness and
increased serum creatine kinase levels), persisting despite
discontinuation of statin therapy. Perform muscle biopsy to
diagnose; shows necrotizing myopathy without significant
inflammation. Treat with immunosuppressive agents
• Avoid large amounts of grapefruit juice during therapy; may
increase risk of toxicity
• Instruct patients to take medication as directed and not to skip
doses or double up on missed doses. Advise the patient to
avoid drinking more than 200 mL/day of grapefruit juice during
therapy. Medication helps control but does not cure elevated
serum cholesterol levels
• Advise patient that this medication should be used in
conjunction with diet restrictions (fat, cholesterol,
carbohydrates, alcohol), exercise, and cessation of smoking
• Instruct patient to notify the health care professional if signs of
liver injury or if unexplained muscle pain, tenderness, or
weakness occurs, especially if accompanied by fever or malaise
• Advise patients to notify health care professional of all Rx or
OTC medications, vitamins, or herbal products being taken and
to consult with health care professionals before taking other
medications, especially St. John’s Wort.
• Emphasize the importance of follow-up exams to determine
effectiveness and to monitor for side effects
ANTIPLATELET AGENTS
Platelet Aggregation Inhibitors
- Sample Medications: Clopidogrel (Plavix), ASA, also called
acetylsalicylic acid (Aspirin, Asaphen, Entrophen, Novasen),
Prasugrel (Effient), Ticlopidine
- Action: Inhibits platelet aggregation by irreversibly inhibiting
the binding of ATP to platelet receptors. Therapeutic Effects:
Reduction in risk of MI and stroke.
- Indication:
o Acute coronary syndrome (ST-segment elevation MI, non-
ST-segment elevation MI, or unstable angina)
o Patients with established peripheral arterial disease,
recent MI, or recent stroke.
- Contraindications
o Hypersensitivity to the medication
o Pathologic bleeding (peptic ulcer, intracranial
hemorrhage); Concurrent use of omeprazole or
esomeprazole
o Lactating mothers
o Use Cautiously in: Patients at risk for bleeding (trauma,
surgery, or other pathologic conditions); History of GI
bleeding/ulcer disease; Severe hepatic impairment;
Hypersensitivity to another thienopyridine (prasugrel)
o OB: Use only if clearly indicated
o Pedia: Safety and effectiveness not established.
- Adverse Effects
o Incidence of adverse reactions similar to that of aspirin.
o CNS: depression, dizziness, fatigue, headache
o EENT: epistaxis. Resp: cough, dyspnea, eosinophilic
pneumonia
o CV: chest pain, edema, hypertension
o GI: GI BLEEDING, abdominal pain, diarrhea, dyspepsia,
gastritis.
o Derm: ACUTE GENERALIZED EXANTHEMATOUS
PUSTULOSIS, DRUG RASH WITH EOSINOPHILIA AND
SYSTEMIC SYMPTOMS, STEVENS-JOHNSON SYNDROME,
TOXIC EPIDERMAL NECROLYSIS, pruritus, purpura, rash.
o Hemat: BLEEDING, NEUTROPENIA, THROMBOTIC
THROMBOCYTOPENIC PURPURA
o Metab: hypercholesterolemia
o MS: arthralgia, back pain. Misc: fever, hypersensitivity
reactions.
Nursing Considerations
o Assess the patient for symptoms of stroke, peripheral
vascular disease, or MI periodically during therapy.
o Monitor the patient for signs of thrombotic thrombocytic
purpura (thrombocytopenia, microangiopathic hemolytic
anemia, neurologic findings, renal dysfunction, fever). May
rarely occur, even after short exposure (2 wk). Requires
prompt treatment.
o Lab Test Considerations: Monitor bleeding time during
therapy. Prolonged bleeding time, which is time- and dose-
dependent, is expected.
o Monitor CBC with differential and platelet count
periodically during therapy. Neutropenia and
thrombocytopenia may rarely occur.
o Discontinue clopidogrel 5– 7 days before planned surgical
procedures. If clopidogrel must be temporarily
discontinued, restart as soon as possible. Premature
discontinuation of therapy may increase risk of
cardiovascular events.
o PO: Administer once daily without regard to food.
o Advise patients to notify the health care professional
promptly if fever, weakness, chills, sore throat, rash,
unusual bleeding or bruising, extreme skin paleness,
purple skin patches, yellowing of skin or eyes, or
neurological changes occur.
o Advise the patient to notify the health care professional of
medication regimen prior to treatment or surgery.
o Instruct patients to notify the health care professional of
all Rx or OTC medications, vitamins, or herbal products
being taken and to consult the health care professional
before taking any other Rx, OTC, or herbal products,
especially those containing aspirin or NSAIDs or proton
pump inhibitors.
Antihypertensive Medications
ACE Inhibitors
o Sample Medications: Benazepril (Lotensin), Captopril, Enalapril
(Vasotec), Lisinopril
o Action
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o ACE inhibitors block the conversion of angiotensin I to the
vasoconstrictor angiotensin II
o They also prevent the degradation of bradykinin and other
vasodilatory prostaglandins. ACE inhibitors also increase plasma
renin levels and decrease aldosterone levels.
o Therapeutic Effects: Lowering of BP in hypertensive patients.
o Indications:
- Hypertension
- CHF
- Post MI
- Diabetes Mellitus
- Certain chronic kidney diseases
Contraindication
- Hypersensitivity
- History of angioedema with previous use of ACE inhibitors (also
in absence of previous use of ACE inhibitors for benazepril)
- Concurrent use with aliskiren in patients with diabetes or
moderate-to-severe renal impairment (CCr 60 mL/min)
- OB: Can cause injury or death of fetus— if pregnancy occurs,
discontinue immediately
- Lactation: Certain ACE inhibitors appear in breast milk;
discontinue drug or use formula
Nursing Considerations
- During initial dose adjustment and periodically during therapy.
Notify health care professional of significant changes
- Monitor frequency of prescription refills to determine
adherence
- Assess the patient for signs of angioedema (swelling of face,
extremities, eyes, lips, tongue, difficulty in swallowing or
breathing); may occur at any time during therapy. Discontinue
medication and provide supportive care
- Lab Test Considerations: Monitor BUN, creatinine, and
electrolyte levels periodically. Serum potassium, BUN and
creatinine may beq, whereas sodium levels may bep. IfqBUN or
serum creatinine concentrations occur, dose reduction or
withdrawal may be required
- Monitor CBC periodically during therapy. Certain drugs may
rarely cause slight decrease in hemoglobin and hematocrit,
leukopenia, and eosinophilia
- May cause increased AST, ALT, alkaline phosphatase, serum
bilirubin, uric acid, and glucose levels
- Correct volume depletion, if possible, before initiation of
therapy
- PO: Precipitous drop in BP during first 1– 3 hr after first dose
may require volume expansion with normal saline but is not
normally considered an indication for stopping therapy.
Discontinuing diuretic therapy or cautiously increasing salt
intake 2– 3 days before initiation may decrease risk of
hypotension. Monitor closely for at least 1 hr after BP has
stabilized. Resume diuretics if BP is not controlled.
Angiotensin II Receptor Blockers (ARBS)
- Sample Medications: Micardis (telmisartan), Cozaar (losartan),
Atacand (candesartan), Avapro (irbesartan)
- Action
- Blocks vasoconstrictor and aldosterone-producing effects of
angiotensin II at receptor sites, including vascular smooth
muscle and the adrenal glands. Therapeutic Effects: Lowering
of BP. Slowed progression of diabetic nephropathy (irbesartan
and losartan only). Decreased risk of stroke patients with
hypertension and left ventricular hypertrophy
- Indication
- Alone or with other agents in the management of hypertension
- Treatment of diabetic nephropathy in patients with type 2
diabetes and hypertension (irbesartan and losartan only)
- Reduction of risk of death from cardiovascular causes in
patients with left ventricular systolic dysfunction after MI
(valsartan only)
- Contraindication
- Hypersensitivity; Concurrent use with aliskiren in patients with
diabetes or moderate-to-severe renal impairment
- Severe hepatic impairment (candesartan)
- OB: Can cause injury or death of fetus— if pregnancy occurs,
discontinue immediately
- Lactation: Discontinue drug or use formula
- Use Cautiously in: HF (may result in azotemia, oliguria, acute
renal failure and/or death); Volume- or salt-depleted patients
or patients receiving high doses of diuretics Obstructive biliary
disorders (telmisartan) or hepatic impairment
- Adverse Effects
- CNS: dizziness, anxiety, depression, fatigue, headache,
insomnia, weakness
- CV: hypotension, chest pain, edema, tachycardia
- Derm: rashes
- EENT: nasal congestion, pharyngitis, rhinitis, sinusitis
- GI: abdominal pain, diarrhea, drug-induced hepatitis,
dyspepsia, nausea, vomiting
- GU: impaired renal function
- F and E: hyperkalemia
- MS: arthralgia, back pain, myalgia
- Misc.: Angioedema
- Nursing Considerations
- Assess BP (lying, sitting, standing) and pulse periodically during
therapy. Notify the health care professional of significant
changes
- Monitor frequency of prescription refills to determine
adherence
- Assess the patient for signs of angioedema (dyspnea, facial
swelling). May rarely cause angioedema
- HF: Monitor daily weight and assess the patient routinely for
resolution of fluid overload (peripheral edema, rales/crackles,
dyspnea, weight gain, jugular venous distention)
- Lab Test Considerations: Monitor renal function and electrolyte
levels periodically. Serum potassium, BUN, and serum
creatinine may beq.
- May cause increased AST, ALT, and serum bilirubin levels
(candesartan and olmesartan only)
- Emphasize the importance of continuing to take as directed,
even if feeling well. Take missed doses as soon as remembered
if not almost time for the next dose; do not double doses.
Instruct the patient to take medication at the same time each
day. Warn patient not to discontinue therapy unless directed by
health care professional
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- Caution the patient to avoid salt substitutes containing
potassium or food containing high levels of potassium or
sodium unless directed by the health care professional
- May cause dizziness. Caution patient to avoid driving or other
activities requiring alertness until response to medication is
known
- Instruct the patient to notify health care professional of
medication regimen prior to treatment or surgery
- Instruct patient to notify health care professional immediately
if swelling of face, eyes, lips, or tongue occurs, or if difficulty
swallowing or breathing occurs
- Hypertension: Encourage the patient to comply with additional
interventions for hypertension (weight reduction, low-sodium
diet, discontinuation of smoking, moderation of alcohol
consumption, regular exercise, stress management).
Medication controls but does not cure hypertension.
Nursing Problems
- Ischemic
o Impaired physical mobility related to hemiparesis, loss of
balance and coordination, spasticity, and brain injury
o Acute pain (pain shoulder) related to hemiplegia and disuse
o Self-care deficits (bathing, hygiene, toileting, dressing and
feeding) related to stroke sequelae
o Impaired comfort related to altered sensory reception,
transmission, and/or integration
o Impaired swallowing
o Impaired urinary elimination related to flaccid bladder,
detrusor instability, confusion, or difficulty in communicating
o Constipation related to change in mental status or difficulty in
communicating
o Acute confusion related to brain infarction
o Impaired verbal communication related to brain damage
o Risk for impaired skin integrity related to hemiparesis,
hemiplegia, or decreased mobility
o Interrupted family processes related to catastrophic illness and
caregiving burdens
o Sexual dysfunction related to neurologic deficits or fear of
failure
Hemorrhagic
o Risk for ineffective tissue perfusion (cerebral) related to
bleeding or vasospasm
o Anxiety related to illness and/or medically imposed restrictions
( aneurysm precautions)
Nursing Considerations
Ischemic
o Improving mobility and preventing joint deformities. Ensure
correct positioning to prevent contractures ( e.g splint applied
at night to the affected extremity )
o Preventing Shoulder Adduction. A pillow is placed in the axilla
when there is limited external rotation;this keeps the arm away
from the chest.A pillow is placed under the arm, and the arm is
placed neutral (slightly flexed) position, with distal joints higher
than the more proximal joints.This help to prevent edema and
the resultant joint fibrosis that will limit the range of motion if
the patient regains the control of the arm.
o Positioning head and fingers.
o The hand is placed in slight supination (palm faces
upward)
o If the upper extremity is flaccid, a splint can be used
to support the wrist and hand in a functional position.
o If the upper extremity is spastic, a hand roll is not
used , because it stimulates the grasp reflex. A dorsal
wrist splint is useful in this to allow the palm to be
free of pressure.
o Spasticity- Botulin toxic A is injected into the wrist
and finger to reduce spasticity (the effects last for 2-4
months). Other treatments include stretching,
splinting, and oral medication such as baclofen,
diazepam, dantrolene and tizanidine.
o Changing position
o The patient’s position should be change every 2 hours
to reduce pressure and prevent pressure ulcers.
o To place the px in a side lying position, place a pillow
between the legs before the patient is turned
o The upper thigh should not be acutely flex to
promote venous return and prevent edema
o If possible, the px is placed in a prone position for 15
to 30 minutes several times a day. A small pillow or a
support is place under the pelvis, extending the level
of the umbilicus to the upper third of the thigh
o It promotes hyperextension of the hip joints which is
essential for the gait and helps prevent knee and hip
flexion contractures
o To drain bronchial secretions and prevent contractual
deformities of the shoulders and knees.
o Establishing an exercise Program
o The affected extremity are exercised passively and
put through a full range of motion four or five times a
day to maintain joint mobility, regain motor control,
prevent contractures in the paralyzed extremity,
prevent further deterioration of the neuromuscular
system, and enhance circulation.
o The patient is observed for s/s that may indicate PE or
excessive cardiac output overload during exercise ,
these include SOB, chest pain, cyanosis and
increasing pulse rate with exercise.
o Frequent short periods of exercise always are
preferable
o The patient is encouraged and reminded to exercise
the unaffected side at intervals throughout the day.
o Provide written schedule to the patient
o The patient can be instructed to put the unaffected
leg under the affected one to assist in moving it when
turning and exercising.
o Quadriceps muscles setting and gluteal setting
exercises started early to improve muscle strength
needed for walking; these are performed at least five
times daily for 10 minutes at a time.
o Preventing shoulder pain
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 o The nurse should lift the patient by the flaccid
shoulder or pull on the affected arm or shoulder.
Overhead pulley should be avoided
o The flaccid should be positioned on a table or with
pillows while the patient is seated.
o Encourage patient to do ROM
o The patient is instructed to interlace the fingers, place
the palms together and push the clasped hands
slowly forward to bring the scapulae forward; he or
she then raises both hands above the head. This
should be repeated throughout the day.
o Elevation of the arm is also important to prevent
edema
o Other treatment includes injections to the shoulder
joint with corticosteroid acupuncture, electrical
stimulation, heat or ice, and soft tissue massage
o Assisting to physical changes
o Patients with decreased field of vision should be
approached on the side where visual perception is
intact.All visual stimuli ( e.g., clock, calendar,
television) should be placed on the side.
o The nurse should make eye contact with the patient
and draw their attention to the affected side by
encouraging the patient to move the head.
o Increasing natural or artificial lighting in the room and
providing eyeglasses are important aids to increase
vision.
o Assisting with nutrition
o Patients must be observed for paroxysms of
coughing, food dribbling out of or pooling in one side
of the mouth, food retained for long periods in the
mouth, or nasal regurgitation when swallowing
liquids.
o A swallow assessment is performed as soon as
possible after the patients arrival to the ED
(preferably within 4 to 24 hours)
o Patient may be started on a thick liquid or pureed diet
o Having the px sit upright, preferably out of bed in a
chair, and instruct him/her to tuck the chin toward
the chest as he/she will help prevent aspiration
o In a patient with a feeding tube, the tube should be
placed in the duodenum to prevent aspiration
o Attaining Bladder and bowel control
o Intermittent catheterization with sterile technique is
carried out
o Upright posture and standing position are helpful for
male patients during the aspect of rehabilitation.
o A high fiber-diet and adequate fluid intake (2 to 3
L/day) and regular time (usually breakfast) should be
established
o Maintaining skin integrity
o A specialty bed (e.g., low air-loss bed) may be used
until the patient can move independently or assist in
moving.
o Do regular turning position (e.g every 2 hours)
o Monitoring and managing potential complications.
o Neurologic flowsheet is monitored
o Changes in blood pressure, pulse, and respiration is
reported immediately
o If s/s of pneumonia develop, cultures are obtained
Hemorrhagic
o Closely monitored for neurologic deterioration resulting from
recurrent bleeding, increasing ICP, or vasospasm.
o Neurologic flow record is maintained
o The blood pressure, pulse, level of consciousness (an indicator
of cerebral perfusion), pupillary responses, and motor function
are checked hourly
o Monitor and manage potential complications
o Vasospasm- calcium channel blocker nimodopine should be
given for prevention and fluid expanders in the form of triple H-
therapy may be prescribed as well
o Seizure- maintain airway and prevent injury. Medication
therapy is initiated at this time
o Hydrocephalus- changes in patient responsiveness are reported
immediately
o Hyponatremia- laboratory data must be checked frequently.
Treatment most often is the use of IV hypertonic 3% saline.
o Rebleeding- Hypertension is the most serious and modified risk
factor, which shows the importance of appropriate
antihypertensive treatment
o Blood pressure is should be fully maintained
o Secure the aneurysm if the patient is a candidate for surgery
or endovascular treatment
Microvascular Complications
Diabetic microvascular disease (or microangiopathy) is characterized
by capillary basement membrane thickening. The basement
membrane surrounds the endothelial cells of the capillary.
Researchers believe that increased blood glucose levels react through
a series of biochemical responses to thicken the basement membrane
to several times its normal thickness. Two areas affected by these
changes are the retina and the kidneys (Grossman & Porth, 2014).
DIABETIC RETINOPATHY
Anatomy and Pathophysiology
The Eye
• The human eye is divided into
anterior and posterior
segments. The anterior segment
includes the cornea, pupil, iris,
lens, and the aqueous humor.
The posterior segment includes
the vitreous humor, choroid,
sclera, macula, optic nerve, and
retina.
• The wall of the eye has three layers.
o The outermost white layer is the sclera, a tough,
fibrous tissue that protects the eye and helps
maintain its shape. The cornea, a domed, transparent
75
 structure, is continuous with the sclera and covers
the anterior eye.
o The vascular middle layer, or uvea, consists of the
choroid in the posterior segment and the iris in the
anterior segment.
o The retina, or inner layer, lines the back two-thirds of
the choroid and possesses a rich vascular supply.
• Light passes through the pupil and enters the posterior
segment of the eye via the crystalline lens. Fluid fills the entire
eye, supporting its structure and various metabolic functions.
The anterior segment contains the clear, lymph-like, watery
aqueous humor, while the posterior segment holds clear,
jellylike vitreous humor. Unlike the retina, a healthy vitreous
chamber contains no blood vessels.
• As light enters the eye, it is bent by the cornea and lens, passes
through the vitreous, and is focused on the retina. Retinal
neural tissues transform light into electrical impulses, which are
transmitted by the optic nerve to the brain and interpreted as
visual images. The macula is a small area just lateral to the
center of the retina that provides detailed central visual acuity.
CONCEPT MAP
What causes diabetic retinopathy?
• Diabetic retinopathy is caused by high blood sugar due to
diabetes. Over time, having too much sugar in the blood can
damage the retina — the part of the eye that detects light and
sends signals to the brain through a nerve in the back of your
eye (optic nerve).
• Diabetes damages blood vessels all over the body. The damage
to the eyes starts when sugar blocks the tiny blood vessels that
go to the retina, causing them to leak fluid or bleed. To make
up for these blocked blood vessels, the eyes then grow new
blood vessels that don’t work well. These new blood vessels can
leak or bleed easily.
Risk factors
• Anyone who has diabetes can develop diabetic retinopathy.
Risk of developing the eye condition can increase as a result of:
o Duration of diabetes — the longer you have diabetes,
the greater your risk of developing diabetic
retinopathy
o Poor control of your blood sugar level
o High blood pressure
o High cholesterol
o Pregnancy
o Tobacco use
o Being African-American, Hispanic or Native American
Complications
Diabetic retinopathy involves the abnormal growth of blood vessels
in the retina. Complications can lead to serious vision problems:
• Vitreous hemorrhage. The new blood vessels may bleed into
the clear, jelly-like substance that fills the center of the eye. If
the amount of bleeding is small, the person might see only a
few dark spots (floaters). In more-severe cases, blood can fill
the vitreous cavity and completely block the vision.
Vitreous hemorrhage by itself usually doesn't cause permanent
vision loss. The blood often clears from the eye within a few
weeks or months. Unless the retina is damaged, the vision may
return to its previous clarity.
• Retinal detachment. The abnormal blood vessels associated
with diabetic retinopathy stimulate the growth of scar tissue,
which can pull the retina away from the back of the eye. This
may cause spots floating in your vision, flashes of light or
severe vision loss.
• Glaucoma. New blood vessels may grow in the front part of
your eye and interfere with the normal flow of fluid out of the
eye, causing pressure in the eye to build up (glaucoma). This
pressure can damage the nerve that carries images from your
eye to your brain (optic nerve).
• Blindness. Eventually, diabetic retinopathy, glaucoma or both
can lead to complete vision loss.
CONCEPT MAP
• Diabetic retinopathy results from damage to retinal blood
vessels and red blood cells (RBCs), platelet aggregation, relative
hypoxemia and hypertension. Three stages of retinopathy lead
to loss of vision: nonproliferative (stage I), characterized by
thickening of the retinal capillary basement membrane and an
increase in retinal capillary permeability, vein dilation,
microaneurysm formation, and superficial (flame-shaped) and
deep (blot) hemorrhages; preproliferative (stage II), a
progression of retinal ischemia with areas of poor perfusion
that culminate in infarcts; and proliferative (stage III), the result
of neovascularization (angiogenesis) and fibrous tissue
formation within the retina or optic disc. Traction of the new
vessels on the vitreous humor may cause retinal detachment or
hemorrhage into the vitreous humor withsevere blurring or loss
of vision. Macular edema (fluid accumulation and retinal
thickening near the center of the macula) is the leading cause
of visual impairment (blurring) among persons with diabetes.
• Blurring of vision also can be a consequence of hyperglycemia
and sorbitol accumulation in the lens. Dehydration of the lens,
aqueous humor, and vitreous humor also reduces visual acuity.
In addition to the ocular vasculopathy associated with
hyperglycemia, activation of inflammatory cells (i.e., retinal glial
and immune cells) and release of inflammatory mediators
contribute to chronic neuroinflammation with injury to retinal
sensory cells and loss of vision (optic neuropathy).
76

Diagnostic Procedures
• Visual Acuity. Visual acuity is tested by assessing a person's
ability to read a chart displaying random letters and numbers at
various distances. A visual acuity test is an eye exam that
checks how well you see the details of a letter or symbol from a
specific distance.
• Ophthalmoscopy or fundoscopy is performed to look inside the
fundus of the eye and determine retinal health. A device called
an ophthalmoscope contains a light and a special magnifying
glass for examining the fundus.
• Fluorescein Angiography (FA): Fluorescein is a fluorescent dye.
Fluorescein Angiography helps in assessing degree of retinal
ischaemia and delineates retinal vascular abnormalities.
Microaneurysms appear as hyper-fluorescent spots which leaks
the dye in late phases of FA. ‘Blot’ and ‘Dot’ haemorrhages
appear hypo-fluorescent in contrast to micro-aneurysms.
Nonperfused areas appear as dark patches or homogeneous
hypo-fluorescent areas. NVD and NVE also show leakage of dye
on FA. Intra-retinal micro-vascular abnormalities do not leak
dye.
• Optical Coherence Tomography (OCT): OCT generates cross-
sectional image of the retina with light. OCT helps in measuring
retinal thickening. Periodic OCT determine whether the retinal
thickening in macular area due to oedema is regressing or not
with treatment. Any vitreomacular traction can also be
assessed.
• B-scan ultrasonography: B-scan ultrasonography evaluates
retina when the media is not clear e.g. vitreous haemorrhage.
MEDICAL SURGICAL MANAGEMENT
• Focal Laser Photocoagulation (FLP): This procedure, which is
utilized in DME management, involves the use of a laser beam
to seal leaky blood vessels, thereby preserving normal retinal
thickness and function. Although it does not restore vision, FLP
may attenuate vision loss. Adverse effects include an initial
decrease in central vision. Inadvertent central retinal burns may
lead to permanent central blindness
• Panretinal (Scatter) Laser Photocoagulation (PLP): PLP is aimed
at arresting leakage and neovascularization of blood vessels,
thereby reducing the risk of vitreous hemorrhage and retinal
detachment. Since PLP involves application of laser light in the
peripheral retina, some patients may experience compromised
peripheral vision. Loss of accommodation and central vision
have been reported in some patients. PLP is the mainstay of
PDR and severe NPDR therapy.
• Vitrectomy: This procedure involves removal of vitreous humor
and may be warranted in severe PDR to attenuate vision loss
secondary to vitreous hemorrhage and retinal detachment
involving the macula.
PHARMACOLOGY WITH NURSING CONSIDERATIONS
Corticosteroids
• These agents possess anti-inflammatory properties and the
ability to downregulate VEGF, thereby reducing leakage from
damaged retinal capillaries.
• Intravitreal triamcinolone acetonide (IVTA) is currently used as
an off-label adjunctive treatment for DME and may be useful in
PDR. A biodegradable, extended-release dexamethasone
implant has shown promise for DME management, with a
potentially superior side-effect profile compared to IVTA.
• Corticosteroids should be used cautiously in patients with a
history of cataracts and glaucoma. A summary of dosing and
adverse effects is provided in TABLE 1.
• Nursing Considerations:
o Proper tapering of steroids
o Monitor sings and symptoms of infection
o Provide support
o Not for immediate relief VEGF Inhibitors
VASCULAR ENDOTHELIAL GROWTH FACTOR (VEGF)
• VEGF is a suitable therapeutic target because it is upregulated
in DR and contributes to neovascularization and capillary
leakage in severe DR.
• Three drugs are currently available in the market—
bevacizumab, pegaptanib, and ranibizumab (TABLE 1). While
ranibizumab has been approved by the FDA for secondary DME
resulting from thrombosis and retinal vein occlusion, all the
VEGF inhibitors have found off-label application in the
treatment of DME. Because VEGF inhibitors are administered
intravitreally, adverse systemic effects are minimized. Safety
studies are still in progress for this class of drugs.
• Nursing Considerations
o Monitor for S&S of an infusion reaction
(hypersensitivity); infusion should be interrupted in
all patients with severe infusion reactions and
appropriate therapy instituted.
o Monitor BP at least every 2–3 wk; if hypertension
develops, monitor more frequently, even after
discontinuation of bevacizumab.
o Withhold drug and promptly notify the physician for
S&S of CHF, hemorrhage (e.g., epistaxis, hemoptysis,
or GI bleeding), or unexplained abdominal pain.
o Lab tests: Urinalysis for proteinuria and 24 h urine if
protein 2+ or greater.
o Monitor for dizziness, lightheadedness, or loss of
balance. Take appropriate safety measures
Renin-Angiotensin System (RAS) Inhibitors
• Angiotensin-converting enzyme (ACE) inhibitors and
angiotensin II receptor blockers (ARBs) reduce DR and VEGF
77
 levels in PDR. Lisinopril, an ACE inhibitor, is used off-label to
attenuate DR progression in nonhypertensive type I patients.
• Therapy may be discontinued if hypotension and hyperkalemia
persist.
• Nursing Considerations
o Hypotension should be managed according to
appropriate guidelines
o Treatment with an ACE inhibitor can be started in the
community in the majority of people with heart
failure.
o In patients taking diuretics, close supervision is
needed when commencing treatment.
o The initial dose of ACE has a risk of first-dose
hypotension, therefore patients should be advised to
sit or lie down for 2-4 hours after this.
o Evaluate therapeutic response.
Antiplatelet Drugs
o Platelet aggregation contributes to capillary occlusion and
microaneurysm formation in DR. The antiplatelet drug
ticlopidine has an off-label indication to delay the rate of
microaneurysm formation in NPDR.
o Nursing Considerations
o Drug Interactions: 1) increased risk of bleeding with
aspirin, NSAIDS, heparin, enoxaparin, and other anti-
clotting drugs; 2) Omeprazole and other proton pump
inhibitors may decrease efficacy of clopidogrel; 3)
Feverfew, garlic, ginger, and ginkgo may increase risk
of bleeding.
o Do not administer clopidogrel to ACS patients if CABG
is planned within 5 – 7 days. [Controversial evidence
about this warning!]
o Platelet function and bleeding time return to baseline
in 7 – 10 days.
o Monitor patient for signs of thrombotic
thrombocytopenic purpura (low platelet count, neuro
symptoms, renal dysfunction, fever).
o Monitor for signs and symptoms of bleeding (urine,
stool, hematoma, epistaxis, petechiae).
o May cause elevation of serum liver enzymes–
establish baseline enzymes and bilirubin levels.
NURSING MANAGEMENT
Nursing Problems
o Disturbed Sensory Perception: Visual related to blurry vision
o Risk for Injury related to decreased vision
o Risk for falls related to blurry vision
Nursing Considerations:
Disturbed Sensory Perception: Visual related to blurry vision
o Encourage patient to see an ophthalmologist at least yearly.
o Provide sufficient lighting for the patient to carry out activities.
o Provide lighting that avoids glare on surfaces of walls, reading
materials, and so forth.
o Provide night light for the patient’s room and ensure lighting is
adequate for the patient’s needs.
Acute pain related to blocked blood vessels
o Encourage patient to rest the eyes
o Encourage patient to wear prescribed glasses
o Encourage patient to avoid staring at bright lights
o Encourage patient to take pain medication unless
contraindicated
Risk for Injury related to decreased vision
o Assess patient for degree of visual impairment.
o Inform about special devices that can be used.
o Ensure the room environment is safe with adequate lighting
and furniture moved toward the walls. Remove all rugs, and
objects that could be potentially hazardous.
o Keep patient’s glasses and call bell within easy reach.
o Instruct patient and/or family regarding the need to maintain a
safe environment.
o Instruct patient and/or family regarding safe lighting. The
patient should wear sunglasses to reduce glare. Advise family
to use contrasting bright colors in household furnishings.
General Nursing Considerations:
o Encourage patient to manage diabetes. Encourage him to
make healthy eating and physical activity part of his daily
routine. Try to get at least 150 minutes of moderate aerobic
activity, such as walking, each week. Take oral diabetes
medications or insulin as directed.
o Encourage patient to monitor blood sugar level.
o Encourage patient to ask his doctor about a glycosylated
hemoglobin test. The glycosylated hemoglobin test, or
hemoglobin A1C test, reflects the average blood sugar level for
the two- to three-month period before the test. For most
people, the A1C goal is to be under 7 percent.
o Encourage patient to keep blood pressure and cholesterol
under control. Eating healthy foods, exercising regularly and
losing excess weight can help. Encourage the patient to take
the prescribed medication religiously.
o Encourage patient to quit smoking if he is a smoker. Smoking
can also make managing the disease and regulating insulin
levels more difficult because high levels of nicotine can lessen
the effectiveness of insulin.
o Encourage patient to pay attention to vision changes.
Encourage him to contact his eye doctor right away if he
experiences sudden vision changes or your vision becomes
blurry, spotty or hazy.
NEUROPATHY
Diabetic Neuropathies
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o Refers to a group of disease that affect all types of nerves,
including peripheral (sensorimotor), autonomic and spinal
nerves
o Prevalence increases with age of the patient and duration of
disease

Peripheral Neuropathy

o Most commonly affects the distal portions of the nerves,

especially nerves of the lower extremities
o It affects both sides of the body symmetrically
o May spread in a proximal direction
o Approximately half of patients with diabetic neuropathy do not
have symptoms (decrease in deep tendon reflexes and
vibratory sensation may be the only indication of neuropathic
changes)

Clinical Manifestations:

o Initial symptoms: paresthesias such as prickling, tingling or

heightened sensation and burning sensations
o As the neuropathy progresses: numb feet, decrease in
proprioception, decreased sensation of light touch, decreased
sensations of pain and temperature, deformities of the
foot (Charcot joints)

Autonomic Neuropathy
o Neuropathy of the autonomic nervous system which results in a
broad range of dysfunctions affecting almost every organ
system of the body
o Clinical Manifestations:
o Cardiovascular: slightly tachycardic heart rate,
orthostatic hypotension, silent or painless myocardial
infarction and ischemia
o Gastrointestinal: early satiety, bloating, nausea, vomiting,
constipation, diarrhea and unexplained wide swings in glucose
levels related to inconsistent absorption of the glucose from
ingested food secondary to inconsistent gastric emptying
o Renal: urinary retention, decreased sensation of bladder
fullness and other urinary symptoms of neurogenic bladder
resulting from autonomic neuropathy
o Sexual Dysfunction: Erectile dysfunction
Sudomotor Neuropathy
o Refers to a decrease or absence of sweating of the extremities
with a compensatory increase of sweating in the upper body
o Dryness of the feet increases the risk for the development of
foot ulcers
Anatomy and Pathophysiology
A typical neuron cell contains:
o Cell body - Contains a single nucleus
o Dendrites - Short, often highly branching cytoplasmic
extensions that are tapered from their bases at the neuron cell
body to their tips
o Axon - A single long process extending from the neuron cell
body
o Axon hillock - The area where the axon leaves the neuron cell
body
o Collateral axons - Branching out of axons
o Myelin sheaths
o Specialized layers that wrap around the axons of
some neurons
o They are made of oligodendrocytes in the CNS and
Schwann cells on the PNS
o Myelination of an axon increases the speed and
efficiency of action potential generation along the
axon
o Node of Ranvier - Gaps in the myelin sheaths where ion
movement occurs
o Synapse - A junction where the axon of one neuron interacts
with another neuron or with cells of an effector organ such as a
muscle or gland.
o Sensory nerves (afferent)
o From the PNS conducts action potentials from
sensory receptors to the CNS
o Motor nerves (efferent)
o Conducts action potentials from the CNS to effector
organs
o Somatic nervous system

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 o Transmits action potentials from the CNS to the
skeletal muscles
o Autonomic nervous system
o Transmits action potentials from the CNS to the
cardiac muscle, smooth muscle and glands
o Action potentials
o In an unstimulated cell, there is uneven charge distribution
specifically negative charged inside the cell membrane
(abundance of K+) and positively charged outside the cell
membrane (abundance of Na+). This happens due to the
greater permeability of the cell membrane to K+ rather than
Na+. This uneven charge distribution is called resting
membrane potential and the cell is polarized.
o Nerve cells are excitable cells meaning that the resting
membrane potential changes in response to stimuli that
activate gated ion channels. When the cell membrane is at rest,
the voltage-gated channels are closed. When a stimulus is
applied Na+ channels open briefly and Na+ diffuses into the cell
making the inside of the cell positive. This is called
depolarization which results in a local potential.
o If the local potential reaches a threshold value, voltage-gated
Na+ channels to open which initiates an action potential. Action
potentials occur in an all-or-none fashion, meaning a certain
value (threshold value) has to be reached in order for the
action potential to occur.
o These action potentials are conducted slowly in unmyelinated
axons and more rapidly in myelinated axons. This is because in
myelinated axons, the action potentials can “jump” from one
node of Ranvier the next. This is faster because action
potentials no longer have to travel along the entire cell
membrane. For a comparison, traveling through unmyelinated
axons would be like doing a tandem walk while traveling
through myelinated axons would be skipping. The action
potential will then reach the synapse where it activates the
release of neurotransmitters to be able to communicate with
another neuron or effector organ.
Blood supply to the nerves
Vasa nevorum
o It is the overarching term for the arteries that supply blood to
the interior and exterior elements of peripheral nerves.
o The vasa nervorum is not considered a stable enough system to
name and describe in its entirety as it varies greatly within
people. What is understood about it is the following:
1. Irregular – it is not a stable system of supply. It is an
irregular source of nutrition that supplies each peripheral
nerve from adjacent blood vessels.
2. It branches from adjacent blood vessels - blood vessels
close to a nerve will provide branches to supply the nerve
at irregular intervals. After entering a nerve, a nutrient
artery will branch into plexuses that may be seen on the
surface or, in some cases, lying parallel to the nerve. These
form anastomoses at intervals throughout the course of
the nerve, reinforcing the blood supply within the
epineurium (the external connective-tissue sheath of a
nerve trunk)
3. They are tortuous – they have winding paths; they are not
straight; they are full of twists and turns in order to be
able to accommodate movement and not tear during
motion (they are built to deal with motion)
CONCEPT MAP
DIAGNOSTIC PROCEDURES
Hemoglobin A1c
o Hemoglobin A1c is an important laboratory screening test for
diabetic neuropathy. Hemoglobin A1c measurement is useful to
assess the adequacy of recent diabetes control; levels are likely
to be elevated in patients with diabetic neuropathies. In some
cases, especially with asymmetrical syndromes, the severity of
the elevation does not always correlate with the severity of the
nerve disease.
Fasting Plasma Glucose
o Fasting Plasma Glucose is an important laboratory screening
test for diabetic neuropathy. A fasting blood glucose test can be
useful to see how well the body is able to manage blood sugar
levels in the absence of food. When we do not eat for several
hours, the body will release glucose into the blood via the liver
80
 and, following this, the body's insulin should help to stabilize
blood glucose levels.
Monofilament Test
o Monofilament testing is an inexpensive, easy-to-use, and
portable test for assessing the loss of protective sensation, and
it is recommended by several practice guidelines to detect
peripheral neuropathy in otherwise normal feet.
o Monofilament testing of both feet should be conducted with
clients who have one or both of the following:
o a diagnosis of diabetes and / or a diabetic ulcer.
o numbness, tingling, burning or a “crawling” sensation in one or
both feet.
o Monofilament testing should be done at least once a year as
part of an overall foot assessment.
o This procedure should be used in conjunction with the
Guideline for Diabetic and Neuropathic Ulcers if the client has a
wound.
Nerve Conduction Velocity
o Conventional NCV testing includes measurement of the speed
of both motor and sensory conduction. The amplitude of the
distal response is also measured. The proximal component of
conduction can be investigated with H-reflex (S1 root) or F-
wave (motor pathways only) response. NCV tests measure how
long it takes nerves to transmit signals. Damaged nerves don't
transmit messages as quickly as they should.
Electromyography
o EMG tests can help assess how well muscles are responding to
the signals from nerves. If the nerves going to the muscles are
damaged, they won't give clear signals and therefore, the
muscles won't respond well. The examiner searches for
abnormal spontaneous potentials, voluntary motor unit
recruitment, and motor unit configuration. In weak patients,
the recruitment characteristics can often help distinguish a
neuropathic from a myopathic process.
MEDICAL MANAGEMENT
The main goal of diabetes treatment is to normalize insulin activity
and blood glucose levels to reduce the development of
complications.
Glycemic Control
o Of all treatments, tight and stable glycemic control is probably
the most important for slowing the progression of neuropathy,
Because rapid swings from hypoglycemia to hyperglycemia
have been suggested to induce and aggravate neuropathic pain,
the stability of glycemic control may be as important as the
actual level of control in relieving neuropathic pain. The
Diabetes Control and Complications Trial (DCCT) demonstrated
that tight blood sugar control in patients with type 1 diabetes
decreased the risk of neuropathy by 60% in 5 years. The effect
of tight glycemic control on polyneuropathy in patients with
type 2 diabetes or those with impaired glucose
tolerance/impaired fasting glucose is not as clear and requires
further prospective study.
SURGICAL MANAGEMENT
Nerve Decompression Surgery
Nerve Decompression Surgery to reduce peripheral neuropathy.
Similar to carpal tunnel syndrome surgery, nerve decompression
surgery helps improve symptoms of DPN of the foot and prevents
amputation. Nerve decompression surgery is a minimally invasive
surgical procedure to relieve pressure caused by a neuroma – a
pinched or entrapped nerve. It has been entrenched in medical
training that the symptoms of diabetic peripheral neuropathy are
irreversible.
Purpose:
The aim of nerve decompression is to either remove whatever is
pressing on the nerve or open up any narrow spaces to give the
nerve more room, or both. Nerve decompression surgery can be
thought of as two subtypes: spinal and peripheral.
Nutritional therapy
Nutritional management of diabetes includes the following goals:
A. Blood glucose levels in the normal range or as close to normal
as is safely possible
1. Blood glucose levels in the normal or as close to normal range
or close to normal as is safely possible
2. A lipid and lipoprotein profile that reduces the risk for vascular
disease
3. Blood pressure levels in the normal range or as close to normal
as is safely possible
B. To prevent, or at least slow, the rate of development of the
chronic complications of diabetes by modifying nutrition and
lifestyle
C. To address individual nutrition needs, taking into account
personal and cultural preferences and willingness to change
D. To maintain the pleasure of eating by only limiting food choices
when indicated by scientific evidence
Dietary Supplements
Vitamin supplementation is being studied to see if that can have an
impact. One study of zinc sulfide showed improvement in glycemic
control in 60 patients. Certain B vitamins are often prescribed in an
attempt to reduce paresthesias.
PHARMACOLOGY WITH NURSING CONSIDERATIONS
C: Tricyclics Antidepressant (Amitriptyline, Amoxapine,
Desipramine)
A: act on approximately five different neurotransmitter pathways to
achieve their effects. They block the reuptake of serotonin and
norepinephrine in presynaptic terminals, which leads to increased
concentration of these neurotransmitters in the synaptic cleft.
I: panic disorder,bulimia,chronic pain (for example, migraine,
tension headaches, diabetic neuropathy, and post herpetic
81
neuralgia), phantom limb pain, chronic itching, and premenstrual
symptoms.
C: Under age 25 or over age 65, Have diabetes, heart problems, or a
thyroid disorder, Have any conditions affecting your urinary tract or
an enlarged prostate, Have glaucoma, Have a liver disease, Have a
history of seizures, Take medications to help manage your mood.
A: Sedation, Confusion, Dry mouth, Orthostasis, Constipation,
Urinary retention, Sexual dysfunction, Weight gain.
N: Assess for the mentioned cautions and contraindications (e.g.
drug allergies, hepatorenal diseases, cardiac dysfunction, etc.) to
prevent any untoward complications. Perform a thorough physical
assessment to establish baseline data before drug therapy begins, to
determine the effectiveness of therapy, and to evaluate for the
occurrence of any adverse effects associated with drug therapy.
Monitor results of electrocardiogram and laboratory tests (e.g. renal
and liver function tests) to monitor the effectiveness of the therapy
and provide prompt treatment to developing complications.
C: Anticonvulsants (Carbamazepine or Gabapentin)
A: Suppress the excessive rapid firing of neurons during seizures
I: Diagnosed with epilepsy experience recurrent seizures; however,
not all seizures are a result of epilepsy. A seizure can also be caused
by head trauma, low blood sugar, alcohol or drug withdrawal, or
high fever and may last from a few seconds to several minutes.
C: Prior history of hypersensitivity or allergic reaction to that
medication. Other contraindications exist but are more drug-
specific, including hepatic failure, certain blood diseases, narrow-
angle glaucoma.
A: Increased suicidal ideation, Immediately report fever, rash,
and/or lymphadenopathy; CNS depression: dizziness, somnolence,
and ataxia.
N: Administer first dose at bedtime to decrease dizziness and
drowsiness, Monitor for worsening depression, suicidal thoughts or
behavior, and/or any unusual changes in mood or behavior, Taper
dose; do not stop abruptly
C: Antiarrhythmics (Quinidine, Procainamide, Lidocaine)
A: Act by blocking the membrane sodium, potassium, and calcium
channels, but no agent has exclusive action on a given type of
channel.
I: For the rapid conversion of atrial fibrillation or flutter of recent
onset to sinus rhythm, up to 70% (dose-dependently) convert to
sinus rhythm within 30 minutes.
C: sinus bradycardia, 2nd or 3rd degree AV block, long QT syndrome,
heart failure, cardiogenic shock, drug hypersensitivity, asthma (beta
blocker contraindication)
A: possible issues with your liver, kidneys, thyroid or lungs,
tiredness, nausea , shortness of breath
N: Patients should be advised to closely follow the recommended
dosing regimen. Patients or family members may need instruction
on how to take a pulse rate and should report any
abnormalities. Patients should also be advised that this medication
may cause dizziness and visual changes. Patients may also notice
orthostatic blood pressure decrease with position changes and
should be advised to change positions slowly. Patients should be
advised to avoid grapefruit juice during medication therapy. They
should also monitor for gingival sensitivity and be sure to maintain
good oral hygiene. Patients may also notice increased
photosensitivity and should take protective measures.
C: Opioids (oxycodone (OxyContin), hydrocodone (Vicodin),
codeine, morphine, and many others.)
A: Primarily inhibitory N-type voltage-operated calcium channels
and open calcium-dependent inwardly-rectifying potassium
channels. This results in hyperpolarization and a reduction in
neuronal excitability. Kappa receptors may act only on calcium
channels.
I: acute pain, chronic cancer pain, chronic non-cancer pain.
C: Severe respiratory instability, acute psychiatric instability or
uncontrolled suicide risk, diagnosed non-nicotine substance use
mismedication drug capable of inducing life-limiting drug-drug
interactions.
A: Drowsiness, confusion, nausea, constipation, euphoria, slowed
breathing
N: Teach patient about the risk of opioid diversion. Providing patient
with information on the safe keeping and proper disposal of opioids.
Tracking patient’s analgesic use
C: Pregabalin
A: By binding presynaptically to the alpha2-delta subunit of voltage-
gated calcium channels in the central nervous system, pregabalin
modulates the release of several excitatory neurotransmitters
including glutamate, substance-P, norepinephrine, and calcitonin
gene related peptide.
I: indicated for the management of neuropathic pain associated
with diabetic peripheral neuropathy, postherpetic neuralgia,
fibromyalgia, neuropathic pain associated with spinal cord injury,
and as adjunctive therapy for the treatment of partial-onset seizures
in patients 1 month of age and older.
C: suicidal thoughts, depression, myasthenia gravis, a skeletal
muscle disorder, decreased lung function, chronic obstructive
pulmonary disease, chronic kidney disease stage 3A (moderate),
chronic kidney disease stage 3B (moderate)
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A: Less commom: Chest pain, cold sweats, cool, pale skin,
productive cough, difficult or labored breathing, muscle aches,
twitching or jerking, or weakness, noisy breathing, seizures,
tightness in the chest. Rare: Blistering, peeling, or loosening of the
skin, bloating or swelling of the face, arms, hands, lower legs, or
feet, chills, cough, diarrhea, difficulty with swallowing, dizziness, fast
heartbeat, hives, itching, skin rash, joint or muscle pain, puffiness or
swelling of the eyelids or around the eyes, face, lips, or tongue, red
skin lesions, often with a purple center, red, irritated eyes, sore
throat, sores, ulcers, or white spots in the mouth or on the lips,
unusual tiredness or weakness
N: Pregabalin therapy should be stopped gradually over at least 1
week to decrease risk of seizure activity and avoid unpleasant
symptoms such as diarrhea, headache,insomnia, and nausea. If
patient has evidence of hypersensitivity(red skin, urticaria, rash,
dyspnea, facial swelling, wheezing), stop drug at once, notify the
prescriber, and give supportive care. Monitor patient closely for
adverse reactions. Notify prescriber if significant adverse reactions
persist. Monitor patient closely for evidence of suicidal thinking or
behavior, especially when therapy starts or dosage changes.
NURSING MANAGEMENT
Nursing problem:
✓ Risk for disturbed Sensory Perception related to endogenous
chemical alteration
✓ Risk for injury related to peripheral sensory neuropathy
✓ Risk for impaired skin integrity related to decreased circulation
and sensation caused by peripheral neuropathy and arterial
obstruction
✓ Risk for sexual dysfunction related to peripheral neuropathy
✓ Risk for infection related to decreased leukocyte function
✓ Fatigue related to altered body chemistry
✓ Functional urinary incontinence related to neuromuscular
limitations
✓ Acute pain related to peripheral neuropathy
Nursing consideration
Risk for disturbed Sensory Perception related to endogenous
chemical alteration
✓ Maintain blood glucose levels within normal range.
✓ Monitor vital signs and mental status.
✓ Call the patient by name, reorient as needed to place, person,
and time. Give short explanations, speak slowly and enunciate
clearly.
✓ Keep patient’s routine as consistent as possible. Encourage
participation in activities of daily living (ADLs) as able
✓ Provide bed cradle. Keep hands and feet warm, avoiding
exposure to cool drafts and/or hot water or use of heating pad
✓ Assist patient with ambulation or position changes
Risk for injury related to peripheral sensory neuropathy
✓ Assess for the presence of contributing factors that increase the
risk for injury.
✓ Instruct the patient in the principle of hygiene: wash the feet
daily in warm water using mild soap; avoid soaking the feet. Dry
carefully and gently, especially between toes. Use moisturizing
lotion at least once daily. Avoid the area between the toes
✓ Instruct the patient to inspect the feet daily for cuts, scratches,
and blisters. A mirror may be necessary to assess the bottom of
the foot. Instruct to use both visual inspection and touch
✓ Teach the patient to inspect the shoes daily by feeling the
inside of the shoe for irregularities or sharp objects
✓ Instruct the patient to always wear protective footwear; never
go barefoot
✓ Instruct the patient to trim nails straight across and to file sharp
corners to match the contour of the toe
✓ Instruct the patient to wear clean, well-fitting stockings made
from soft cotton, synthetic blend, or wool
Risk for impaired skin integrity related to decreased circulation and
sensation caused by peripheral neuropathy and arterial obstruction
✓ Assess integrity of the skin. Assess knee and deep tendon
reflexes and proprioception
✓ Inspect feet daily for erythema or trauma
✓ Use foot cradle on the bed. Use space boots on ulcerated heels,
elbow protectors, and pressure-relief mattresses.
✓ Wash feet daily with mild soap and warm water. Check water
temperature before immersing feet in the water.
✓ Change socks or stockings daily. Encourage the patient to wear
white cotton socks
✓ Instruct patient not to walk barefoot
✓ Reinforce that all cuts and blisters need to be cleaned and
treated with antiseptic preparation.
Risk for sexual dysfunction related to peripheral neuropathy
✓ Obtain sexual history, including usual pattern of functioning
and level of desire
✓ Determine importance of sex to the px and the partner and
client’s motivation for change
✓ Avoid making value judgements
✓ Encourage and accept expressions of concern, anger, grief, and
fear
✓ Provide sex education, explanation of normal sexual
functioning when necessary
Risk for infection related to decreased leukocyte function
✓ Teach and promote good hand hygiene
✓ Provide catheter or perineal care. Teach female patients to
clean from front to back after elimination
✓ Provide meticulous skin care by gently massaging bony areas,
keep skin dry. Keep linens dry and wrinkle-free
✓ Administer antibiotics as indicated
✓ Recommend obtaining vaccines, as indicated
Fatigue related to altered body chemistry
✓ Assess muscle strength of patient and functional level of
activity
✓ Discuss with patient the need for activity. Plan schedule with
patient and identify activities that lead to fatigue
✓ Alternate activity with periods of rest and uninterrupted sleep
✓ Increase patient participation in ADLs as tolerated
✓ Alternate activity with periods of rest or uninterrupted sleep
83
✓ Perform activities slowly with frequent rest periods
✓ Promote energy conservation techniques by discussing ways of
conserving energy while bathing, transferring and performing
ADLs.
✓ Instruct patient to perform deep breathing exercises
✓ Administer oxygen as ordered
Functional urinary incontinence related to neuromuscular limitations
✓ Determine the frequency and timing of incontinent void
✓ Administer prescribed diuretics in the morning to lessen night
time voiding
✓ Provide bedside commode, urinal, or bedpan as indicated
✓ Schedule voiding for every 3 hours to minimize bladder
pressure
✓ Implement bladder training program as indicated
✓ Emphasize importance of perineal care following voiding
As blood flows into each nephron, it enters a cluster of tiny blood
vessels—the glomerulus. The thin walls of the glomerulus allow
smaller molecules, wastes, and fluid—mostly water—to pass into
the tubule. Larger molecules, such as proteins and blood cells, stay
in the blood vessel.
Tubules
A blood vessel runs alongside the tubule. As the filtered fluid moves
along the tubule, the blood vessel reabsorbs almost all of the water,
along with minerals and nutrients your body needs. The tubule helps
remove excess acid from the blood. The remaining fluid and wastes
in the tubule become urine.

Acute pain related to peripheral neuropathy

✓ Perform comprehensive assessment of pain to include

location, characteristics, onset/duration, frequency,
quality, severity, and precipitating factors
✓ Observe nonverbal cues
✓ Assess for referred pain
✓ Provide comfort measures
✓ Encourage diversional activities
✓ Administer analgesics as indicated
✓ Encourage adequate rest periods
✓ Provide for individualized physical exercise program that
can be continued by the px when discharged

NEPHROPATHY

Anatomy and Physiology

Diabetic nephropathy is a serious kidney-related complication of

type 1 diabetes and type 2 diabetes. It is also called diabetic kidney
disease. It affects your kidneys' ability to do their usual work of
removing waste products and extra fluid from your body.

The Kidneys

The kidneys are a pair of bean-shaped organs on either side of your

spine, below your ribs and behind your belly. Each kidney is about 4
Blood Flow through the kidneys
or 5 inches long, roughly the size of a large fist.
✓ Blood flows into your kidney through the renal artery. This
✓ The kidneys' job includes:
large blood vessel branches into smaller and smaller blood
✓ To filter your blood.
vessels until the blood reaches the nephrons. In the nephron,
✓ They remove wastes
your blood is filtered by the tiny blood vessels of the glomeruli
✓ Control the body's fluid balance, and
and then flows out of your kidney through the renal vein.
✓ Keep the right levels of electrolytes.
✓ In a single day, your kidneys filter about 150 quarts of blood.
Nephrons Most of the water and other substances that filter through your
glomeruli are returned to your blood by the tubules. Only 1 to 2
Each of your kidneys is made up of about a million filtering units quarts become urine.
called nephrons. Each nephron includes a filter, called the
glomerulus, and a tubule. The nephrons work through a two-step How does diabetes cause Kidney disease?
process: the glomerulus filters your blood, and the tubule returns
✓ When our bodies digest the protein we eat, the process creates
needed substances to your blood and removes wastes.
waste products. In the kidneys, millions of tiny blood vessels
Glomerulus (capillaries) with even tinier holes in them act as filters. As

84
 blood flows through the blood vessels, small molecules such as
waste products squeeze through the holes. These waste
products become part of the urine. Useful substances, such as
protein and red blood cells, are too big to pass through the
holes in the filter and stay in the blood.
✓ Diabetes can damage this system. High levels of blood sugar
make the kidneys filter too much blood. All this extra work is
hard on the filters. After many years, they start to leak and
useful protein is lost in the urine. Having small amounts of
protein in the urine is called microalbuminuria.
✓ When kidney disease is diagnosed early, during
microalbuminuria, several treatments may keep kidney disease DIAGNOSTIC PROCEDURES
from getting worse. Having larger amounts of protein in the
urine is called macroalbuminuria. When kidney disease is Screening for diabetic nephropathy must be initiated at the time of
caught later during macroalbuminuria, end-stage renal diagnosis in patients with type 2 diabetes since 7% of them already
disease, or ESRD, usually follows. have microalbuminuria at that time
✓ In time, the stress of overwork causes the kidneys to lose their
For patients with type 1 diabetes, the first screening has been
filtering ability. Waste products then start to build up in the recommended at 5 years after diagnosis.
blood. Finally, the kidneys fail. This failure, ESRD, is very
serious. A person with ESRD needs to have a kidney transplant If microalbuminuria is absent, the screening must be repeated
or to have the blood filtered by machine (dialysis). annually for both type 1 and 2 DM patients.

✓ Blood tests: Patients with diabetes need to monitor their

condition and know how well their kidneys are working
✓ Urine tests: These provide information about the patient's
kidney function. High levels of protein called microalbumin may
indicate that the kidneys are being affected by the disease.
✓ Imaging tests: X-rays and ultrasounds can also be used to
assess the kidney’s structure and its size. The patient can also
undergo CT scanning and magnetic resonance imaging (MRI) to
determine how well blood is circulating within your kidneys.
✓ Renal function testing: This can assess your kidney’s filtering
capacity using the renal analysis testing. This includes: ACR
(Albumin to Creatinine Ratio) and GFR (glomerular filtration
rate). GFR is a measure of kidney function and is performed
through a blood test. Your GFR will determine what stage of
kidney disease you have.

MEDICAL SURGICAL MANAGEMENT

In treating diabetic nephropathy, we must treat and control diabetes

and high blood pressure. With good management of the blood sugar
and blood pressure, we may prevent and delay kidney dysfunction
and its complications.

✓ Controlling high blood pressure: Medications called

angiotensin-converting enzyme (ACE) inhibitors and
angiotensin II receptor blockers (ARBs) are used to treat high
blood pressure. Studies support the goal of a blood pressure
reading below 140/90 millimeters of mercury (mm Hg)
depending on your age and overall risk of cardiovascular
disease.
✓ Manage high blood sugar. Several medications have been
CONCEPT MAP shown to help control high blood sugar in people with diabetic
nephropathy. Studies support the goal of an average
hemoglobin A1C of less than 7%.
✓ Lower high cholesterol. Cholesterol-lowering drugs called
statins are used to treat high cholesterol and reduce protein in
the urine.

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✓ Control protein in urine. Medications can often reduce the
level of the protein albumin in the urine and improve kidney
function. This includes ACEI (angiotensin converting enzyme
inhibitors) and ATRB (angiotensin receptor blockers).
✓ Kidney dialysis: This treatment is a way to remove waste
products and extra fluid from your blood. The two main types
of dialysis are hemodialysis and peritoneal dialysis. In the first,
more common method, you may need to visit a dialysis center
and be connected to an artificial kidney machine about three
times a week, or you may have dialysis done at home by a
trained caregiver. Each session takes three to five hours. The
second method may be done at home as well.
✓ Kidney Transplant: This is usually done if the diabetic
nephropathy reaches the final stages and if there is a suitable
donor that can provide a kidney. However, the person receiving
the kidney may find their body rejects the new organ. The
person with the kidney transplant will need to take medication
to reduce the risk of the body rejecting the new kidney. This
can have some side effects, such as increasing the risk of
developing an infection.
NUTRITIONAL THERAPY
Dietary changes: If the patient has kidney disease, they must keep
track of the following:
✓ Water: Although essential, too much water or fluid may
increase the risk of swelling and high blood pressure
✓ Sodium: This can raise blood pressure as it is a constituent of
salt.
✓ Protein: For a person with kidney disease, protein can cause
waste to build up in the blood, putting extra pressure on the
kidneys.
✓ Phosphorus: This occurs in many protein and dairy foods. Too
much phosphorus can weaken the bones and put pressure on
the kidneys
✓ Potassium: People with kidney disease can have higher levels
of potassium than is healthful, which can affect nerve cells
PHARMACOLOGY WITH NURSING CONSIDERATIONS
Pharmacologic interventions include glucose control,
antihypertensive treatment and restriction of dietary proteins.
SGLT2 Inhibitors:
✓ SGLT2 inhibitors work by preventing the kidneys from
reabsorbing glucose back into the blood.
✓ This allows the kidneys to lower blood glucose levels and the
excess glucose in the blood is removed from the body via urine.
The kidneys work by filtering glucose out of the blood and then
reabsorbing glucose back into the blood. The proteins that
reabsorb glucose are called sodium-glucose transport proteins.
✓ SGLT2 inhibitors block these proteins which means less glucose
gets reabsorbed back into the blood and gets passed out of the
body via the urine.
✓ Some drugs include: Forxiga, invokana and Jardiance
Adverse effects: UTI, yeast infection, upper respiratory tract
infection, increased urination, thirst, n & v and joint pain
Nursing Considerations:
✓ Maintain good fluid intake
✓ Monitor input and output
✓ Avoid low carbohydrate diets
✓ Temporarily stop drug intake in situation of acute illness, n&v
and inability to drink or eat
✓ If ketoacidosis is suspected, stop drug and seek medical advice
✓ Should be taken once daily, in the morning before the first meal
✓ Monitor kidney function
✓ Monitor for UTI
✓ Patients are at risk for amputation and should be monitored for
PVD
Antihypertensive agents:
- can help slow down the profession of kidney damage by
interfering with the renin-angiotensin system.
- ACE Inhibitors: captopril, enalapril, lisinopril, benazepril,
ramipril
- Adverse effects: dry cough, fatigue, hyperkalemia, headache,
loss of taste
- Nursing considerations:
- Assess for contraindications to the drug like renal impairment,
hyponatremia and hypovolemia
- Obtain baseline status for weight, vital signs, overall skin
condition, and laboratory tests like renal and hepatic function
tests, serum electrolyte, and complete blood count (CBC) with
differential to assess patient’s response to therapy.
- Monitor vital signs constantly especially blood pressure
- Monitor input and output
Angiotensin receptor blockers:
- valsartan, esprosartan, losartan potassium
- Adverse effects: respiratory symptoms, high potassium levels, n
& v, headache and fatigue
- Nursing considerations:
- Assess for contraindications to the drug like renal impairment,
hyponatrmia and hypovolemia
- Obtain baseline status for weight, vital signs, overall skin
condition, and laboratory tests like renal and hepatic function
tests, serum electrolyte, and complete blood count (CBC) with
differential to assess patient’s response to therapy.
- Monitor vital signs constantly especially blood pressure
- Monitor input and output
PHARMACOLOGY WITH NURSING CONSIDERATIONS
Nursing Problems
✓ Impaired renal Tissue Perfusion related to Glomerular
Malfunction
✓ Impaired Urinary Elimination related to failing glomerular
filtration secondary to impaired excretion of nitrogenous
products due to renal failure
✓ Excess Fluid Volume related to decreased glomerular filtration
rate and sodium retention
✓ Imbalanced Nutrition: Less than Body Requirements related to
catabolic state, anorexia, and malnutrition secondary to renal
failure
✓ Risk for Decreased Cardiac Output related to fluid and
electrolyte imbalances, accumulation of toxins, and soft tissue
calcification
Nursing Considerations
✓ Assess fluid status and identify potential sources of imbalance.
✓ Implement a dietary program to ensure proper nutritional
intake within the limits of the treatment regimen.
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✓ Educate patients on the importance of blood pressure control
ensuring that they are aware that reducing raised blood
pressure is a key factor in preventing the progression of CKD.
✓ Encourage home blood pressure monitoring where
appropriate.
✓ Promote positive feelings by encouraging increased self-care
and greater independence.
✓ Promote intake of high-biologic –value protein foods: eggs,
dairy products, meats.
✓ Alter schedule of medications so that they are not given
immediately before meals.
✓ Encourage alternating activity with rest.
✓ Teach the patient and significant others on what problems to
report: nausea, vomiting, change in usual urine output,
ammonia odor on breath, muscle weakness, diarrhea,
abdominal cramps, clotted fistula or graft, and signs of
infection.
✓ Stress the importance of follow-up examinations and treatment
to the patient and family because of changing physical status,
renal function, and dialysis requirements.

"I have high blood sugars, and Type 2 diabetes is not going to kill
me. But I just have to eat right, and exercise, and lose weight, and
watch what I eat, and I will be fine for the rest of my life." – Tom
Hanks

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