6 Integrated Endocrine Nursing Practice

Prioritize instability and deterioration

For an unstable patient, first address airway, breathing, circulation, and changes in mental status. Follow emergency and medication protocols, and promptly escalate deterioration.

Endocrine nursing care also requires attention to how medicines relate to food intake and to possible treatment-related harm. Use the prescribed care plan and local protocols, and individualize patient education.

Manage hypoglycemia and insulin safely

A patient who becomes diaphoretic and confused after rapid-acting insulin, with a glucose of $48\ \text{mg/dL}$ ($2.7\ \text{mmol/L}$) and an inability to swallow safely, needs prompt treatment for Severe hypoglycemia. Use the facility protocol, such as glucagon or IV dextrose; do not give juice by mouth when swallowing is unsafe or wait before treating. After treatment, recheck glucose and reassess, then review the treatment plan to reduce recurrence.

Coordinate Prandial insulin with food intake. If the meal tray is delayed or the patient is nauseated, assess glucose and clarify the dose and meal plan before giving mealtime insulin; follow orders or protocol. Do not give the full dose simply to stay on schedule or give it with the expectation that the patient will eat later.

Do not independently omit all insulin when a meal is missed. In a person with type 1 diabetes, Basal insulin is generally still needed even when the person is not eating. In particular, do not stop basal insulin for the rest of the day without direction.

Recognize hyperglycemic emergencies

Vomiting, deep rapid breathing, and elevated ketones in a person with diabetes may indicate Diabetic ketoacidosis (DKA). If potassium is $3.2\ \text{mmol/L}$ before an insulin infusion, promptly notify the treating team and delay insulin so potassium can be replaced under protocol. Insulin can lower serum potassium further. When potassium is below $3.5\ \text{mmol/L}$, potassium replacement should begin and insulin should be delayed until the level is above that threshold, following the treating team's orders and protocol. Continue close electrolyte and cardiac monitoring as indicated.

During illness, a person with type 1 diabetes should check glucose more often, check ketones as instructed, and follow a clinician-provided sick-day plan. Illness can increase the risk of dehydration and DKA. The person should contact the care team for persistent vomiting, inability to keep fluids down, or worsening symptoms; they should not stop basal insulin or wait for glucose to become extremely high before taking action.

Markedly elevated glucose with severe dehydration and increasing confusion in an older adult with type 2 diabetes may indicate Hyperglycemic hyperosmolar state (HHS). Arrange urgent emergency evaluation and anticipate close monitoring and IV fluid treatment. Do not delay care for home measures such as eating a large meal, walking, or taking diabetes medicine from a home supply.

Use thyroid medicines and respond to complications

For hypothyroidism, take Levothyroxine consistently on an empty stomach with water. Calcium and iron can interfere with its absorption, so follow instructions to separate these products. Do not take it only when fatigue occurs or stop it when energy improves; do not change the dose without the prescriber's advice.

Fever and sore throat in a patient taking Methimazole require prompt assessment because they may indicate a serious reduction in white blood cells. Contact the prescriber urgently and follow instructions about whether to take the next dose; do not treat these symptoms as routine or wait for a later appointment.

After thyroidectomy, rapidly increasing neck swelling with difficulty breathing is an airway emergency. Activate the appropriate emergency response immediately; it may signal a compressive postoperative bleed that threatens the airway. Do not treat it as an expected change or delay response to try oral calcium.

Tingling around the mouth or in the fingers after thyroid surgery can indicate hypocalcemia. Promptly assess and report the symptoms so treatment can be guided.

Identify thyroid storm

High fever, marked tachycardia, agitation, and confusion in a person with hyperthyroidism, especially during an infection, may indicate Thyroid storm. Arrange emergency care and continuous monitoring. This is life-threatening; routine follow-up, exercise, or leaving the patient alone to rest is not an appropriate response.

Respond to adrenal crisis and glucocorticoid risks

Vomiting, severe weakness, low blood pressure, and confusion in a person with adrenal insufficiency after an illness may indicate Adrenal crisis. Activate urgent care, support circulation, and anticipate parenteral glucocorticoids and IV fluids. Do not withhold glucocorticoids until diagnostic results are available or rely only on oral fluids and delayed reassessment; treatment should not be delayed for test results when crisis is suspected.

Long-term Glucocorticoids such as prednisone can suppress the body's own cortisol production. A patient should not stop long-term treatment abruptly, even if feeling better. Advise them to contact the prescriber about a safe plan to reduce or change the dose. Patients should also know when to seek advice about stress dosing during illness, according to their individualized plan.

Monitor glucose and infection risk

For a patient with Cushing syndrome receiving glucocorticoid therapy, monitor glucose and assess for infection. Glucocorticoids can worsen hyperglycemia, and Cushing syndrome is associated with increased infection risk. Report changes, reinforce prescribed medication instructions, and ensure medication changes are clinician-directed; do not advise the patient to stop treatment or avoid reporting possible signs of infection.