CHAPTER 15
ENDOCRINE SYSTEM AND DIABETES
Working in conjunction with the nervous
system, the endocrine system is responsible for secreting substances,
hormones, which are then transported via the circulatory system to target
organs. It is the hormones which regulate the proper functioning of the target
organs.
The secreted
hormones regulate numerous bodily processes and functions such as metabolism, growth
and development, tissue function such as insulin release, urinary elimination,
reproductive activity, steroid production, and water metabolism for example. The glands which are associated with this
system include the pituitary, thyroid, parathyroid, pineal, adrenal, as well as
the pancreas, ovaries, and testes which perform other functions as well as
endocrine.
You can liken
this system to a home’s thermostat which regulates temperature. If the temperature is too cold, the
thermostat turns the heat turn on; upon reaching the desired temperature, or if
too hot, the thermostat turns the heat off.
The endocrine system works in a similar manner. It ensures that the body maintains an ideal
functioning level based upon hormone levels in the blood that are sent to the
brain (the thermostat) for evaluation.
If the hormonal levels are not optimal, the brain sends signals, via the
pituitary, to other endocrine glands which direct target organs to carry out a
task. All of this is done via hormones,
chemical messages, which turn a target organ on or off.
A portion of the brain, the hypothalamus, by
constantly assessing hormone levels in the blood, dictates a gland’s release of
hormones to maintain optimal body functioning.
It is continuous, and changes are
made constantly depending on what the body’s needs and requirement may be at
any given moment. This is a feedback
mechanism, but it is not immediate in its response. The target organ’s response time is usually
not immediate and prolonged because the hormonal message is delivered via the
circulatory system (blood).
As stated previously, hormone levels in the
blood are first evaluated in the brain by the hypothalamus. The hypothalamus then sends signals to the
pituitary gland. The pituitary gland, often called the “master gland of the body” causes
hormonal release or suppression by any of the endocrine glands. The target organs then respond so the body
maintains an optimal level of function (homeostasis).
Because there are many players in this
system, breakdowns can occur anywhere
during this feedback cycle. This
includes: 1) a malfunction occurs
between the hypothalamus and pituitary gland; 2) the pituitary gland is
unsuccessful in communicating commands to a target gland; 3) the target gland
receives instructions from the pituitary but is unable to act on them because
it is unable to secrete, or restrain from secreting its hormone; and 4) the
target organ of the hormone is unresponsive to the hormone.
To identify a
disease process,
it is necessary to determine whether it is a problem of communication between
the pituitary and target organ, or simply an inability for the target organ to
comply with pituitary’s direction to secrete a hormone
(hypo-responsiveness).
Disorders and
illnesses from this system result when a gland secretes too little of a hormone
(hypo-secretion), resulting in a hormonal deficiency so homeostasis cannot be
maintained. The opposite is also
true. If there is an overproduction
(hyper-secretion), too much of the hormone is released into the body. Hormone
levels, whether too high or low, create numerous diseases that may require
life-long treatment to maintain normal levels.
Once the cause of
the disorder is determined based upon specific testing of the pituitary and target
gland, the diagnosis typically is handled by medication or surgical removal
(excision) of part or all a gland, but usually one that does not require
long-term nursing services. However,
diabetes may not be treated this way.
Therefore, the focus of this section will be devoted to Diabetes Mellitus.
Diabetes Mellitus is a chronic disease of the endocrine section of
the pancreas which secretes insulin.
Lack of insulin causes high and
damaging levels of sugar in the blood (hyperglycemia). As a disorder of carbohydrate metabolism, is
it evidenced by the body’s inability to use nutrients for fuel and
storage. This hyperglycemia is the
disease’s hallmark and is caused by an
inadequate or complete lack of insulin production or resistance to insulin’s
action. Other typical signs of the
disease include increase urination (polyuria), increased thirst (polydipsia),
and increased hunger (polyphagia).
Diabetes is the
most common of all endocrine disorders.
While the actual cause is not known, there is an auto-immune factor, a
life-style and age component, as well as a genetic predisposition. Two types of diabetes are diagnosed and
depend on the circumstances and age upon which the disease presents. Regardless, this is a life-long chronic and incurable disease. Patients are usually tasked with life style
changes and medication administration to counteract the disease process. However,
with compliance and adherence to proper therapy, in accordance to the patient’s
underlying health, there can be decreased complications and prolonged
life.
Under normal
functioning, the pancreas secretes insulin into the blood. The purpose of insulin is to decrease blood
glucose (sugar) levels by “transporting” it into cells where it is used as an
energy source for normal cellular body functioning as well as to store
remaining sugar in the liver in the form of glycogen. This prevents accumulation of sugar in the
blood, as it is either stored until it is needed or used for cellular
function.
Without glucose
as an energy source, because insulin is not available, the body breaks down
fatty acids. Although short term energy is provided by
fats, their incomplete metabolism creates ketones. When
these ketones accumulate they can cause lasting detrimental effects and death
because they lower the pH of the blood (ketoacidosis), which has small range
for the body to function.
In addition, as
fats break down and high levels of sugar remain in the body, blood vessel
damage occurs. Results include atherosclerosis and other
cardio-vascular insufficiencies, stroke, nerve damage, peripheral vascular
disease and poor circulation, resulting in neuropathy with pain and numbness in
extremities, especially feet, along with renal insufficiency and loss requiring
dialysis, as well as vision damage or blindness, and skin ulcerations, slow
wound healing with associated decreased infection resistance due to decreased
blood flow, gangrene, perhaps even amputation.
Without diabetes,
insulin secretion is increased by the pancreas when blood glucose levels rise approximately
thirty to sixty minutes after meals to transport glucose for energy. Insulin
levels then decrease and return to normal two to three hours after glucose
levels in the blood decrease.
With diabetes,
without insulin, glucose is not removed from the blood and used for energy, and the body is
required to perform metabolism of other nutrients to obtain energy. To control diabetes, medication (insulin or
oral drugs) is given to try to mimic the normal functioning of the pancreas.
There are two
types of diabetes mellitus which are differentiated by age of onset, etiology (cause)
of the disease, and other presenting factors:
Type 1 –
IDDM (insulin-dependent diabetes mellitus) usually presents at 25 years old or
less. Its onset is abrupt, and the
patient’s weight is less than or within the normal range. In fact, the patient may be losing weight
even though presenting with polyphagia (increased appetite). Outstanding
is the lack of insulin present. The
reason for this lack may be immune-related, due to genetic predisposition, or
of a completely unknown cause (idiopathic).
The speed that the pancreas function is destroyed is variable, but the
rate happens more rapidly in the young.
To control this
type of diabetes insulin is administered by injection and diet is regulated. Insulin administration and dosage is very
individualized and patient-specific. The
goal of insulin injections is to provide the body with a proper level of
glucose in the blood for the body to function normally while keeping the levels
from becoming dangerously low (hypoglycemia).
Often, different types of insulin must be injected to mimic the natural
effect of those released by the body, such as rapid, intermediate, and
long-acting insulin. In addition, the
timing of the injections will vary based upon issues such as the amount of
blood glucose that was tested from a blood sample, timing of meals, length and
type of exercise performed, the injection site, and the type of insulin that
will be injected.
Levels of glucose
in the blood must be tested daily to manage this disease. By using a drop or two of blood from a finger
stick put on a special testing paper, the amount of sugar in the blood is read
by machine. This process may occur many
times a day. The amount of insulin
dictated by a physician (endocrinologist) is then injected into the body. Specific body sites are used to inject
insulin because it must be introduced into the skin, not muscle. In addition, different sites use (metabolize)
the insulin faster than others, providing more rapid absorption rates,
therefore altering peak action times.
The sites used for injection include the abdomen, upper arms, thighs,
and hips.
Usually, vascular
and neurologic changes eventually develop.
Because the body itself secretes no insulin, and as it is injected into
tissues rather than being released as needed, blood glucose levels often
fluctuate and are difficult to control within a desired range. But if
detected early, with patient compliance, the manifestations of the disease,
although eventually presenting, can be offset with proper diet, patient
compliance, and medical attention
Type 2 –
NIDDM (non-insulin-dependent diabetes mellitus) occurs more
frequently, usually presents after age 40, and is a gradual process. The patient is often obese. Some insulin may be present in the body, but
the amount being secreted may be insufficient to meet the body’s needs. However, at times there is also a complete
deficiency of insulin production. There is a strong inherited and
predisposition to this type of diabetes, but it often lacks auto-immune
destruction of the pancreas that typifies Type 1. These patients do not usually have increased
appetites or exhibit weight loss but do suffer from side effects such as itchy
skin (pruritus) and numbness (peripheral neuropathy) related to long-lasting
glucose and fat metabolism.
While diet is
essential to manage this type of diabetes, medications are often varied. If the patient is not obese, sometimes
dietary changes alone can control it.
Oral medications (hypoglycemic medications) may treat the mild/moderate
forms of the disease that is usually associated with obesity but not severe
enough to require insulin. There are numerous oral medications, and
they work differently on the body.
For example, some may stimulate the pancreas to produce more
insulin. Other drugs may work to delay
absorption of glucose by acting on digestion by the small intestine. However, if
the patient’s glucose levels are not lowered sufficiently using the oral
medications, and the disease is severe, insulin may need to be injected. A variety of medications are tried first to
provide a controlled level of sugar in the blood, as determined by finger
sticks, prior to initiating injectable medications.
Compared with
Type 1, the same vascular and neurologic changes usually develop. However, one major difference is that this
type of diabetes is usually easy to control, and stable once proper medication
is determined, and the patient is compliant with treatment. But it is important to note that because this
diabetes type is long in progressing, it is often diagnosed late, once other
complications have manifested.
Care Considerations for
Diabetes Mellitus
1) Although family members can support the patient, ultimately the patient
must have conviction and be self-motivated to comply with the management of
diabetes due to life-style changes and blood monitoring, diet restrictions and
potentially painful interventions. Medication administration, especially
insulin injections, requires a strict control to maintain blood glucose levels
at an optimum range. This may require
self-testing of blood before meals, at various times during the day, and before
bed. Based upon the blood results,
self-administration of insulin, which is injected into the skin, may be
required. In addition, dietary changes are usually
essential. This may include reduction
or elimination of favorite foods and/or addition of items that are not
preferred. Life-style modifications,
compliance, and motivation to make these changes are essential for
treatment. The patient is responsible
for reducing the disease process, or the rapidity of its harmful effects. The
patient must restrict his diet. The
patient must test his blood sugar. The
patient may possibly inject himself with insulin. While family members can assist,
especially with household dietary changes, ultimately the patient must comply
with a diabetes-friendly diet. Emotional
support proves vital, along with support groups and counseling.
2)
Teaching is essential for the patient to understand the ramifications of
diabetes. Compliance is increased when
the patient understands the broadly encompassing effects of the disease and
damage to vessels which provide oxygen to various structures: eyes, kidneys, skin, for example. Diabetes can cause secondary problems such
as blindness, renal failure which may require dialysis, and osteomyelitis and
amputation due to infection, respectively.
A patient’s more diligent and active treatment observance to control
diabetes, once consequences are detailed, often occurs when complications and
progression of the disease are understood.
3)
Finger-sticks are necessary to obtain scientific and measurable levels of
glucose in the blood. Required for insulin injections, these
self-tests are also often necessary to determine efficacy of oral hypoglycemic
agents. The number of times to test will
be dictated by a physician. Initially,
and if compliance if a factor, this may need to be performed numerous times a
day. A meaningful record should be maintained not only to capture data but
to ensure completion. Technique in
performing finger sticks should be taught by a diabetes-specialist nurse or
other professional and the instruction should include at least one family
member. A professional in the field will
teach the optimum technique. In
addition, in times of hypo- or hyperglycemic crisis, someone else can perform
testing if the patient is unable to do so.
4)
Management of insulin is required. Most
injectable insulins require refrigeration but should be at room temperature
prior to administration. The patient
should verify these requirements with a health-care professional and/or
pharmacist. Improper storage can degrade
efficacy of insulin and greatly reduce its effectiveness.
5) If
injecting insulin,
sites of injection matter greatly. Learn
and identify the proper sites on the body for administration, which usually
include the abdomen, upper arms, thighs, and hips. Each site differs in rate of absorption, and
of those listed previously, the abdomen has the most rapid action and the least
rapid action is from injections at the hips.
Physical constraints may dictate not using a site. Sites will likely
need to be rotated. Consult a medical professional.
6) When
injecting insulin, specialized equipment is essential. Used often are disposable single-use syringes
with attached small 25- or 26- gauge needles that are half-inch in length. These small needles ensure the insulin is
delivered into the skin and not the muscle.
The small diameter of the needle reduces discomfort. (The larger the gauge of the needle indicates
a smaller diameter size.) To reduce
mistakes in doses, the syringes used must be calibrated in insulin units/mL –
not milliliters (mL) solely, as insulin is prescribed in units. Use of
non-insulin, non-unit-measured syringes cannot be used – they are not
interchangeable and can cause under- and/or over-medication administration. If syringes are multi-use, ensure they are
cleaned, dried, and cared for according to the manufacturer’s
requirements. And for efficacy and
comfort reasons, never use a dull needle for administration of insulin. Use of
the proper equipment ensures safety, assures that the appropriate amount of
insulin is instilled into tissue, and decreases risk of adverse reactions from
inappropriately injected insulin.
7) For
preparation of insulin for administration, allow insulin to reach room
temperature, or follow pharmacy recommendations. Wash hands.
After testing blood glucose to determine amount of insulin to inject,
fill syringe with that amount of air and inject the air into the vial, after
cleansing vial top with alcohol. Then
withdraw units to be injected. Ensure no
air bubbles are present. To prevent
infection, washing hands frequently helps to eliminate contamination. With excess glucose in the body, infection
occurs more frequently. Instilling air
into the vial eases withdrawal of contents into the syringe. Eliminate air bubbles to help ensure proper
amount of insulin will be injected and that the syringe space is not reduced by
air and that air will not be injected along with the medication.
8) Preparation and insulin administration. Wash hands.
Cleanse site with alcohol swab and allow to dry. Pinch
fold of skin, relax muscles, and insert needle at 90o angle into
subcutaneous (non-muscle) tissue, penetrating the skin fold quickly. (If
patient is very thin, insert needle at 45o angle.) Do not change direction of needle during
insertion or removal: go in and out
without turning. Withdraw needle. Messaging of area is detrimental and should
not be done, but pressure applied to site is acceptable. Rotate
injection sites often to prevent hardening of the skin and other problems,
such a dimpling or sunken areas. Use
abdomen, upper arms, thighs, and hips as directed by physician. If using the same area of body, ensure at
least a one-inch area is maintained between injection sites. Cleansing site and washing hands minimizes
risk for infection. Rotating needle once
inserted into skin causes discomfort and provides no benefit. Massaging skin changes the route of insulin
and causes decreased efficacy. Rotating
sites and allowing for injection margins of at least one inch minimizes atrophy
of the skin to allow for lifelong injection sites.
9) Know
the signs and symptoms of hypoglycemia which can occur in Type 1 or Type 2
diabetes. This condition results when there is too
little glucose in the blood, typically resulting in an over-administration of
insulin or medication, or taking insulin and then not eating, or exercise that
was too intense or too long in duration.
Symptoms include headache,
vagueness, nervousness, dizziness, uncoordinated movements, paleness (pallor),
sweating, palpitations, and fast heart rate (tachycardia). Eventual seizures, loss of consciousness and
coma can occur. If symptoms arise,
first test the patient’s blood if able.
If blood glucose level is low or hypoglycemia is suspected, have patient
consume a fast-acting carbohydrate such as orange juice, milk, hard candies,
honey, bread/crackers, or other foods containing sugar. Administer to patient’s safety and
comfort. Call 911 as necessary. In addition, the patient should always have a
readily available supply of candy or another sugar source that can be self-administered
if the patient suspects possible hypoglycemia.
10)
Meticulous skin care is necessary. Feet should be inspected daily for
small injuries that can be complicated due to decreased blood flow and lack of
sensation (neuropathy). Inspect feet
while sitting down and hold them up to a mirror to reflect image. This aids in obtaining full view of the soles
of the feet, often difficult to visualize.
Never soak feet for any length of
time. Soaking leads to excessive
softening of skin (maceration) and promotes infection because the skin is more
prone to injury. Wash and dry skin thoroughly.
Blot skin: do not rub. Drying
gently decreases harm to skin yet ensures moisture is removed. Avoid
constricting socks and foot wear. These decrease blood flow which is already
compromised.
11) Provide full and complete gentle oral care. Dental hygiene is essential to prevent
dryness, gingivitis, and periodontal disease.
Obtain professional dental care often, every four to six months, to
minimize diabetic complications. Use
soft toothbrushes when brushing. Monitor
for bad breath, unpleasant tastes, sore, red and/or bleeding gums, and tooth
pain, and if these occur, consult your dentist as soon as possible. These could be signs of oral infection and
require professional treatment.
12) Risk for injury increases for the patient with diabetes due to
multiple causes, depending on the progression and stage of the disease. Neuropathies can affect gait and
sensation. Visual damage can cause
blurred vision, cataracts, and other problems leading to blindness. With variances in glucose in blood,
especially hypoglycemia, seizures or altered levels of consciousness can be
exhibited. To prevent injury, ensure rooms are clear of debris. Provide night lights to assist with
visualization, especially if vision has been adversely affected. Patients should always wear protective
covering on feet, such as slippers or shoes – socks do not prevent injury. Know the signs and symptoms of hypoglycemia
to provide quick treatment and prevent severity. Monitor water temperature to ensure it is not
too hot and can cause injury.
Neuropathies cause loss of sensation and burns could easily occur
without the patent noticing them in time.
13) Risk
for infection increases in the diabetic patient.
Injuries are slower to heal due to decreased blood circulation. In addition, glucose in the blood promotes
bacterial growth. Keep nails clean and
intact. Monitor for urinary tract
infections and yeast infections, especially vaginally and in skin folds. Be protective of feet, even regarding small
cuts or abrasions. Feet are a likely target for infection due to decreased blood supply, loss
of sensation, and lack of visibility of the soles and outer aspects of
feet. Know the signs and symptoms of infection, which include temperature,
pain, malaise, swelling, redness, and discharge. Consult medical professionals should this
occur. Due to underlying diabetes and
the effects of the disease, it is not recommended to self-treat infections.
14) A
diabetic diet should be followed by the patient. This is as individualized to the patient as
in his insulin regime. Consultation with
medical professionals, a nutritionist, and a dietician is recommended to
determine the amount of carbohydrates, proteins, and fats that should be
consumed to ensure a balance among caloric intake, energy utilization, and
dosing and timing of insulin. A diet that limits sugar, alcohol, salt,
and fats is usually recommended. In
addition, eating complex carbohydrates decreases sugar levels and, therefore,
the amount of insulin that needs to be injected. Caloric intake is often reduced, especially
in the obese patient. Foods that promote
satiation (feeling of fullness), especially those high in fiber, are
suggested. A food-exchange program is
often taught which allows the patient to select set amounts of food, based upon
specific patient parameters, from basic food groups to allow for independence,
as well as teaching skills in reading food labels. Dietary
changes can greatly increase the efficacy of medications as well as leading to
better quality of life in general.
Professionals can pinpoint specifics and knowledge in label reading can
bring hidden bad ingredients to the forefront.
Consultation with professionals can provide eating strategies and
options that may be overlooked by a layman.
This then increases compliance and makes eating a pleasure rather than a
diet.
15)
Maintain records of tested blood glucose levels, insulin injected (including
time administered, type, and amount given), and diet/foods eaten. Records provide means for medical
professionals to evaluate treatment regime.
They also enhance the participation and compliance of the patience by
having “to do” and “record” actions.
16)
Patient concerns include a lack of independence, an altered self- image, fear
of economic loss due to illness or loss of work, coping with a chronic illness,
and/or fear of complications. With
diabetes, more frequent visits to medical professionals will be required. One is no longer free to do what and when he
desires and may feel trapped by medication administration and dietary
constraints. With additional medications
and doctor visits, funds may be depleted.
Fear of complications and living with a chronic illness can seem
daunting for a newly diagnosed diabetic patient, especially when outward signs
and symptoms of the disease may not have presented yet. All of these are genuine concerns and
realistic losses to the patient. However, with patience and teaching, the patient
becomes more aware and self-motivated. Control over the disease
increases. Over time, he will probably
feel better, which also leads to continued compliance. Stress the benefits, his accomplishments. Allow for frustration and
disappointment. Backward steps may
occur, but with encouragement, they will hopefully be few and progress will
continue.
###
Contact information:
Diane R. Beggin, RN
40 Sycamore Drive
Montgomery, NY 12549
Web site: http://ManageNursingCareAtHome.com
Book: HOW TO MANAGE NURSING CARE AT HOME, by Cooper and Beggin
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