diabetic emergencies report

7/30/2019 Diabetic Emergencies Report

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Diabetic Emergencies

I. Definition:Diabetic ketoacidosis is a serious complication of diabetes that occurs when your body produces high levelsof blood acids called ketones. Diabetic ketoacidosis develops when your body is unable to produce enough

insulin and an increase in insulin counter-regulatory hormones (catecholamines, cortisol, glucagon and growthhormone). Insulin normally plays a key role in helping sugar (glucose) a major source of energy for yourmuscles and other tissues enter your cells. Without enough insulin, your body begins to break down fat as analternate fuel. This process produces a build-up of toxic acids in the bloodstream called ketones, eventuallyleading to diabetic ketoacidosis if untreated.

II. Predisposing Factors: An illness. An infection or other illness can cause your body to produce higher levels of certain hormones, such

as adrenaline or cortisol. Unfortunately, these hormones work against insulin sometimes triggering an episodeof diabetic ketoacidosis. Pneumonia and urinary tract infections are common culprits.

A problem with insulin therapy. Missed insulin treatments or inadequate insulin therapy can leave you with toolittle insulin in your system, triggering an episode of diabetic ketoacidosis.

Other possible triggers of diabetic ketoacidosis may include: Stress Physical or emotional trauma High fever Surgery Heart attackAlcohol or drug abuse, particularly cocaine Factors that antagonize insulin such as steroids use, glucagon and growth hormones; lipolysis

III. Epidemiology:A. PREVALENCEoIn the landmark Diabetes Control and Complications Trial, the rate of DKA in adults on the conventional

insulin protocol was 1.8 per 100 person-years compared to a rate of 2.0 per 100 person-years in those onan intensive insulin protocol

oDKA is a common finding at the time of diabetes presentation, occurring in 29% of patients with type 1diabetes and 10% of patients with type 2 diabetes

oFrom 1985 to 2005, there was a 42% increase in the number of hospitalizations for DKAB. MORTALITYo Overall mortality rate for adults is less than 1%o Mortality rate in the elderly and in patients with significant comorbidities is greater than 5%o Most common cause of death in children and adolescents with type 1 diabetes

C. ECONOMIC IMPACTo Results in more than 500,000 hospital days per year in the U.S.o Direct and indirect cost of 2.4 billion U.S. dollars annually

D. AGEo 18% are under age 20o 56% are aged 18 to 44 yearso 24% are aged 45 to 65 years

E. RACEo Slightly more predominant in whites (45% non-whites).

IV. Clinical Signs and Symptoms:


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Excessive thirst Frequent urination Nausea and vomitingAbdominal pain Weakness or fatigue Shortness of breath

Fruity-scented breath ConfusionMore-specific signs of diabetic ketoacidosis which can be detected through home blood and urine testing kits

include: High blood sugar level (hyperglycemia) High ketone levels inyour urine

V. Laboratory Results and Analysis:Blood tests used in the diagnosis of diabetic ketoacidosis will measure:

Blood sugar level. If there isn't enough insulin in your body to allow sugar to enter your cells, your bloodsugar level will rise (hyperglycemia). As your body breaks down fat and protein for energy, your blood sugarlevel will continue to rise.

Ketone level. When your body breaks down fat and protein for energy, toxic acids known as ketones enteryour bloodstream.

Blood acidity. If you have excess ketones in your blood, your blood will become acidic (acidosis). This canalter the normal function of various organs throughout your body.

VI. Management: FLUID REPLACEMENT. You'll receive fluids either orally or through a vein (intravenously) until

you're rehydrated. The fluids will replace those you've lost through excessive urination, as well as help dilutethe excess sugar in your blood.

ELECTROLYTE REPLACEMENT. Electrolytes are minerals in your blood that carry an electriccharge, such as sodium, potassium and chloride. The absence of insulin can lower the level of severalelectrolytes in your blood. You'll receive electrolytes through your veins to help keep your heart, muscles

and nerve cells functioning normally. INSULIN THERAPY. Insulin reverses the processes that cause diabetic ketoacidosis. Along with fluids

and electrolytes, you'll receive insulin therapy usually through a vein. When your blood sugar level fallsbelow 240 mg/dL (13.3 mmol/L) and your blood is no longer acidic, you may be able to stop intravenousinsulin therapy and resume your normal subcutaneous insulin therapy.**As your body chemistry returns to normal, your doctor will consider what may have triggered the episode of diabetic

ketoacidosis. Depending on the circumstances, you may need additional treatment. For example, if you have previouslyundiagnosed diabetes, your doctor will help you create a diabetes treatment plan. If your doctor suspects a bacterialinfection, he or she may prescribe antibiotics. If a heart attack seems possible, your doctor may recommend further

evaluation of your heart.**

I. Definition:Diabetic hyperglycaemic hyperosmolar syndrome (HHS) is a complication of type 2 diabetes that involves

extremely high blood sugar (glucose) levels without the presence of ketones. Ketones are by products of fatbreakdown. Normally, the kidneys try to make up for high glucose levels in the blood by allowing the extra glucose toleave the body in the urine. If you do not drink enough fluids, or you drink fluids that contain sugar, the kidneys can


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no longer get rid of the extra glucose. Glucose levels in the blood can become very high as a result. The blood thenbecomes much more concentrated than normal (hyperosmolarity).**Hyperosmolarity is a condition in which the blood has a high concentration of salt (sodium), glucose, and other substances that

normally cause water to move into the bloodstream. This draws the water out of the body's other organs, including the brain.Hyperosmolarity creates a cycle of increasing blood glucose levels and dehydration.**

II. Predisposing Factors: A stressful event such as infection, heart attack, stroke, or recent surgery Congestive heart failure Impaired thirst Limited access to water (especially in patients with dementia or who are bedbound) Older age Poor kidney function Poor management of diabetes -- not following the treatment plan as directed Stopping insulin or other medications that lower glucose levels

III. Epidemiology:a. PREVALENCE

oHHNS: 0.5-1.0/1000 diabetics/year.oHyperglycemic hyper osmolality is also present in 18% to 33% of cases of DKA.oIt is 10% to 50% for HHNS

b. MORTALITYoMortality as high as 12-45%, increases with age and higher level of serum osmolalityoNo significant decrease in the incidence of HHNS or associated morbidity/mortality in the last 15-20 years

c. ECONOMIC IMPACToResults in more than 500,000 hospital days per year in the U.S.oDirect and indirect cost of 2.4 billion U.S. dollars annuallyo1 in every 1000 hospital admissions

d. AGEoUsually elderly, type II diabetics, frequently patients who are unable to maintain adequate fluid intake

because of stroke, dementia, neglect, etce. RACE

Slightly more predominant in whites (45% non-whites).

IV. Clinical Signs and Symptoms: Coma

Confusion

Convulsions

Fever

Increased thirst

Increased urination (at the beginning of the syndrome)

Lethargy

Nausea Weakness

Weight lossSymptoms may get worse over a period of days or weeks.Other symptoms that may occur with this disease: Dysfunctional movement Loss of feeling or function of muscles Speech impairment
http://www.nlm.nih.gov/medlineplus/ency/article/003205.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003200.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003085.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003088.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003174.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003174.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003088.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003085.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003200.htmhttp://www.nlm.nih.gov/medlineplus/ency/article/003205.htm


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V. Laboratory Results and Analysis:Blood sugar level. If there isn't enough insulin in your body to allow sugar to enter your cells, your bloodsugar level will rise (hyperglycemia). As your body breaks down fat and protein for energy, your blood sugarlevel will continue to rise.

Blood acidity and osmolarity. If you have excess ketones in your blood, your blood will become acidic(acidosis). This can alter the normal function of various organs throughout your body. .

Glycosylated hemoglobin (A1C)a blood test that indicates your average blood sugar level for thepast two to three monthsKidney function. Testing the amount of blood urea nitrogen or creatinine in your blood

VI. Management: - HHNS can be severe enough to require hospitalization, especially if occurring in a

newly diagnosed diabetic. Several things may be done while you are in the hospital to monitor, test, and treatyour condition. They include: Monitoring You will be checked often by the hospital staff. You may have fingers ticks to check your blood sugar regularly. This may be done as often as every hour.

You will learn how to check your blood sugar level in order to manage your diabetes when you go home.

A heart (cardiac) monitor may be used to keep track of your heartbeat. Your blood oxygen level may be monitored by a sensor that is attached to your finger or earlobe. Your fluid intake may be monitored closely by keeping track of everything you eat and drink and any IV

fluids you receive. You may have a small tube (catheter) placed into your bladder through the urethra (the opening from the

bladder to the outside of the body) to drain and measure urine from the bladder. Testing

Testing may include:Blood tests (Hemoglobin A1c) to check your average blood sugar over the past 3 months.Blood tests to check for infections.Blood tests to test for mineral (sodium and potassium) levelsBlood tests to check blood thickness and its ability to form clotsBlood tests to check to see if your body is making insulinBlood, urine, or other tests to monitor how well your organs are functioningUrine tests to check for bacteria in your urine.Arterial blood gas (ABG): A blood test to measure the levels of oxygen and carbon dioxide in your blood.X-rays: Pictures of the inside of the chest to check for infection.

TreatmentThe treatment for HHNS depends on the cause and how well you respond to treatment. The goal of treatment is

to return your blood sugar to a normal level and keep it in a normal range. Treatment may include: You will have a small tube (IV catheter) inserted into a vein in your hand or arm. This will allow for medicine

to be given directly into your blood and to give you fluids, if needed. Your provider may prescribe medicines to:o Keep your blood sugar controlledo Treat other medical problems that may have been caused by or made worse because of diabeteso Treat paino Treat or prevent an infectiono Prevent blood clotso Prevent side effects, such as nausea or constipation, from other treatmentso Replace vitamins and minerals
http://www.rightdiagnosis.com/treat/hospitalization.htm


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You may receive oxygen through a small tube placed under your nose or through a mask placed over yourface.

If you develop blood clots, you may need surgery to remove them. You may need kidney dialysis to help filter your blood if your kidneys are not working properly.

- Extreme HHNS requires gradual blood sugar lowering in a hospital

setting. Milder HHNS can be treated mainly by reducing blood sugars using insulin.

- Fluids such as water are required to replace the lost fluid and fix thedehydration.

I.AdultFluid replacement in adults with DKA:In both DKA and HHNS the first goal is to restore circulating volume. In DKAthis is done with an initial infusion of isotonic saline, 500 to 1000mL/hour over1 to 2 hours (faster in hypovolemic shock). The usual fluid deficit in adults withDKA is 3 L to 5 L.

Approximate infusion rate in moderately dehydrated adults with DKA:a.1st liter 1 Normal saline over the 1st 60 minutes.b.Next 2 liters of saline at 500 ml/hr (7ml/kg/hr) until dehydration resolves.c.Next 2 liters saline at 250 ml/hr x 4 hr.d.When the serum sodium rises to 145, switch to 0.45% NaCl ( normal saline).e.Blood glucose is expected to decrease by 75-100mg/dl/hr. When it reaches 250f. mg/dL, change IV fluids to D5 NS & decrease rate to 100 to 200 ml/hr.In HHNS it

averages 9 liters.

II.ChildIn children fluids are replaced more slowly because of the danger of

exacerbating cerebral edema. Fluids are administered at a constant rateover the first 48 hours of treatment. Fluid administration is notfront-end-loaded as it is in adults.

The margin of error is smaller in children, so you have to calculate fluidrequirements more precisely. Total fluid replacement equals the maintenancerequirement plus the fluid deficit calculated as follows:

Maintenance requirements:b. 100 mL/Kg for the 1st 10 Kg of weightc. +50 mL/Kg for the next 10 Kg of weightd. +20 mL/Kg for the remainder of the child weighte. Maintenance for 5 Kg child=500 mL/24 hr

Fluid deficit: The percent dehydration estimated as in Table 2:Fluid replacement: The total fluid replacement (e.g. the maintenance requirements

plus the calculated deficit) is infused evenly over a 48 hour period in order to reducethe risk of cerebral edema.

Example: If the patient were a 5 Kg child with 10% dehydration the replacement volumewould be 500cc (daily Maintenance) + 250cc (total estimated deficit/2)=750cc each 24 hours

for 2 days (48 hours).

I.AdultFluid replacement in adults withhyperosmolar hyperglycemicsyndrome (HHNS):1. If the serum osmolality320mOsmol, administer Normal

saline, 1500cc/hour for the firsthour, 1000cc/hour over the next 2hours, then reduced to 500-750cc/hour. When serumosmolality is less than320mOsmol, 1 Normal salineshould be used. 5% glucose isadded to the electrolyte solutionwhen the blood sugar reaches250mg/dL. The average fluiddeficit in HHNS is 9 liters.Hypotension requires faster initial

infusion rates.

- HHNS is a severe condition that can cause other metabolic

changes. Hospital care will test and address other chemical imbalances.

- Once the main symptoms are alleviated, it is important to

identify what caused the HHNS, so as to avoid it recurring. A common cause is that the patient is diabetic, butdid not know they were.

REFERENCES:
http://www.rightdiagnosis.com/h/hyperglycemic_hyperosmolar_nonketotic_syndrome/underly.htmhttp://www.rightdiagnosis.com/treat/fluid_replacement.htm


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Huether and McCance (2005). Acute Complications of Diabetes Mellitus. Understanding Pathophysiology. 3rd ed.pp. 493-494. Philippines: Elsevier (Singapore) PTE LTD.

Delaney, M. Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic Nonketotic Syndrome. Endocrinology andMetabolism Clinics 2000;29:683-705.

Umpierrez GE, Khajavi M, Kitabchi AE: Review: Diabetic ketoacidosis and hyperglycemic nonketoticsyndrome.Amer J Med Sci1996;311(5):225-233.

Treatment List for Hyperosmolar Hyperglycemic Nonketotic Syndrome. Retrieved last July 11, 2013 from

http://www.rightdiagnosis.com/h/hyperglycemic_hyperosmolar_nonketotic_syndrome/treatments.htm#treatment_list

Hyperosmolar Hyperglycemic Nonketotic State. Retrieved last July 11, 2013 fromhttp://www.summitmedicalgroup.com/library/adult_care/ac-diabeteshhns_dx/

Hyperosmolar Hyperglycemic Nonketotic Syndrome Retrieved last July 11, 2013 from

http://www.corephysicians.org/news-and-health-library/health-library/diabetes/diab3913/

Diabetic Ketoacidosis. Retrieved last July 7, 2013 fromhttp://www.diabetes.org/living-with-diabetes/complications/ketoacidosis-dka.html

Diabetic Ketoacidosis Epidemiology and Its Current Impact on Society. Retrieved last July 7, 2013 fromhttp://www.mayoclinic.com/health/diabetic-ketoacidosis/DS00674/DSECTION=prevention

Saint Mary's University
http://www.rightdiagnosis.com/h/hyperglycemic_hyperosmolar_nonketotic_syndrome/treatments.htm#treatment_listhttp://www.rightdiagnosis.com/h/hyperglycemic_hyperosmolar_nonketotic_syndrome/treatments.htm#treatment_listhttp://www.summitmedicalgroup.com/library/adult_care/ac-diabeteshhns_dx/http://www.corephysicians.org/news-and-health-library/health-library/diabetes/diab3913/http://www.corephysicians.org/news-and-health-library/health-library/diabetes/diab3913/http://www.diabetes.org/living-with-diabetes/complications/ketoacidosis-dka.htmlhttp://www.diabetes.org/living-with-diabetes/complications/ketoacidosis-dka.htmlhttp://www.diabetes.org/living-with-diabetes/complications/ketoacidosis-dka.htmlhttp://www.diabetes.org/living-with-diabetes/complications/ketoacidosis-dka.htmlhttp://www.mayoclinic.com/health/diabetic-ketoacidosis/DS00674/DSECTION=preventionhttp://www.mayoclinic.com/health/diabetic-ketoacidosis/DS00674/DSECTION=preventionhttp://www.mayoclinic.com/health/diabetic-ketoacidosis/DS00674/DSECTION=preventionhttp://www.diabetes.org/living-with-diabetes/complications/ketoacidosis-dka.htmlhttp://www.diabetes.org/living-with-diabetes/complications/ketoacidosis-dka.htmlhttp://www.corephysicians.org/news-and-health-library/health-library/diabetes/diab3913/http://www.summitmedicalgroup.com/library/adult_care/ac-diabeteshhns_dx/http://www.rightdiagnosis.com/h/hyperglycemic_hyperosmolar_nonketotic_syndrome/treatments.htm#treatment_list


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School of Health SciencesGRADUATE SCHOOL DEPARTMENT

Bayombong, Nueva Vizcaya

In Partial Fulfillment for the Requirements in

DIABETES

NURSING(Diabetic emergencies)

Submitted To:

Magdalena Juan, RN, MSNInstructor

Submitted by:

Emily faye L. Turingan, rn

Alma Vanessa M. Zapatero, rnKAtrina P. SERQUInA, RN

Student


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First Semester

School year 2013-2014

diabetic emergencies report

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