M1.5 ATI Engage AMS Alterations in Endocrine Function; complete A+ guide; Updated 2025/26.

M1.5 ATI Engage AMS Alterations in Endocrine Function Alterations in Endocrine Function Overview Learning Objectives  Explain the pathophysiology of endocrine function.  Explore epidemiological and etiological risk factors that contribute to clients experiencing alterations in endocrine function.  Describe the impact of alterations in endocrine function on a client’s overall health.  Differentiate the clinical presentation of clients experiencing alterations in endocrine function.  Explore the role of the nurse when caring for clients experiencing alterations in endocrine function.  Apply the nursing process through the use of clinical judgment functions while providing care to clients experiencing alterations in endocrine function. The endocrine system is a major regulatory system of the human body. Glands communicate with the body through the secretion of hormones. Hormones, which are composed of biochemical substances, bind with specific target receptors and are necessary for cellular metabolism (glucose control, energy production, and utilization), body growth, development, responses to injury or stress, and reproduction. Hormones are stored in and released from the endocrine system glands, such as the hypothalamus, pituitary, thyroid, parathyroid, adrenals, pancreas, ovaries, testes, and pineal glands. Disorders, disruptions, or imbalances of the endocrine system usually involve increases or decreases in the production of a hormone or the failure of a target cellular receptor. Nurses must understand the endocrine system because of its complex interaction with other body systems.M1.5 ATI Engage AMS Alterations in Endocrine Function The hypothalamus is located deep in the brain and coordinates the endocrine system through the production and release of hormones. The major role of the hypothalamus is to maintain the body’s homeostasis. It is the hypothalamus that links the endocrine system with the nervous system and secretes hormones to regulate the pituitary gland. The hypothalamus controls the pituitary gland’s release of hormones and detects hormone levels as they work together in a feedback relationship called the hypothalamic-pituitary axis. The hormones involved include thyroidstimulating hormone (TSH), follicle-stimulating hormone (FSH), luteinizing hormone (LH), growth hormone, prolactin, and adrenocorticotropic hormone. The pituitary gland is a small pea-sized gland just below the hypothalamus connected by a pituitary stalk (also known as infundibulum). One of the pituitary gland’s main responsibilities is secreting hormones to stimulate or regulate most of the other endocrine glands, such as TSH. This hormone is produced in the anterior pituitary and is released to stimulate the thyroid gland to release thyroid hormones. The hypothalamus and the pituitary gland regulate many body functions, such as body temperature (through TSH thyrotropin-releasing hormone), fluid balance (antidiuretic hormone or vasopressin), blood pressure (dopamine), appetite, stress (cortisol), sleepM1.5 ATI Engage AMS Alterations in Endocrine Function (melatonin via the pineal gland), and reproductive health (gonadotropinreleasing hormone). The adrenal glands are located on the superior aspect of each kidney and are responsible for secreting cortisol and aldosterone. Alterations in these hormones can result in disorders such as Addison’s disease and Cushing’s syndrome. Addison’s disease is a disorder of the adrenal glands in which the glands are damaged and unable to produce adequate amounts of cortisol and aldosterone. An insufficient amount of these hormones diminishes the body’s ability to maintain metabolism, electrolyte balance, blood pressure, and blood glucose levels and also creates an inability to control inflammation. Cushing’s syndrome is a disorder in which excessive amounts of cortisol are excreted. This results in associated health problems such as hypertension, osteoporosis, metabolic syndrome, diabetes, and increased risk for infections. This module will focus on major disorders of the pancreas and thyroid glands, including hyperglycemia, hypoglycemia, type 1 and type 2 diabetes mellitus, metabolic syndrome, hypothyroidism, and hyperthyroidism. This module will:  Explain the pathophysiology.  Explore epidemiological and etiological risk factors that can contribute to alterations in endocrine function.  Describe the impact of alterations in endocrine function on a client’s overall health.  Differentiate the clinical presentation of clients experiencing alterations in endocrine function.  Explore the role of the nurse and explain how to use the nursing process to manage care when caring for clients experiencing alterations in endocrine function.M1.5 ATI Engage AMS Alterations in Endocrine Function Hyperglycemia Anatomy, Physiology, and Pathophysiology The pancreas is an endocrine gland that is approximately six inches long and pear-shaped. It lies transverse across the upper abdomen, behind the stomach, with the wider end (head) on the lower right side. The pancreas is connected to the duodenum by the pancreatic duct. The thinner end (tail) is connected on the left toward the spleen. The pancreas has two main functions in the endocrine system. The first function is as an endocrine gland, secreting the hormone insulin in beta glands or glucagon to regulate blood glucose levels. The second function is as an exocrine gland, secreting enzymes for digestion such as amylase and lipase. Glucagon is released in response to blood glucose levels to prevent hypoglycemia. Insulin is the key hormone that unlocks the cell to allow the absorption of glucose. Glucose is the main source of fuel for the body and brain and requires insulin to move across cell membranes into cells. Insulin is an essential hormone that is produced in the beta cells of the pancreas. Hyperglycemia is defined by a fasting blood glucose concentration greater than 126 mg/dL. Insulin is produced in the islets of Langerhans from beta cells. Hyperglycemia is a hallmark of type 1 diabetes mellitus (DMT1) and type 2 diabetes mellitus (DMT2). Insulin resistance is a failure of the insulin receptors, which are located on the membrane of the target cells, to accept insulin. Also, cell receptors may become insulin resistant, or the pancreas gradually loses its ability to produce enough insulin.M1.5 ATI Engage AMS Alterations in Endocrine Function The cells require glucose for energy. When they are not able to absorb the glucose they need because of a lack of insulin, the liver will release glucagon stores and stimulate hepatic glucose production through gluconeogenesis and glycogenolysis. Gluconeogenesis generates glucose from non-carbohydrate sources, such as proteins, lipids, pyruvate, or lactate. Glycogenolysis mainly occurs in the hepatocytes of the liver and the myocytes of the muscles. The liver will attempt to regulate glucose with glucagon, but if hyperglycemia continues, cortisol, catecholamines, and growth hormones will be released. Then, lipolysis and proteolysis occur to produce glucose, which can lead to rapidly increasing blood glucose levels. As excess blood glucose levels rise, the glucose then travels into the kidney’s renal tubules, which can lead to increased urination and excretion of water, sodium, and potassium. The most severe level of hyperglycemia can occur if blood glucose levels continue to rise and a hyperglycemic hyperosmolar state (HHS) occurs, which is a metabolic complication related to DMT2, resulting in severe dehydration, plasma glucose greater than 600 and increased plasma osmolarity greater than 320 mOsm/L, absence of ketosis, hypotension, and altered mentation. Epidemiological and Etiological Risk Factors Many factors can contribute to hyperglycemia, including ones the client can control and those that the client cannot control. Risk factors include modifiable lifestyle factors, taking certain steroid medications, illness or infection, chronic stress, or insomnia. However, non-modifiable factors of having a genetic or familial predisposition to a metabolic disorder, such as diabetes mellitus or metabolic syndrome, can be risk factors. Other causes for hyperglycemia include missing or taking insufficient dosages of medications for DMT1 or DMT2, such as insulin, using an improper technique for insulin administration, using expired insulin, or nonM1.5 ATI Engage AMS Alterations in Endocrine Function adherence to diet or exercise plans. Secondary causes of hyperglycemia may include total parenteral nutrition (TPN), dextrose infusions, and the use of some medications, such as glucocorticoids, phenytoin, and estrogens. Modifiable Lifestyle Risk Factors Modifiable risk factors for hyperglycemia include a body weight that is 120% of expected weight, diet high in simple carbohydrates, sedentary habits, smoking, or excess stress. Epidemiology Incidences of hyperglycemia have increased over the last 20 years partially due to higher rates of obesity, decreases in physical activity, and an increasing population of older adults. The U.S. has a high rate of clients with diabetes mellitus, and because diabetes mellitus is closely linked to hyperglycemia, it is also common in the U.S. and is expected to rise. Hyperglycemia affects all sexes equally with a higher incidence in clients who are from low- or medium-income households or are members of historically marginalized ethnic or racial groups. For example, a study published on uncontrolled hyperglycemia incidence in Philadelphia found that clients who were 18 to 54 years old had the highest prevalence of uncontrolled hyperglycemia at 36%, and it was also associated with increased total cholesterol to high-density lipoprotein ratio, heart disease, and lower socioeconomic status (SES). Comorbidities and Complications Comorbidities include autoimmune disorders, hyperlipidemia, hypertension, gestational diabetes, polycystic ovary syndrome (PCOS), metabolic syndrome, Cushing’s syndrome, acromegaly, and pheochromocytoma. Hyperglycemia can cause a chain reaction of damage throughout the body, and if untreated, leads to metabolic syndrome, the precursor to DMT2. If blood glucose levels become extremely high and persist, it can lead to coma and death. Complications of untreated hyperglycemia can cause permanent damage to the blood vessels, nerves, tissues, and organs leading to coronary artery disease, cerebrovascular disease, peripheral vascular disease, retinopathy, nephropathy, poor healing of wounds, and depression. Impact on Overall Health The effects of high blood glucose levels are quickly compounded if not controlled. When glycogen stores are released by the liver, it further increases hyperglycemia and impairs glucose utilization by the peripheralM1.5 ATI Engage AMS Alterations in Endocrine Function tissues. As the kidneys deal with excess blood glucose levels, polyuria can cause fluid imbalance and the loss of sodium and potassium. That can further lead to more advanced complications of hyperglycemia and hypovolemic hypotension. Polyphagia and polydipsia are also indications of the effects of hyperglycemia. With chronic hyperglycemia, excess glucose triggers an inflammatory process, and early diagnosis and treatment can prevent the progression of hyperglycemia before it can affect major organs. The client’s quality of life can also be significantly reduced because of secondary conditions such as cardiovascular disease, and complications if hyperglycemia remains untreated. Manifestations of advanced hyperglycemia, such as diabetic ketoacidosis (DKA), may include a fruity odor to the client’s breath and deep rapid Kussmaul respirations (to blow off the acid to compensate) along with nausea, vomiting, or abdominal pain. For more information on DKA, see Critical Endocrine Dysfunction. Blood glucose naturally rises at night during sleep, but excessively elevated blood glucose levels can negatively affect sleep quality and patterns. Decreased sleep can cause glucose levels to rise and cause insulin resistance. A client who has hyperglycemia needs to have good sleeping habits, including plenty of time to sleep and experiencing all stages of sleep, to prevent sleep habits from negatively affecting glucose levels. Sleep disturbances from disorders such as disordered breathing, obstructive sleep apnea, and other sleep-breathing issues are also associated with higher glucose levels or glucose intolerance. Effects of Hyperglycemia on Body Systems  Circulatory: Blood vessel damage, cardiovascular disease, poor wound healing  Respiratory: Kussmaul respirations  Digestive: Nausea, vomiting, painM1.5 ATI Engage AMS Alterations in Endocrine Function  Nervous: Vision problems, neuropathy, depression, insomnia, stres Considerations of the Aging Adult Chronic, uncontrolled hyperglycemia causes damage and inflammation to the vascular walls and increases atherosclerosis, which inhibits circulation and commonly becomes compromised in older adults. It can lead to peripheral artery disease with resultant poor circulation, which increases the risk of potential loss of toes or even limbs. It can also lead to carotid artery disease with an increased risk of strokes and heart attacks. In addition, hyperglycemia in older adults damages the peripheral nerves causing tingling, numbness, and neuropathic pain and may damage the optic nerve and cause blindness. Clinical Presentation Hyperglycemia may have no immediately obvious manifestations. It can be present for years before a client eventually seeks treatment for problematic manifestations. In clients who have severe hyperglycemia, physical assessment findings may be significant. Clients may report increased urine output, thirst, and weight loss. Because of dehydration, mucous membranes may be dry. Vital sign changes can include low blood pressure and fast heart rate. Changes in cognition can occur; a client who has hyperglycemia may be confused, lethargic, or comatose. When hyperglycemia progresses to diabetic ketoacidosis, gastrointestinal manifestations such as abdominal pain, nausea, and vomiting are common. The client’s breathing may be fast and shallow and their breath may have a fruity odor.M1.5 ATI Engage AMS Alterations in Endocrine Function Lab Testing and Diagnostic Studies Blood glucose testing is used to diagnose hyperglycemia. Both fasting and postprandial levels can be evaluated. Hyperglycemia is diagnosed when a fasting blood glucose level is above 125 mg/dL or when the client’s blood glucose level is 1 to 2 hr after eating exceeds 180 mg/dL. Hemoglobin A1C (HbA1c) is a blood test that provides information about the average blood glucose level over the previous two to three months. For example, an HbA1c of 7% indicates that the estimated average glucose over the previous two to three months was 154. As the HbA1c percentage increases and decreases, it correlates with higher and lower estimated average glucose levels. Comparing HbA1c With Estimated Average Blood Glucose Level HbA1c Estimated Average Glucose Level (mg/dL) 6% 126 7% 154 8% 183 9% 212 10% 240 When hyperglycemia is caused by a tumor or a disease other than diabetes, diagnostic imaging may be necessary. CT scans, ultrasounds, and MRIs are used to diagnose and evaluate the disease trajectory. Role of the Nurse The role of the nurse when providing care to a client who has hyperglycemia may involve monitoring, medication administration, or teaching. Perform laboratory testing for hyperglycemia via capillary blood sampling or venous blood sampling. Capillary blood can be tested using a portable (point-of-care) glucose monitoring device. If point-of-care test results are inconclusive, venous blood can be obtained and sent to the lab for analysis. For more information on fluid and electrolyte imbalances, see Fundamentals: Fluid, Electrolyte, and Acid-Base Regulation. For more information on medication administration, see Fundamentals: Medication Administration.M1.5 ATI Engage AMS Alterations in Endocrine Function Individual Factors While the nurse may have encountered clients who have hyperglycemia in the past, it is important to avoid making assumptions about someone’s motivation, intent, or abilities. Ensure that care is delivered in the client’s preferred language by accessing interpreter services when necessary. Remove personal biases and stereotypes to connect authentically and provide optimal care. Environmental Factors Environmental factors, including social determinants of health (SDOH), will impact a client’s ability to safely manage any chronic condition, including hyperglycemia. Glycemic crises are more likely when clients have inadequate financial resources. A lack of consistent access to quality healthcare, affordable medications and supplies, and affordable, healthy food increases the risk of hyperglycemia. Successful self-management is less likely when clients have inadequate access to safe housing and food. Safety Considerations Safety considerations related to hyperglycemia include managing and disposing of lancets appropriately. To minimize infection risk, lancets should not be reused or shared with anyone. Clients who have recurring hyperglycemia should obtain a medical ID, usually a bracelet or necklace, that can provide key medical information if the client is not able to communicate. Client Education Client education will initially focus on how frequently to monitor for hyperglycemia, how to use a blood glucose monitor, and possibly a target blood glucose goal. Proper storage of equipment and test strips is important. Tell clients to avoid exposing test strips to extreme temperatures or moisture. The nurse will review with the client when to check urine for the presence of ketones. Teaching will include identifying possible triggers for hyperglycemia, such as illness or stress. Provide coaching to the client to encourage self-management of hyperglycemia. Lifestyle modifications including exercise and changes in the diet may be recommended by the provider to reduce or maintain body weight needed to lower blood glucose levels. Exercise is not recommendedM1.5 ATI Engage AMS Alterations in Endocrine Function if ketones are present in the urine because this could cause blood glucose levels to rise even higher. Dietary modifications such as reduced portion sizes and decreased intake of carbohydrates, should be reviewed and reinforced. Collaborating with a dietitian for additional nutritional recommendations should be encouraged. Some clients who have hyperglycemia will require the administration of medication to lower blood glucose levels. To manage hyperglycemia, changes to medication dosage or frequency may be necessary. Provide education when changes to the medication regimen occur. Nursing Process Recognize Cues (Assessment) Assessment of a client who has hyperglycemia begins with determining blood glucose levels and identifying potential complications. Laboratory results may include random, fasting, and postprandial glucose levels. HbA1c may be reviewed. Ask the client if they have experienced polydipsia, polyphagia, and polyuria and observe for these manifestations. If a hyperglycemic crisis occurs, assess vital signs, hemodynamic stability, electrolyte levels, and mental status. Analyze Cues and Prioritize Hypotheses (Analysis) Immediate priorities for a client who has hyperglycemia are identifying blood glucose levels, initiating prompt treatment, and preventing progression to a hyperglycemic crisis. Consider potential causes of hyperglycemia. These can include dietary changes, a decrease in physical activity, physical stress related to an infection, emotional stress, or medications such as steroids and diuretics. Generate Solutions (Planning) Planning focuses on solutions to lower blood glucose levels both in the moment and over the long term. Because many factors can cause hyperglycemia, potential solutions can be varied. These can include making dietary changes, adjusting the level of physical activity, recovering from an illness, decreasing stress, reviewing medications, improving hydration, and adjusting the frequency of self-monitoring. Take Action (Implementation)M1.5 ATI Engage AMS Alterations in Endocrine Function Implementation focuses on interventions to optimize blood glucose control. Medication administration can be necessary. The use of sliding-scale insulin administration in the acute care setting is highly discouraged. This type of treatment is reactive, treating hyperglycemia after it has occurred, versus proactive, preventing hyperglycemia from occurring. Basal or basal plus bolus treatment is the preferred approach to blood glucose management in hospitalized clients that are NPO or have poor nutritional intake. A Basal, prandial, and corrective approach is preferred in hospitalized clients with good intake. Interventions related to lifestyle changes may involve coaching on diet and physical activity and providing referrals to a nutritionist and diabetic educator. Evaluate Outcomes (Evaluation) Review blood glucose levels and HbA1c. Note whether blood glucose level is lower and if glycemic control has improved. Evaluation includes identifying if complications of hyperglycemia are present and if there are indications of improvement or worsening of the client's condition. Treatment and Therapies A collaborative and comprehensive treatment plan will be developed for clients who are experiencing hyperglycemia. Hyperglycemia can be managed through lifestyle modifications in diet and exercise, and potentially with the addition of prescribed oral hypoglycemic medications such as metformin (Glucophage). For some clients, treatment with insulin will be necessary. Clients will require instructions on appropriate methods for weight loss or, in some cases, weight maintenance. Changes in portion size and caloric intake are essential in the management of hyperglycemia. Clients should participate in a regular exercise routine such as daily walking or an aerobic workout two to three times per week. For clients who have chronic hyperglycemia, collaboration with an endocrinologist is often necessary. Oral Hypoglycemic Medications  Sulfonylureas o Examples  Diabeta (glyburide)  Glucotrol (glipizide)  Amaryl (glimepiride)M1.5 ATI Engage AMS Alterations in Endocrine Function o Action  Decreases blood glucose by increasing insulin secretion from beta cells in the pancreas o Adverse Effects  Hypoglycemia, weight gain, nausea, diarrhea, dizziness, and headache o Client Teaching  Take 30 min before meals or with first meal of the day.  Monitor for hypoglycemia.  Thiazolidinediones o Examples  Actos (pioglitazone)  Avandia (rosiglitazone) o Action  Decreases resistance to insulin o Adverse Effects  Liver toxicity, weight gain, and edema o Client Teaching  May take with or without food.  Monitor liver function.  Report changes in appetite, jaundice, abdominal pain, or dark urine.  Monitor for hypoglycemia.  Biguanides o Examples  Glucophage (metformin) Action  Decreases amount of glucose produced in the liver and decreases the amount of glucose absorbed from food Adverse Effects  Indigestion, bloating, abdominal pain, constipation, headache, and metallic taste Client Teaching  Take 30 min before meals or with first meal of the day.  Do not take if NPO.M1.5 ATI Engage AMS Alterations in Endocrine Function  Hold for procedures requiring contrast dye.  Monitor for hypoglycemia. Dipeptidyl Peptidase-4 (DPP-4 Inhibitors) Examples  Januvia (sitagliptin) Action  Increases insulin production and lowers glucagon secretion Adverse Effects  Upper respiratory infection, runny nose, indigestion, edema, changes in urination, and diarrhea Client Teaching  Take with or without food.  Monitor kidney function.  Monitor for hypoglycemia. Sodium-Glucose Transport Protein 2 (SGLT2) Inhibitors Examples  Invokana (canagliflozin)  Forxiga (dapagliflozin)  Jardiance (empagliflozin) Action Decreases renal glucose reabsorption and increases elimination of glucose by urination Adverse Effects UTIs, increased urination, increased thirst, nausea, and constipation Client Teaching  Monitor renal function.  Take before first meal of the day.  Hold prior to surgical procedures.M1.5 ATI Engage AMS Alterations in Endocrine Function  Monitor for hypoglycemia. Hypoglycemia Pathophysiology Hypoglycemia is a failure of glucose homeostasis, which is the role of the pancreas and liver. Levels of glucose in the blood are meant to rise and fall while the body maintains low blood glucose levels through gluconeogenesis and glycogenolysis. However, blood glucose levels that are too low result in hypoglycemia. This occurs when there is a plasma concentration of glucose 70 mg/dL or less, and the blood glucose level is insufficient to meet the demands of the cells of the body. Hypoglycemia triggers the sympathetic nervous system to take action, which causes the release of epinephrine and norepinephrine hormones from the adrenal glands to raise blood glucose levels. These hormones do that by tapping into glucose reserves and releasing more glucose into theM1.5 ATI Engage AMS Alterations in Endocrine Function bloodstream. The pancreas also responds by releasing the hormone glucagon, which can regulate blood glucose levels. Glucose is the brain’s primary source of energy and cannot function without it. Neuroglycopenia occurs when levels of glucose fall below the normal range. Etiology and Risk Factors Hypoglycemia occurs most often in people who have DMT1 due to difficulty in managing medications. The client may have taken their insulin or oral hypoglycemic medication but may have a sudden decrease in glucose, or the client may be taking too high of a dosage of these medications. It can also occur when a client who has diabetes takes their insulin or other medication too early, has a malfunctioning insulin pump, does not eat enough, increases exercise without eating more, or misses a meal. Epidemiology Although clients who have DMT1 are three times more likely than other clients to experience hypoglycemia, it can occur in clients who have DMT2 or those who do not have diabetes. Hypoglycemia in clients who do not have diabetes can be caused by conditions such as trauma, surgery, drug use, sustained alcohol use, pancreatitis, anorexia, malnutrition, or liver or kidney malignancies. The prevalence of hypoglycemia in clients who seek medical care for the condition is generally listed as 4% for DMT1 and 1% to 3% for DMT2, but it is thought that the actual prevalence might be much higher because most clients do not seek medical treatment unless hypoglycemia becomes severe and affects the ability to perform daily activities. The average client who has DMT1 may experience up to one or more hypoglycemic events per week. That only includes episodes that the client notices. Likely many more mild hypoglycemic events occur, especially while the client is asleep. Others may develop hypoglycemia unawareness from frequent low glycemic levels, which results in the client not having any remarkable manifestations until glucose levels drop significantly. Risk Factors Clients who have predisposing conditions, such as diabetes, or who lack self-awareness of early manifestations of hypoglycemia such as shakiness or diaphoresis, are at a higher risk of developing the condition. However, medications can also affect the level of risk. Clients who are insulinM1.5 ATI Engage AMS Alterations in Endocrine Function dependent or are taking sulfonylureas, which includes oral hypoglycemic medications such as Diabeta (glyburide), Glucotrol (glipizide), or Amaryl (glimepiride), are at higher risk of experiencing hypoglycemia. Other medications that can cause medication-induced hypoglycemia include the following.  Antiarrhythmic medications, such as Cardioquin (quinidine)  Antibiotics, such as Levaquin (levofloxacin)  Beta blockers, such as atenolol  Nonsteroidal anti-inflammatory (NSAIDS) pain relievers, such as indomethacin  Insulin  Insulin response enhancers like Glucophage (metformin) when used with sulfonylureas drugs  SGLT2 inhibitors, such as Invokana (canagliflozin), with or without sulfonylureas  Sulfonylureas, such as Glucotrol (glipizide)  Thiazolidinediones, such as Actos (pioglitazone) peroxisome proliferator, when used with sulfonylureas Comorbidities and Complications Clients who have DMT1 or DMT2 and have hypoglycemic episodes (ranging from mild to severe) have a higher risk of mortality, have more comorbidities, and are more likely to have a cardiovascular event, such as a stroke or heart failure. Comorbidities include hypertension, renal disease, psychological impacts, cancer, and prior strokes or cardiac disease. Impact on Overall Health Frequent hypoglycemic events can lead to a generally lower quality of health and life. Individuals who experience hypoglycemia tend to develop anxiety and fear of these events happening more frequently. Recurring episodes may increase necessary absences from work, the inability to safely operate a motor vehicle, and difficulties in personal relationships. Also, frequent hypoglycemia can change a client's stress response. A client canM1.5 ATI Engage AMS Alterations in Endocrine Function develop hypoglycemia unawareness, a condition in which severe hypoglycemia develops with no early warning manifestations. Instead, the first manifestations of a hypoglycemic incident may be serious complications such as heart palpitations and tachycardia. Hypoglycemia is also associated with sleep disturbances, which can add to the client’s stress level. Nocturnal hypoglycemia occurs at night during sleep. It can cause nightmares, night sweats, irritability, confusion, and crying or yelling during sleep. Effects of Hypoglycemia on Body Systems  Circulatory: Rapid heartbeat and heart palpitations  Endocrine: Epinephrine may not be released for early warning signs of hypoglycemia  Digestive: Hunger  Nervous: Weakness, lack of coordination, chills, sweating, dizziness, confusion, light-headedness, headaches, nervousness, anxiety, sleep disturbances, irritability, tingling, and blurred vision Considerations of the Aging Adult An older adult is more sensitive to hypoglycemia and is at higher risk for adverse complications, such as falls, accidents, injury, bone fractures, heart attacks, and early onset dementia. Even one episode of severe hypoglycemia in an older adult could result in seizures, coma, cardiac arrhythmia, or death. Clinical Presentation Hypoglycemia can have a varied presentation. Many manifestations of hypoglycemia can also be associated with other health issues and medications used to treat those health issues. Clients who have hypoglycemia commonly experience shakiness and anxiety. Chills,M1.5 ATI Engage AMS Alterations in Endocrine Function diaphoresis, hunger, and nausea can occur. Emotional changes can include irritability and labile mood. Clients may demonstrate fatigue, low energy, clumsiness, and a lack of coordination. Confusion, dizziness, headache, vision problems, and fatigue can occur during periods of hypoglycemia. Sleep-related manifestations include nightmares and calling out during sleep. A client who has hypoglycemia may be pale. Tachycardia can occur. Tingling and numbness can affect the tongue, cheeks, and lips. Some clients will experience seizures. There are three levels of hypoglycemia based on blood glucose levels and clinical presentation: Level 1: blood glucose level between 54 mg/dL and 70 mg/dL with manifestations that include tremors, diaphoresis, tachycardia, blurred vision, confusion, headache, fatigue, weakness, hunger, and dizziness Level 2: blood glucose level less than 54 mg/dL with manifestations that include confusion, erratic behavior, and difficulty moving Level 3: not dependent on blood glucose level; clients present with manifestations that include seizures, agitation and combativeness, or coma and can lead to death. Laboratory and Diagnostic TestingM1.5 ATI Engage AMS Alterations in Endocrine Function Blood glucose testing is used to diagnose hypoglycemia. Hypoglycemia is present if the blood glucose level is 70 mg/dL or less. Clients need to have individualized targets for blood glucose control. Especially for clients who have hypoglycemia unawareness, a threshold of 70 mg/dL to initiate hypoglycemia treatment may be too low. Continuous glucose monitors (CGMs) have emerged as an effective method for monitoring blood glucose levels. CGMs measure glucose levels by using a skin sensor and send this information to a device. This type of monitoring allows clients to observe how they respond to certain treatments. There are different types of CGMs. There are real-time CGMs, which display glucose levels continuously, or intermittently scanned CGMs, which monitor blood glucose levels continuously but only show a result when scanned by a specific reader or smartphone application. When used as directed and combined with insulin administration CGMs can be useful in regulating blood glucose levels and lowering or maintaining HA1c levels. CGMs can reduce hypoglycemic events and are especially helpful in identifying dangerously low blood sugar levels in clients who have hypoglycemia unawareness. Clients must be able to complete self-monitoring of blood glucose through finger-sticks to calibrate the machine and to verify questionable results. There are limitations to the use of CGMs. This type of monitoring loses accuracy in clients with poor oxygenation, in temperature extremes, and when used in clients that take medications such as ascorbic acid (Vitamin C), acetaminophen (Tylenol), or levodopa (L-DOPA).M1.5 ATI Engage AMS Alterations in Endocrine Function Role of the Nurse The role of the nurse when providing care to a client who has hypoglycemia is similar to providing care to a client who has hyperglycemia. Monitor blood glucose levels, administer medications, and provide education. Testing for hypoglycemia is performed via capillary blood sampling or venous blood sampling. Capillary blood is often tested using a portable (point-of-care) glucose monitoring device. When point-of-care test results are inconclusive, a central laboratory can analyze venous blood. Provide an awake and alert client who is experiencing hypoglycemia (with a blood glucose below 70 mg/dL) with 15 to 30 grams of fast-acting carbohydrates (see 15-15 rule at the end of the module). Administer glucagon intravenously, subcutaneously, intranasally, or intramuscularly to clients who are unable to swallow or have an altered level of consciousness. Treatment of Hypoglycemia: Examples of Fast-Acting Carbohydrates  3 to 4 glucose tablets  6 to 8 hard candies or gummies  8 oz low fat or skim milk  1 tablespoon corn syrup, sugar, or honey  ½ cup (4 oz) 100% fruit juice or regular soda  2 tablespoons of raisins  4 to 5 crackers Environmental Factors Hypoglycemia risk can increase when a client changes their work schedule, travels to different time zones, or exercises more than usual. Food insecurity and unpredictable access to nourishing foods increase the likelihood of hypoglycemic episodes.M1.5 ATI Engage AMS Alterations in Endocrine Function Risk Factors for Hypoglycemia  Changes in work schedule  Travel to different time zones  Exercising more than usual  Food insecurity  Unpredictable access to nourishing foods Cultural Considerations Many religious and cultural traditions involve fasting. Consulting with the provider can help nurses and clients understand who should forgo fasting due to the risk of hypoglycemia. Temporary medication adjustments and increased monitoring may be necessary. Individual Factors Some clients will experience dangerously low blood sugar levels with minimal or no manifestations. Because CGMs can alarm when blood sugar levels are low, they are an especially helpful tool for clients who have hypoglycemia unawareness. Client Education Provide teaching about potential manifestations of hypoglycemia, frequency of blood glucose monitoring, and blood glucose targets. Because dietary intake and exercise can cause hypoglycemia, the nurse will provide education on these topics. The client will receive education about what types of food and supplies to keep on hand. Glucose tablets, hard candies, and other sources of rapid glucose intake are necessary. Injectable glucagon may be used in a hypoglycemic emergency. Provide teaching to the client and any people they are in frequent contact with on how to administer injectable glucagon and when to call 911.M1.5 ATI Engage AMS Alterations in Endocrine Function Nursing Process Recognize Cues (Assessment) Assessment of a client who has hypoglycemia begins with identifying manifestations, assessing the level of consciousness, and determining blood glucose level. When a client is at risk for hypoglycemia, the assessment may focus on the client’s ability to recognize and act on signs of hypoglycemia Analyze Cues and Prioritize Hypotheses (Analysis) Preventing complications of serious hypoglycemia is high a priority area of focus. Consider the manifestations that were present and the client’s risk for unrecognized hypoglycemia. Generate Solutions (Planning) Planning focuses on strategies to prevent and treat hypoglycemic episodes. Collaborate with other members of the health care team to determine the best plan for clients to maintain blood glucose levels above 70 mg/dL. Take Action (Implementation Phase) Implementation focuses on interventions to prevent and promptly correct hypoglycemia. Interventions include blood glucose monitoring, ensuring adequate oral intake, and administering oral sources of glucose, injectable glucagon, or intravenous dextrose. In clients who have hypoglycemia unawareness, interventions may involve increasing the frequency of blood glucose monitoring, using a CGM, and making medication adjustments. Evaluate Outcomes (Evaluation Phase) Evaluate whether the blood glucose level has stabilized and if manifestations related to hypoglycemia are persistent or have resolved. Evaluate the client’s response to teaching, including their ability to prevent, identify, and treat hypoglycemia. Treatments and TherapiesM1.5 ATI Engage AMS Alterations in Endocrine Function When hypoglycemia occurs, prompt treatment is necessary. Treatment of a blood glucose between 54 mg/dL and 70 mg/dL follows the 15-15 rule. For a blood glucose within this range the client should consume 15 grams of fast carbs, wait 15 minutes and recheck blood glucose level. If the level remains less than 70 mg/dL another 15 grams of fast carbs should be consumed. Once blood glucose level is within rage it is recommended to eat a meal to prevent another episode of hypoglycemia. Examples of 15 grams of fast carbs include 3 to 4 glucose tablets; 8 oz of low fat or skim milk; 1 Tbsp of corn syrup; 4 oz of 100% fruit juice or regular soda; 1/2 to 1 tube of glucose gel (the exact amount that equals 15 grams should be discussed with a pharmacist, diabetes educator, or dietician); or 1 Tbsp of honey, sugar, jam, or jelly. With acute hypoglycemia, clients should avoid foods with fat and protein because they can delay the body’s ability to absorb sugar. For a blood glucose level less than 54 mg/dL in a client that is still awake and able to swallow, 30 grams of fast carbs (double the amounts listed above) should be consumed with a recheck of blood glucose level 15 minutes later. If blood glucose level remains less than 70 mg/dL the client should consume another 30 grams of fast carbs. If the client is unable to safely ingest glucose by mouth, injectable glucagon should be used. This medication can be given via intramuscular or subcutaneous injection. A glucagon kit should be kept in the home. Family members should receive instruction on how to use it and reasons to call 911: if the client loses consciousness, has a seizure, or if glucagon cannot be administered. Intravenous dextrose can also be used when intravenous access is present.M1.5 ATI Engage AMS Alterations in Endocrine Function Type 1 Diabetes Mellitus Pathophysiology Type 1 diabetes mellitus (DMT1) is an autoimmune disease that involves the destruction of the beta cells in the pancreatic islets of Langerhans in the pancreas, where insulin is produced. DMT1 occurs in three stages. 1. Presence of greater than 2 or more pancreatic autoantibodies 2. HbA1c between 5.7% and 6.4%, impaired glucose tolerance, and the presence of two pancreatic autoantibodies 3. Hyperglycemia with clinical manifestations as well as two or more pancreatic autoimmune antibodies Because of the autoimmune destruction of the beta cells of the pancreas and the resulting loss of insulin production, hyperglycemia and potentially DKA can occur if untreated. Without insulin, glucose absorption is not possible. Because the body, including the brain, depends on glucose as a major source of energy, insulin is necessary for multiple essential functions of the body. That includes stimulating liver storage of glucose as glycogen, stimulating the uptake of potassium and amino acids into cells as, and metabolizing proteins and minerals. Pathophysiology of DMT1 1.Glucose is extracted from food in the digestive system (stomach). 2.The pancreas produces too little or no insulin in beta cells (pancreas). 3.There is an increase in blood glucose levels (blood vessels). 4.Muscles and organs cannot use glucose without insulin (muscle and organ).M1.5 ATI Engage AMS Alterations in Endocrine Function Etiology and Risk Factors It is not known why DMT1 occurs, but it is thought that it may be linked to genetics or a viral environmental exposure that triggered an autoimmune response. DMT1 tends to run in families, so it is thought that genetics plays a role, although no specific gene has been identified. However, it has been found that there are circulating pancreatic autoimmune antibodies in the blood that attack beta cells that can be detected prior to a person developing diabetes. Studies are being conducted on a possible connection between a virus or environmental factor that may trigger the autoimmune beta-cell destruction response. Epidemiology According to the Centers for Disease Control and Prevention (CDC), 244,000 Americans younger than 20 have been diagnosed with DMT1. Approximately 1.6 million adults over the age of 20, which is 5.7% of all adults that have a type of diabetes, have DMT1 and use insulin. Risk Factors Risk factors include a genetic predisposition, family history, and age. DMT1 is typically a juvenile-onset condition, and it usually occurs between ages 4 and 6 or in early adolescence between ages 10 and 14. However, DMT1 can occur at any age. Geography can also be a factor in the development of DMT1. The highest incidence can be found in Finland and other parts of Northern Europe, with rates 400 times more than what is seen in the lowest incidence areas, which are China and Venezuela. In the U.S., DMT1 represents approximately 5% to 10% of all people who have diabetes, and it is steadily rising.M1.5 ATI Engage AMS Alterations in Endocrine Function Comorbidities and Complications Maintaining regulated blood glucose can reduce the risk of complications or slow the progress. However, DMT1 is an autoimmune, chronic, progressive disease, which leads to complications that can be disabling or lifethreatening. Fifty percent of clients who have DMT1 will develop a serious complication, and their quality of life tends to be poor, with a high rate of comorbidities and mortality. The risk for heart attacks and strokes is three times more likely in clients who have DMT1. Combined with poor circulation and nerve damage, clients who have DMT1 are also at increased risk of foot ulcers, infection, neurogenic pain, gangrene, limb amputation, renal failure, and blindness from optic nerve damage. The CDC reports that in 2019, diabetes was the seventh leading underlying cause of death in the U.S.. Major cardiovascular disease is a common condition affecting clients who have diabetes mellitus, with ischemic heart disease and stroke in 30 out of 1,000 people. Diabetic retinopathy resulting from diabetes mellitus is the leading cause of new cases of blindness in adults, and it can affect clients with both DMT1 and DMT2. According to national mortality records from the National Vital Statistics System, in the last 3 months of 2020, COVID-19 was the leading cause of death in people who had either type of diabetes mellitus, rather than cardiovascular disease or diabetes alone. There was a 24.7% increase from the first quarter (1.3%) of 2020 in mortality rates of people who had diabetes from COVID-19. Impact on Overall Health Managing DMT1 presents challenges to a client of any age, and this can affect a client’s overall health. DMT1 is linked to a lower life expectancy, three or four times more likely than the general population, related to chronic complications involving the major organs and cardiovascular and renal disease. Clients who have DMT1 are at higher risk of having unstable blood glucose levels, both high and low. Severe hypoglycemia can occur if a meal is missed, and severe hyperglycemia can occur if illness or infection is present, recent surgery has been performed, or other trauma has occurred to the body. This can make an illness more serious in a client who has DMT1 and is more likely to need extra time to recover from it.M1.5 ATI Engage AMS Alterations in Endocrine Function DMT1 is also associated with hyperglycemia-induced polyuria, polydipsia, and polyphagia, which leads to loss of water in the blood and dehydration. Weight loss and muscle wasting from lipolysis and ketone production from the breakdown of muscle and fat is common and can cause muscle weakness and excess fatigue. Clients who have DMT1 may also have psychological conditions, such as generalized anxiety disorder and depression. Sleep disturbances from unstable blood glucose levels may occur, which can lead to an increase in stress. There is also a connection between diabetes, especially DMT1, and dermatological conditions, which may cause significant cosmetic concerns or stress. Clients who have diabetes are more prone to skin irritation and bacterial or fungal infections. Changes in the blood vessels near the skin can cause scaly patches on clients’ legs, which is a condition called diabetic dermopathy. Thickened skin or bumps may also appear on clients who have uncontrolled blood glucose levels. Vitiligo is another common skin condition that clients who have either type of diabetes can experience. Vitiligo is an autoimmune condition that affects skin coloration and appearance. DMT1 has no known cure and must be continuously managed. Technological aids have made controlling blood glucose levels more manageable. Clients have options to use insulin pumps and glucose sensors that send alerts to a smartphone or other electronic devices to help avoid hypoglycemia events. With these systems, clients do not have to test as frequently with a blood sample nor inject themselves with insulin multiple times each day. The development of these devices has assisted in improving the overall quality of life of clients who have DMT1. Long-Term Complications There are many long-term complications associated with poorly controlled diabetes. These can occur with both DMT1 and DMT2. Cardiovascular disease risk is markedly increased. Myocardial infarction and stroke are common. Kidney disease is prevalent and can lead to kidney failure and the need for dialysis or kidney transplant. Nerve and vascular problems caused by consistently elevated blood glucose levels can lead to wounds and the necessity for limb amputation. Diabetic retinopathy can lead to visual impairment and blindness. Pregnancy complications can include neonatal macrosomia and hypoglycemia. Considerations of the Aging AdultM1.5 ATI Engage AMS Alterations in Endocrine Function Approximately 25% of people who have DMT1 are diagnosed late in life, even up to 90 years old. Although DMT1 is often considered a juvenile-onset condition, it can affect older adults. Illness, trauma, infection, or other stressors affect the blood glucose balance of a client who has DMT1 more severely, and that must also be considered with an older client who may have more health conditions. Clinical Presentation Clients who have DMT1 typically present with rapid-onset manifestations. Polyuria, polydipsia, dehydration, fatigue, and unintentional weight loss can occur. The client may experience polyphagia and visual changes such as blurry vision. Additional manifestations may include repeated infections and delayed wound healing. Dry skin and numbness or tingling in feet and hands may also occur.M1.5 ATI Engage AMS Alterations in Endocrine Function Laboratory and Diagnostic Testing A diagnosis is made based on elevated blood sugar level and evaluating the client’s history and physical assessment for manifestations of DMT1. A nonfasting blood glucose level will be 200 mg/dL or higher; a fasting blood glucose level will be 126 mg/dL or higher. HbA1c is 7% or higher. A urinalysis may reveal the presence of elevated glucose or acetone levels. Laboratory tests are used to differentiate DMT1 from DMT2. Certain islet cell antibodies occur only with DMT1. C-peptide levels will be decreased in clients who have DMT1. In clients who have DMT2, C-peptide levels are increased or normal. While DKA can occur in clients who have DMT2, it is more common in clients who have DMT1. Blood glucose level is typically above 250 mg/dL. Blood β-hydroxybutyrate level is elevated and serum ketones are often present. Metabolic panel abnormalities will include HCO3 of 15 mEq/L or less and an anion gap greater than 10. Blood gases typically show a pH under 7.3. A urinalysis will likely be positive for both glucose and ketones. In addition to monitoring for hyperglycemia, clients can use home tests to check urine and blood for the presence of elevated ketones. For more information about DKA, see Critical Endocrine Dysfunction. Role of the Nurse The role of the nurse when providing care to a client who has DMT1 focuses on safely managing the disease and preventing complications. Review laboratory results and monitor vital signs. Medication administration for hyperglycemia is often required. Monitor for and treat hypoglycemia when necessary. Initiate and facilitate referrals to endocrinologists and other services. When diabetes is uncontrolled, skin and wound care may be necessary due to delayed wound healing. If DKA occurs, complex nursing care to support hydration, monitor and replenish electrolytes, and treat acidosis is required. For more information, see Critical Endocrine Dysfunction. Individual Factors Clients may use many types of equipment and supplies to manage DMT1, such as blood glucose meters, CGMs, vials of insulin, syringes, alcohol wipes, insulin pens, and insulin pumps. Clients need to consider which devices meet their needs in terms of both usability and cost. Coordinate with the insurer to identify what options are covered and client costs.M1.5 ATI Engage AMS Alterations in Endocrine Function There are many costs associated with diabetes care. Clients may need to work with their healthcare team to determine if changes to their medication regimen can provide safe treatment while lowering costs. Comparing pharmacies can identify the most affordable option. Clients may require practical and financial support, so they are not forced to decrease or skip medication doses and reuse or share equipment. Environmental Factors Heat and humidity can increase the complexity of diabetes management. Extreme temperature changes affect metabolism, and close monitoring of a client’s blood glucose is necessary. Sweat glands can be impacted by diabetes, which limits the body’s ability to cool itself. Dehydration can occur, which can cause an increase in blood glucose. Hyperglycemia can cause an increase in urine output and continue to worsen dehydration. Increasing fluid intake, shifting physical activity to cooler times of day, maintaining access to an air-conditioned space, and having a plan for a power outage are all important things to consider. Environmental factors can also include a structural lack of access to resources. Social determinants of health (SDOH) strongly impacts diabetes management. Outcomes are improved when clients have adequate financial resources and access to medical care, healthy food, and safe housing. Client Education Initial client education will most likely focus on how to monitor blood glucose levels and self-administer insulin. Because blood glucose levels typically rise due to stress and illness, education around close monitoring during these times is important. Also discuss circumstances in which selftesting for urine ketones is recommended and review the process. Hypoglycemia is a significant cause of morbidity and mortality for clients who have DMT1. Educate clients on how to recognize and treat hypoglycemia. Instruction on how to use CGMs to monitor blood glucose levels and identify hypoglycemia can be helpful. Initiate instruction on dietary recommendations and facilitate referral to a nutritionist. Review the importance of screening for complications, such as visual impairment and foot problems. Clients who have diabetes need to inspect their feet daily. Using a mirror or asking a household member to assist may help. Daily cleansing with warm water is necessary. After ensuring their feet are dry, clients should applyM1.5 ATI Engage AMS Alterations in Endocrine Function lotion to the top and bottom of the foot. Because of the risk of infection, lotion should not be used between the toes. Clients should always wear footwear. Being barefoot increases the risk of wounds. Properly fitted shoes are necessary for optimum foot health. Clients who have diabetes need regular podiatry visits for foot and nail care. Sick Day Rules During illness, managing blood glucose levels can become more difficult. Oral intake often decreases, which can decrease blood glucose levels. However, during times of illness, stress hormones (i.e., epinephrine, cortisol, and growth hormones) are released, which can increase blood glucose levels. If there is not enough insulin to combat this increase in blood glucose the body will begin to break down fat which produces ketones and can eventually lead to diabetic ketoacidosis (DKA). Signs of DKA include increased thirst, polydipsia, fatigue, nausea, vomiting, dyspnea, confusion, and a fruity odor to breath. It is recommended to have a urine test kit available to test for the presence of ketones at home. Due to these variables and potential fluctuations, it is recommended that individuals with DMT1 monitor their blood glucose levels at least every 4 hours during illness. It is also important to continue taking insulin or oral medications as ordered, consume at least 4 to 6 ounces of fluids every 30 minutes, consume at least 50 grams of carbohydrates every 4 hours, monitor weight daily as weight loss can be an indication of hyperglycemia, check temperature at least twice daily (morning and evening) since the presence of a fever can indicate the presence of an infection and can affect blood glucose levels (ADA, n.d.; CDC, 2022). If hypoglycemia develops as a result of illness it should be treated using the 15-15 rule, which is consuming 15 grams of carbohydrates and then rechecking blood glucose levels 15 minutes later (ADA, n.d.). This is discussed in more detail in the hypoglycemia section. In order to be prepared for potential illness, it is recommended that individuals prepare a sick-day kit to keep at home. This kit should include extra batteries, glucose tabs or gel, supplies to monitor blood glucose (test strips, lancets, etc.), cold medications, a 7-day supply of medications, glucometer, and urine test strips (American Diabetes Association, n.d.). If the following occurs during illness the client should go to the emergency room:  Weight loss of more than 5 lbsM1.5 ATI Engage AMS Alterations in Endocrine Function  Inability to keep down fluids for over 4 hours or food for over 24 hours  Moderate to high ketone levels in urine  Temperature greater than 38.3° C (101° F)  Vomiting or diarrhea lasting longer than 6 hours  Presence of dyspnea, confusion, or change in behavior (CDC, 2022) How Nurses Cope With Their Fears and Concerns When Caring for Clients Who Have Unstable Diabetes  They acknowledge and validate their feelings.  They discuss challenges and clinical concerns with an educator or trusted teammate.  They participate in routine debriefing exercises.  They recognize that they are not alone by collaborating with the interprofessional team when clients who have low or high glucose are not responding well to current medications and diet.  They recognize that they do not have to know everything. They reach out to pharmacists, diabetes educators, and nutritionists for support with clinical questions. Nursing Process Recognize Cues (Assessment) Assessment of a client who has DMT1 centers on evaluating glycemic control and the presence of any complications. Blood glucose levels and HbA1c results are evaluated. Physical assessment focuses on vision changes, signs of infection, and wound problems. Carefully assess for signs of worsening condition and potential manifestations of DKA such as mental status changes, nausea, vomiting, increased respiratory rate, abdominal pain, dehydration, and electrolyte abnormalities. Analyze Cues and Prioritize Hypotheses (Analysis)M1.5 ATI Engage AMS Alterations in Endocrine Function In a client who has DMT1, glycemic emergencies are high-priority problems. Hypoglycemia can be life-threatening in clients who have DMT1. Similarly, when hyperglycemia leads to DKA, aggressive treatment is necessary. Organize care around problems that are most dangerous in the short term as well as what can seriously impact morbidity and mortality over time. Generate Solutions (Planning) Planning focuses on ways to optimize glycemic control while avoiding dangerous low and high glucose levels. Other solutions may support the prevention of long-term complications related to uncontrolled blood glucose levels. Planning can include strategies to manage the emotional stressors that can accompany a diabetes diagnosis. Clients may benefit from support on how to simplify a treatment regimen, access mental health counseling, and optimize their use of technology. Take Actions (Implementation) Many nursing interventions are available to optimize glycemic control. Administer insulin and provide education on self-administration. When a client is first diagnosed, coach on how to perform blood glucose checks, administer insulin, and monitor for low and high levels. If complications related to neuropathy, infection, and wound healing occur, provide additional education and wound care. Collaborate with the interprofessional team to facilitate necessary referrals. Evaluate Outcomes (Evaluation) Evaluate if appropriate glycemic targets have been met. Glycemic targets for adults with DMT1 include a HbA1c less than 7%, preprandial glucose of 80-130 mg/dL, 1 to 2 hour postprandial glucose of less than 180 mg/dL, time below 70 mg/dL is less than 4%, time below 54 mg/dL is less than 1%, time above 180 mg/dL is less than 25%, time above 250 mg/dL is less than 5%, and glycemic variability (fluctuations in blood glucose levels that increases a client's risk of developing hypoglycemia) less than 36%. Consider if the client has the appropriate resources and knowledge to safely manage their care. Evaluate if complications related to lack of glycemic control are present and if they have improved or worsened. Treatments and TherapiesM1.5 ATI Engage AMS Alterations in Endocrine Function DMT1 is treated by monitoring blood glucose levels and administering injectable insulin. Insulin may be administered from a vial, pen, or pump. CGMs are helpful devices. As technology advances, more clients may have access to a combined CGM-insulin pump. HbA1c monitoring is used to review information about average blood glucose levels. Eye exams monitor for the development of diabetic retinopathy and should be completed annually or when changes in vision occur. Foot examination performed frequently can identify wounds or sores that may require intervention to avoid possible amputation due to poor wound healing associated with DMT1. Many clients who have diabetes will need podiatry care to prevent foot complications. Neurological sensation testing of the feet is used to diagnose neuropathy. Diabetes educators and nutritionists can support clients with dietary choices including providing information for monitoring carbohydrate and caloric intake, and lifestyle changes such as participating in a regular exercise routine. Insulin Safety Insulin is a powerful medication that requires precise dosing and safe storage and administration. Most insulin is U-100 strength, meaning there are 100 units of insulin in each milliliter. Occasionally U-500 insulin, which has 500 units of insulin in each milliliter, is used. Ensuring that the correct strength and syringe size are used is essential. Injectable insulin can be rapid-acting, short-acting, intermediate-acting, long-acting, or ultra-long-acting. Nurses, clients, and caregivers need to understand the onset of action, peak, and duration of effect for the insulin being used. A rapid-acting inhaled insulin is sometimes used together with a long-acting injectable insulin. All insulin manufactured and sold in the U.S. is synthetic. Animal insulins are available in other countries; import for individual use is permitted. Types of InsulinsM1.5 ATI Engage AMS Alterations in Endocrine Function Rapid-Acting: Begins working within 15 to 30 min and lasts about 3 to 5 hr  Insulin aspart (NovoLog)  Insulin glulisine (Apidra)  Insulin lispro (Humalog) Regular or short-acting: Begins working within 30 to 60 min and lasts about 4 to 12 hr  Human regular (Humulin R, Novolin R) Intermediate-acting: Begins working within 1 to 2 hr and lasts about 14 to 24 hr  NPH (Humulin N, Novolin N) Long-acting: Begins working within 2 to 4 hr and lasts up to 24 hr  Detemir (Levemir)  Glargine (Lantus) Ultra-long-acting: Begins working within 1 hr and lasts 24 to 42 hr  Glargine U-300 (Toujeo) Insulin pens can make dosing and administration simpler and safer for many clients. Insulin pens are intended to be used by only one person and should not be shared. When drawing up multiple insulins into a syringe, some clients will experience challenges related to eyesight or dexterity. When a medication regimen is stable, premixed combination insulins can be a good option. However, some insulins cannot be mixed in the same syringe. For example, glargine (Lantus) cannot be combined in a syringe with any other insulin. Many things affect blood glucose levels and insulin dosing. Exercise, both how much and what time of day, can have a significant effect on blood glucose levels.M1.5 ATI Engage AMS Alterations in Endocrine Function When injecting insulin or using a pump, clients must use appropriate injection sites. Injections will work most quickly when given in the abdomen. They can also be given in the upper arms, thighs, or buttocks. Site rotation is necessary to prevent skin irritation. Safe insulin storage is important. Room temperature insulin is stable for one month. Storing insulin in the refrigerator will prolong its stability. Insulin should not be exposed to high temperatures or direct sunlight. Because of potential risks related to electromagnetic fields, an insulin pump almost always needs to be removed prior to MRI, as well as some x-rays and CT scans. Type 2 Diabetes Mellitus Pathophysiology In clients who have DMT2, there is some insulin production by beta cells of the pancreas, but it is not sufficient to maintain blood glucose levels. There also may be insulin resistance that has developed in the insulin receptors in body tissues. Insulin resistance hampers insulin from tr