NCLEX-RN: Medical–Surgical Nursing

Medical–Surgical Nursing: Endocrine System

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Pancreas Disorders

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Diabetes Mellitus (Types 1 and 2)

Focus topic: Medical–Surgical Nursing

Definition: A group of disorders that have a variety of genetic causes, but have glucose intolerance as a common thread.

A. Classifications.

  • Type 1—insulin-dependent diabetes mellitus with beta cell destruction or defect in function affects about 5% of all diabetics.
    a. Immune mediated—presence of islet cell or insulin antibodies that identify the autoimmune process leading to beta cell destruction.
    b. Idiopathic—no evidence of autoimmunity.
  • Type 2—non–insulin-dependent diabetes mellitus is the most common. Results when body produces insufficient insulin or there is insulin resistance with relative insulin deficiency. Affects 90% of all diabetics. Twenty-one million Americans have type 2 and 41 million are prediabetic.
    a. Type 2 accounts for half of all cases in young people.
    b. Incidence in young has risen dramatically last 10 years.
  • Type 3—Gestational (GDM)—increased blood glucose levels during pregnancy.
  • Type 4—Other specific types—genetic defects of beta-cell function or insulin action, pancreatic diseases, endocrinopathies, or drug- or chemical-induced diabetes.

B. Pathophysiology.

  • Type 1 (insulin-dependent).
    a. Rapid onset—requires insulin due to absence of circulating insulin.
    b. Autoimmune response or idiopathic.
    c. Presence of anti-islet cell antibodies.
    d. Pancreatic beta cells die.
    e. Ketosis unless treated.
  • Type 2 (non–insulin-dependent), formerly adult-onset type.
    a. Gradual onset—may be controlled by diet.
    b. Ninety percent of diabetes cases are this type.
    c. Impaired beta-cell response to glucose (client usually nonobese).
    d. Tissues insensitive to insulin (client usually obese).
    (1) Extrapancreatic defect.
    (2) Normal or high levels of circulating insulin.

C. Somogyi phenomenon. Hypoglycemia usually at night followed by compensatory rebound hyperglycemia in the morning (lasts 12–72 hours).

  • Usually caused by too much insulin or an increase in insulin sensitivity.
  • Client may be stabilized by gradual lowering of insulin dose and increase in diet at the time of the hypoglycemia reaction.

D . Dawn phenomenon.

  • Blood glucose normal until 3 am—begins to rise in early morning hours.
  • Common problem—glucose released from liver in early am—needs to be controlled.
  • Algorithm for hyperglycemia—altering time and dose of insulin (NPH or Ultralente) by one or two units stabilizes client.

Comparison of Type 1 and Type 2 Diabetes

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing

Medical–Surgical Nursing

Medical–Surgical Nursing

Insulin Types and Action

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing

A. Assess for early symptoms.

  • Common to both type 1 and type 2.
    a. Polyuria.
    b. Polydipsia.
    c. Polyphagia.
    d. Blurred vision.
    e. Fatigue.
    f. Abnormal sensations (prickling, burning).
    g. Infections (vaginitis).
    h. Weakness.
    i. Tingling or numbness in hands or feet.
    j. Dry skin.
  • Type 1.
    a. Postural hypotension.
    b. Decreased muscle mass.
    c. Weight loss in spite of increased appetite.
  • Type 2.
    a. Often asymptomatic.
    b. Often obese.
    c. Slow wound healing.
    d. Blurred vision.
    e. Fatigue.
    f. Paresthesias.
  • Type 2 in young people.
    a. Hyperglycemia.
    b. Hypertension.
    c. Dyslipidemia.

B. Assess for distinguishing features of type 1 and type 2 diabetes.
C. Assess for risk factors.

  • Client history—hereditary predisposition.
  • Weight—presence of obesity.
  • High stress levels.

D. Diagnosis of diabetes: assess results of laboratory values.

  • Fasting blood sugar > 126 mg/dL on two separate occasions, postprandial blood sugar > 200 mg/dL and at least once between meals at 2 hours PC; abnormal glucose tolerance test or Orinase tests.
  • Impaired glucose tolerance (IGT) is a fasting blood sugar of 100–125 mg/dL. Current ideal normal fasting level of 80–100 mg/dL.
  • Elevated cholesterol and triglyceride levels.
  • Capillary blood glucose (finger-stick) is most common method.
  • Glycosylated hemoglobin test (HgbA1).
    a. Monitors blood sugar and hemoglobin; determines how well diabetes is controlled.
    b. Reflects glycemic state over preceding 8 to 12 weeks.
    c. Abnormally high in diabetics with chronic hyperglycemia.
    d. Values: normal 4% to 6%; good control less than 7%; fair control 7% to 8%; poor control more than 9%.

A. When diabetic client is hospitalized:

  • Administer IV fluids and medications as ordered.
  • Adhere to procedures for other laboratory tests.
  • Provide meticulous skin care, particularly for lower extremities.
  • Observe for signs of insulin reactions and ketoacidosis.
  • Measure intake and output.

B. Provide emotional support.

  • Allow for verbalization of client’s feelings.
    a. Necessary changes in lifestyle, diet, and activities.
    b. Changes in self-image and self-esteem.
    c. Fear of future and complications.
  • Provide special counseling for adolescents because of their heightened sensitivity to being different and their frequently unusual dietary habits.
    a. Diet should be adequate for normal growth and development, and regulated according to diabetic needs.
    b. The type of diet prescribed is influenced by the philosophy of the physician.
    c. Diets vary from free diets to strict dietary control.
  • Encourage involvement of family.

C. Provide client education (key to effective self-management).

  • Assessment.
    a. Level of knowledge.
    b. Cultural, socioeconomic, and family influences.
    c. Daily dietary and activity patterns.
    d. Emotional and physical status and effect on client’s current ability to learn.
  • Insulin and insulin injections.
    a. Keep insulin at room temperature; refrigerate extra supply of insulin.
    b. Turn insulin bottle top to bottom several times prior to drawing up insulin.
    c. Use sterile injection techniques.
    d. Choose injection sites to prevent injection in dystrophic areas.
    e. Watch for signs of hypo- and hyperglycemia.
  • Self-monitoring of blood glucose level (SMBG).
    a. Balancing blood glucose levels results in fewer complications.
    b. Protocol is taking blood glucose levels two to four times/day.
    (1) Glucose monitors are small and easy to use. Lancets and lasers are used to obtain blood samples.
    (2) A monitor that measures glycated protein is now available—indicator of overall glucose control during previous 2 weeks.
    c. Pattern control is goal.
    d. Use algorithms as guidelines for amount of insulin.
    e. Clients should use a diary or log to record results.
  • Continuous glucose monitoring systems (CGMS) are now available.
    a. Sensor implanted under skin in abdomen sends continuous readings to a pager device clipped on belt.
    b. Glucose readings occur every few seconds for close monitoring.
    c. Appropriate for those with “brittle diabetes,” in a health crisis, or who display a wide range of levels.
  • Oral medications.
    a. Take medications regularly.
    b. Watch for hypoglycemic reactions occurring with sulfonylureas.
    c. Remember that alcohol ingestion in conjunction with sulfonylureas causes an Antabuse (disulfiram)-like reaction.
  • Avoidance of infection and injury.
    a. Report infection or injury promptly to physician.
    b. Maintain meticulous skin care.
    c. Maintain proper foot care.
    (1) Wash with mild soap—dry well.
    (2) Use lanolin to prevent cracking.
    (3) Cut toenails straight across, or have nails trimmed by podiatrist.
    (4) Use clean cotton socks.
    (5) Inspect feet daily—report skin breaks.
    (6) Avoid “bathroom surgery” for corns and calluses.
    d. Be aware that insulin requirements may increase with infections.
    e. Be prepared for healing process impairment.
    f. Avoid tight-fitting garments and shoes.
  • Diet.
    a. Do not vary meal times.
    b. Incorporate diet with individual needs, lifestyle, cultural, and socioeconomic patterns.
    c. Most adults require 30 calories/kg of ideal body weight.
  • Exercise.
    a. Regulate time and amount.
    b. Avoid sporadic, vigorous activities; use aerobic exercise.
    c. Give 10 g CHO before exercise and every hour during exercise.
    d. Do not exercise during peak action time of insulin.
    e. Rigorous exercise while blood sugar is 240–300% may precipitate ketoacidosis.
  • Medic-Alert band.
  • Provide constant availability of concentrated sugar.

Medical–Surgical Nursing

Medical–Surgical Nursing: Syndrome X—Metabolic Syndrome

Focus topic: Medical–Surgical Nursing

Definition: A group of risk factors that, in combination, put someone at higher risk of coronary artery disease. These risk factors include central obesity (excessive fat tissue in the abdominal region), glucose intolerance, high triglycerides and low high-density lipoprotein (HDL) cholesterol, and hypertension.

A. Underlying cause is resistance to insulin.

  • Normally, blood carries the glucose to the body’s tissues, where the cells use it as fuel. Glucose enters the cells with the help of insulin.
  • In insulin resistance, cells don’t respond to insulin and glucose can’t enter the cells. The body reacts by putting out more and more insulin to help glucose get into the cells.
  • This results in higher than normal levels of insulin and glucose in the blood.
  • Increased insulin raises triglycerides level and interferes with how the kidneys work, leading to increased blood pressure.

B. Combined effects of insulin resistance put a client at risk of heart disease, stroke, diabetes, and other conditions.
C. Risk factors.

  • Age—increases with age.
  • Race—greater in Hispanics and Asians.
  • Obesity—body mass index (BMI) > 25, abdominal obesity, having an apple shape rather than a pear shape.
  • History of diabetes—family history of type 2 diabetes or a history of gestational diabetes.
  • Other diseases—high blood pressure, cardiovascular disease, polycystic ovary syndrome.

A. Screening and diagnosis.

  • Elevated waist circumference—greater than 35 inches for women and 40 inches for men.
  • Elevated level of triglycerides of 150 mg/dL or higher, or client receiving treatment for high triglycerides.
  • Reduced HDL < 40 mg/dL in men or < 50 mg/dL in women.
  • Elevated blood pressure ≥ 130 mm Hg systolic, ≥ 85 mm Hg diastolic.
  • Elevated fasting blood glucose of 100 mg/dL or higher.

B. Intervention.

  • Exercise.
  • Weight loss.
  • Stop smoking.

Medical–Surgical Nursing: Complications

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing: Ketoacidosis

Focus topic: Medical–Surgical Nursing

Definition: One of the most serious results of poorly managed diabetes. The two major metabolic problems that are the source of this condition are hyperglycemia and ketoacidemia, both due to lack of insulin associated with hyperglucagonemia.

A. Without insulin, carbohydrate metabolism is affected.
B. Hyperglycemia results from increased liver production of glucose and decreased glucose uptake by peripheral tissues.
C. The liver oxidizes fatty acids into

  • Acetoacetic acid (increased ketone bodies lead to ketoacidosis).
  • Beta-hydroxybutyric acid (acetone is volatile and is blown off by lungs).
  • As glucose levels increase, there is osmotic overload in kidneys, resulting in dehydration and electrolyte losses.
  • As ketone bodies increase, acidosis and comatose states occur.

A. Assess for ketoacidotic coma—usually preceded by a few days of polyuria and polydipsia with associated symptoms (classic symptoms of hyperglycemia).
B. Assess for ill appearance.
C. Assess for anorexia, nausea, and vomiting.
D. Assess for drowsiness, confusion, and mental stupor.
E. Assess for dehydration; deep, rapid breathing; and fruity odor of acetone to breath.
F. Observe for complications of circulatory collapse or respiratory distress.

A. Maintain fluid and electrolyte balance.

  • Normal saline IV until blood sugar reaches 250–300 mg/dL; then a dextrose solution (5% glucose) is started.
  • Potassium added to IV after renal function is evaluated and hydration is adequate.

B. Provide insulin management.

  • Give one-half dose IV during acute phase and one-half dose sub q or low-dose protocol; IV bolus of 5–10 U of regular insulin followed by infusion of 5–10 U/hr until plasma glucose level is 250 mg/100 mL.
  • Regulating level takes 4–6 hours; regulation of pH takes 8–12 hours.
  • Monitor for onset of insulin reaction.

C. Maintain patent airway and adequate circulation to brain (cardiac monitoring if status indicates).
D. Monitor vital signs every 1–2 hours; arterial blood gases (ABGs) hourly until pH is 7.2+.
E. Monitor urine frequently for glucose and acetone.
F. Test blood glucose level every 1–2 hours.
G. Perform hourly urine measurements.
H. Maintain personal hygiene.
I. Keep client warm.
J. Protect from injury.

Medical–Surgical Nursing: Insulin Reaction/Hypoglycemia

Focus topic: Medical–Surgical Nursing

Definition: An abnormally low blood glucose, usually below 50 mg, resulting from too much insulin, not enough food, or excessive activity.

A. Assess for symptoms, especially before meals.
B. Assess for sweating, tremors, pallor, tachycardia, palpitations, or nervousness.

C. Evaluate for headache, confusion, emotional changes, memory lapses, slurred speech, numbness of lips and tongue, alterations in gait, loss of consciousness.
D. Evaluate lab tests.

  • Blood glucose, usually below 50–60 mg/dL.
  • Urine for acetone (usually negative).

Medical–Surgical Nursing

A. Administer oral carbohydrate in form of dextrosol tablet, unsweetened orange juice, or 8 oz. of skim milk if client is alert; administer glucagon (sub q or IV) if client is not alert.
B. Administer carbohydrates by mouth when client awakens.
C. Provide client teaching.

  • Maintain regimen of diet, medications, and exercise.
  • Treat the symptoms early to prevent complications.
  • Instruct client to always carry simple carbohydrates for treatment of early symptoms.
  • Take 200-calorie snack 30 minutes before peak time of insulin to prevent hypoglycemia.
  • Extra food should be taken before engaging in heavy physical exercise.

D. Prevent compensatory rebound hyperglycemia (Somogyi phenomenon).

  • Caused by the body’s attempt to oppose the excessive action of insulin through liver glycogenolysis.
  • Insulin dose is reduced and client returned to stabilized rate.

E. Provide instruction in use of portable insulin pump if ordered.
F. Provide instruction in use of blood sugar monitors.

  • Prick finger and smear drop of blood on reagent strip.
  • Compare results with monitor or chart and record.

Medical–Surgical Nursing: Chronic Complications

Focus topic: Medical–Surgical Nursing

Definition: Chronic complications of diabetes are becoming more common as diabetics live longer. Included in this category are blindness, renal disease, and vascular conditions.
A. Diabetic retinopathy: progressive impairment of retinal circulation that eventually causes vitreous hemorrhage with vision loss.

  • Assessment.
    a. Duration and degree of disease (incidence increases with length of time disease is present).
    b. Impaired vision.
    c. Ability to carry out daily tasks: blood glucose testing and insulin injections.
    d. Need for assistance from others.
  • Implementation.
    a. Assist in ways to maintain independence and self-esteem.
    b. Support client when treatment is implemented: photocoagulation or vitrectomy.
    c. Instruct in actions that prevent or reduce complications: stable blood glucose levels.
    d. Instruct client to have frequent eye examinations.

B. Diabetic nephropathy: the specific renal disease, intercapillary glomerulosclerosis, called Kimmelstiel– Wilson syndrome. It is the result of chronic diabetes.

  • Assessment.
    a. Urine alterations; proteinuria, azotemia, frequent urinary tract infections, neurogenic bladder.
    b. Serum lab values; BUN, creatinine.
    c. Thirst and fatigue.
    d. Hypertension.
  • Implementation.
    a. Administer medications to prevent urinary tract infections.
    b. Instruct client to keep blood glucose levels within normal limits.
    c. Maintain adequate fluid intake.
    d. Instruct in 20- to 40-g protein diet.
    e. Restrict sodium and potassium in diet.

f. Prepare client for dialysis therapy if appropriate.
g. Administer medications to control hypertension.

C. Neuropathy: general deterioration that affects the peripheral and autonomic nervous systems.

  • Assessment.
    a. Peripheral neuropathy.
    (1) Pain in the legs.
    (2) Aching and burning sensations in lower extremities.
    b. Alterations in bowel and bladder function.
    (1) Bowel dysfunction: constipation, diarrhea, nocturnal fecal incontinence.
    (2) Urinary dysfunction: infrequent voiding, weak stream, dribbling, signs of urinary infection.
    c. Autonomic nervous system impairment.
    (1) Sexual dysfunction.
    (2) Orthostatic hypotension.
    (3) Pupillary changes.
    d. Circulatory abnormalities.
    (1) Skin breakdown and signs of infection.
    (2) Thick toenails: suggestive of circulatory impairment.
    (3) Low temperature and poor color in feet; athlete’s feet.
    (4) Thin, shiny, atrophic skin.
    (5) Weak peripheral pulses.
  • Implementation.
    a. Assist client to deal with pain.
    (1) Encourage walking for exercise.
    (2) Provide foot cradle when in bed.
    b. Assist client to deal with bladder–bowel problems.
    (1) Provide privacy for toileting.
    (2) Provide psychological support.
    (3) Administer Lomotil (diphenoxylate/ atropine) as ordered for diarrhea.
    (4) Administer neomycin as ordered to prevent bacterial growth in an atonic bowel.

(5) Administer Urecholine (bethanechol) as ordered.
(6) Establish 2-hour voiding schedule to prevent urinary stasis.
(7) Encourage fluids.
c. Counsel client who has sexual dysfunction.
(1) Allow client to vent feelings about sexual impotence.
(2) Observe for depression (sexual impotence is usually permanent).
d. Provide excellent foot care.
(1) Wash with soap and warm water or antibacterial gel, dry thoroughly.
(2) Massage feet with lanolin or mineral oil to prevent scaling or cracking.
(3) File or cut toenails across nail. Do not injure soft tissue around nail (check hospital policy for nail care).
(4) Prevent moisture from accumulating between toes; use lamb’s wool.
(5) Instruct in well-fitting shoes. Do not go barefoot.
(6) Wear loose-fitting socks.
(7) Exercise feet daily.
(8) See podiatrist regularly.
(9) Notify physician if cuts, pain, or blisters appear on feet.

Complications Associated with Diabetes

Focus topic: Medical–Surgical Nursing

Medical–Surgical Nursing


Medical–Surgical Nursing: Functional Hyperinsulinism/Hypoglycemia

Focus topic: Medical–Surgical Nursing

Definition: A condition that occurs as the result of excess secretion of insulin by the beta cells of the pancreas gland.

A. May be associated with “dumping syndrome” following gastrectomy.
B. May occur prior to development of diabetes mellitus.

A. Assess for personality changes.

  • Tenseness.
  • Nervousness.
  • Irritability.
  • Anxiousness.
  • Depression.

B. Assess for excessive diaphoresis.
C. Assess for excessive hunger.
D. Evaluate muscle weakness and tachycardia.
E. Assess laboratory values—low blood sugar during hypoglycemic episodes.

A. High-protein, low-carbohydrate diet.
B. Counseling may reduce anxiety and tenseness.










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