7.2 Endocrine, GI & Renal Conditions
Key Takeaways
- Treat hypoglycemia (glucose below 4 mmol/L with symptoms) in a conscious client with the Rule of 15: 15 g fast-acting carbohydrate, wait 15 minutes, recheck.
- DKA occurs mainly in type 1 diabetes: Kussmaul breathing, fruity breath, and marked hyperglycemia; treat with IV fluids, IV insulin, and potassium replacement.
- IV potassium chloride is never given by IV push; it is always diluted and infused slowly with an infusion pump.
- Rapid-acting insulin (aspart, lispro) is given within about 15 minutes before a meal; the client must then eat to avoid hypoglycemia.
- Cirrhosis complicated by confusion, asterixis, and musty breath indicates hepatic encephalopathy from rising ammonia; treat with lactulose.
Endocrine, Gastrointestinal, and Renal Conditions
Endocrine, GI, and renal disorders round out Physiological Adaptation and Reduction of Risk Potential. The exam tests your ability to recognize dangerous complications early and to intervene in the correct order. Canadian laboratories report glucose and electrolytes in SI units (mmol/L), so memorize the normal ranges before test day.
Diabetes Mellitus
Type 1 diabetes results from absolute insulin deficiency (autoimmune destruction of pancreatic beta cells) and always requires insulin. Type 2 diabetes involves insulin resistance with relative deficiency and is managed first with lifestyle change and oral agents such as metformin, and sometimes insulin. Normal fasting glucose is about 4-7 mmol/L. Teaching covers a consistent carbohydrate diet, meticulous foot care, blood-glucose self-monitoring, and sick-day rules.
Insulin timing is heavily tested. Rapid-acting insulin (aspart, lispro) is given within about 15 minutes before a meal, and the client must then eat to prevent hypoglycemia. Long-acting basal insulin (glargine) is given once daily and is not timed to meals. When mixing insulins in one syringe, draw up clear (regular) before cloudy (NPH) - the rule is "clear before cloudy."
The Two Diabetic Emergencies
| Feature | Hypoglycemia | Diabetic ketoacidosis (DKA) |
|---|---|---|
| Onset | Sudden | Hours to days |
| Glucose | Low (below 4 mmol/L) | Very high (often above 15-20 mmol/L) |
| Signs | Shaky, diaphoretic, confused, tachycardic | Kussmaul breathing, fruity breath, dehydration |
| Population | Any client with diabetes | Mainly type 1 |
| Treatment | Rule of 15 | IV fluids, IV insulin, potassium |
Hypoglycemia (glucose below 4 mmol/L with symptoms) is treated in a conscious, swallowing client with the Rule of 15: give 15 g of fast-acting carbohydrate such as juice or glucose tablets, wait 15 minutes, and recheck. Never give insulin, which would lower glucose further. If the client is unconscious, give IV dextrose or intramuscular glucagon.
DKA appears mainly in type 1 diabetes and presents with Kussmaul (deep, rapid) respirations, fruity or acetone breath, marked hyperglycemia (for example 24 mmol/L), ketones, and metabolic acidosis. Priorities are IV normal saline to correct dehydration, an IV insulin infusion, and careful potassium replacement, because insulin drives potassium into cells and drops the serum level.
Thyroid Disorders
Hypothyroidism slows metabolism: fatigue, cold intolerance, weight gain, constipation, and bradycardia. It is treated with lifelong levothyroxine taken on an empty stomach each morning. Hyperthyroidism (often Graves disease) speeds metabolism: weight loss, heat intolerance, tachycardia, and exophthalmos; the emergency to recognize is thyroid storm.
Gastrointestinal Conditions
- GERD (gastroesophageal reflux disease): reflux and heartburn. Teach small meals, avoid lying down for 2-3 hours after eating, elevate the head of the bed, and limit caffeine and alcohol; treat with proton-pump inhibitors.
- Peptic ulcer disease (PUD): epigastric pain, often linked to H. pylori or NSAIDs. Watch for melena (black tarry stool) or hematemesis signalling a GI bleed.
- Inflammatory bowel disease (IBD): Crohn disease (any GI segment, skip lesions) and ulcerative colitis (continuous colon inflammation, bloody diarrhea). Monitor fluid, electrolytes, and nutrition.
- Liver disease and cirrhosis: a high-yield complication is hepatic encephalopathy - confusion, asterixis (flapping tremor), and fetor hepaticus (musty breath) caused by rising ammonia that the failing liver cannot clear; treat with lactulose to reduce ammonia.
Renal Conditions and Fluid/Electrolyte Balance
Acute kidney injury (AKI) is a sudden, often reversible loss of function, while chronic kidney disease (CKD) is progressive and irreversible. Both raise creatinine and blood urea nitrogen (BUN) and reduce urine output. Monitor intake and output, daily weights, electrolytes, and signs of uremia. Urinary tract infections (UTIs) cause dysuria, frequency, and urgency; in older adults, new confusion may be the only sign. Teach adequate fluids and front-to-back perineal care.
Key electrolyte normals: potassium 3.5-5.0 mmol/L and sodium 135-145 mmol/L.
| Imbalance | Key danger | Nursing focus |
|---|---|---|
| Hyperkalemia (above 5.0) | Cardiac dysrhythmias, peaked T waves | Cardiac monitoring; never rapid IV potassium |
| Hypokalemia (below 3.5) | Dysrhythmias, muscle weakness | Replace potassium; increases digoxin toxicity |
| Fluid overload | Dyspnea, edema, weight gain | Restrict fluids and sodium, give diuretics |
| Dehydration | High HR, low BP, poor skin turgor | Rehydrate and monitor output |
IV potassium chloride must never be given by IV push - it is always diluted and infused slowly through an infusion pump, because rapid administration causes fatal dysrhythmias. A reported potassium of 6.5 mmol/L puts the cardiac system at greatest risk. Common traps include giving insulin for a symptom that is actually hypoglycemia, and forgetting that insulin therapy lowers serum potassium during DKA management.
DKA vs Hyperosmolar Hyperglycemic State (HHS)
| Feature | DKA | HHS |
|---|---|---|
| Typical client | Type 1 diabetes | Type 2, often older |
| Glucose | High (often 15-25 mmol/L) | Very high (often above 33 mmol/L) |
| Ketones and acidosis | Present; metabolic acidosis | Minimal; little acidosis |
| Breathing | Kussmaul, fruity breath | No Kussmaul breathing |
Both are hyperglycemic emergencies treated with IV normal saline first, then an IV insulin infusion with potassium replacement and hourly glucose checks. HHS causes even more profound dehydration because it develops slowly, without the early warning of acidosis.
Adrenal and Antidiuretic Clues
Addison disease (adrenal insufficiency) causes fatigue, hypotension, hyperkalemia, and hyperpigmentation; an Addisonian crisis is treated with IV fluids and hydrocortisone. Cushing syndrome (cortisol excess) causes moon face, truncal obesity, hyperglycemia, and hypokalemia. For fluid clues, remember SIADH retains water (dilutional hyponatremia, concentrated urine), whereas diabetes insipidus pours out large volumes of dilute urine and risks dehydration.
Clinical Judgment in Action
A client with type 2 diabetes takes basal glargine at bedtime but skips breakfast because of nausea, then feels shaky and diaphoretic with a capillary glucose of 3.2 mmol/L. The correct sequence is the Rule of 15, not holding all care "until the next meal": give 15 g of fast-acting carbohydrate, wait 15 minutes, recheck, and only then address the missed meal and antiemetic needs. Giving insulin here, or waiting an hour to recheck, are the classic wrong answers because both let the glucose fall further.
A conscious client with diabetes is shaky and diaphoretic with a capillary blood glucose of 3.0 mmol/L and is able to swallow. Which action is most appropriate?
A client with type 1 diabetes has deep, rapid respirations, fruity-smelling breath, and a blood glucose of 24 mmol/L. Which condition should the nurse suspect?
A client is prescribed intravenous potassium chloride. Which nursing action ensures safe administration?