I don’t need to tell you that endocrine patients are some of the most common medical patients we see.

But I’ll bet there’s a LOT more that you could be doing with them than you currently are.

The great news about seeing these patients so regularly is that they give us a ton of opportunities to develop new nursing skills - and that’s exactly what we’re going to look at today!

In week 4 of the ‘Up Your Medical Nursing Skills’ challenge, we’ll be focusing on 5 skills to use with your endocrine patients. From diabetes mellitus to Cushing’s and Addison’s, today we’ll be talking about tests to perform, emergency nursing for endocrine emergencies, and some practical interventions you can perform to improve the well-being of your patients in the hospital.

Don’t forget that you can sign up for the VIP email list to unlock extra training  and case studies to accompany this challenge - get on it here if you’re not already!

#1: How to perform an ACTH stimulation test

This is a staple diagnostic in not just our Cushingoid patients, but those who we suspect may have Addison’s disease, too.

We use this test to confirm a diagnosis of hypoadrenocorticism (Addison’s disease) or to differentiate between spontaneous or iatrogenic hypercortisolism (Cushing’s disease).

This is a quick and easy test to perform, and there is no reason for nurses to not perform these in practice!

To perform the test:

1. Collect a baseline blood sample into a serum or serum gel tube.

2. Administer 5mcg/kg of synthetic ACTH intravenously.

3. Set a 60-minute timer and place it on the patient’s kennel.

4. Obtain a second blood sample into a serum or serum gel tube 60 minutes after ACTH administration.

Need to give your ACTH intramuscularly? Collect your second sample 60-90 minutes after administration.

#2: How to place a sampling line (peripherally inserted central catheter)

Placing one of these is one of my favourite nursing hacks. Not only is it a fun skill to perform, but it makes such a difference to our patients.

My particular favourites for a PICC/sampling line are DKA patients. Why? Because these lines can be used to take regular blood samples as well as administer fluids and medications - making them a great device for patients who need lots of blood samples.

Let’s think about our DKA patients for a second. These guys often need multiple IV medications, fluids, CRIs and samples for blood glucose, electrolytes and blood gases.

So placing one of these lines is a great way to minimise venepuncture, whilst administering all of those solutions.

To place one you will need:

• Clippers and antimicrobial skin scrub

• Sterile gloves

• Sterile fenestrated drape

• Sampling catheter (Drum/PICC) kit

• Suture material

• Y or T connector

• Needle-free injection valves

• Sterile saline

• Dressing material

And here’s how to do it:

• Clip and aseptically prepare the site (usually the medial or lateral saphenous vein is used).

• Apply sterile gloves and aseptically prepare your kit.

• Insert an over-the-needle catheter into the vein.

• If using a drum kit:

• Attach the drum introducer device to the catheter and feed the sampling catheter through it.

• Remove the stylet and attach the sampling catheter to the over-the-needle catheter.

• Attach a T or Y connector to the sampling catheter, and attach needle-free injection valves to this.

• Secure the catheter in place with tape and bandage.

• If using a PICC kit:

• Feed the guidewire through the over-the-needle catheter.

• Remove the catheter, leaving the guidewire in the vein.

• Feed the sampling catheter over the guidewire and into the vein.

• Attach a T or Y connector and needle-free injection valves.

• Suture the catheter in place and cover with a sterile dressing and bandage material

• Clearly label the line as a sampling line, with the date placed.

#3: How to calculate and prepare an insulin CRI

Speaking of our DKA patients, the veterinary nurse will commonly be responsible for preparing and administering insulin to these patients.

Neutral insulin is going to be our go-to initially, until the patient is persistently ketone-negative and can be transitioned to a longer-acting insulin.

There are two ways to administer neutral insulin - either by intermittent IM injection or via a constant rate infusion (CRI).

To prepare an insulin CRI, here’s what you need to do:

Take a 500ml bag of 0.9% Saline and remove and discard 20ml.

Dogs: Calculate 4.4iu/kg of neutral insulin and add this to the bag

Cats: Calculate 2.2iu/kg of neutral insulin and add this to the bag

Mix thoroughly then run through, discarding 50ml of solution out of the end of the line - this is important as insulin binds to plastic, so we need to coat the lines first.

Then check the patient’s blood glucose:

The rate at which we run our insulin CRI depends on the patient’s blood glucose level. We need to check this every 1-2 hours, then adjust their fluid rate as required using this guide:

• If the BG is >14mmol/L, run at 10ml/hr

• If the BG is 11-14mmol/L, run at 7ml/hr

• If the BG is 8-11mmol/L, run at 5ml/hr and add a 2.5% dextrose CRI

• If the BG is 5.5-8mmol/L, run at 3ml/hr and add a 5% dextrose CRI

We want to continue administering the insulin CRI until our patient remains ketone-negative. This is why we add the dextrose CRI when their glucose level begins dropping - because it’s the insulin that will reverse the ketogenesis, so we’ll need to keep giving insulin whilst avoiding hypoglycaemia.

Once your patient is ketone negative and well hydrated, it’s time to think about moving them onto a longer-term insulin, and treating them as a non-ketoacidotic diabetic.

#4: How to spot and manage an Addisonian crisis

An Addisonian crisis is a true emergency, and these patients require a lot of intensive stabilisation and nursing care.

It’s seen when our patient can no longer produce not just enough cortisol to maintain normal body functions, but specifically when aldosterone levels also drop.

Aldosterone is responsible for maintaining normal electrolyte balance in the kidney. Specifically, it encourages the kidney to retain sodium and eliminate potassium.

When our patients don’t have enough aldosterone, this balance is disturbed, and our patients present with often life-threatening hyperkalaemia, and hyponatraemia.

Let’s talk about hyperkalaemia…

Potassium exists mostly within the cells in our body, with a comparatively small amount present in the blood. Specifically, there’s a lot of potassium within our muscle cells - including our cardiac muscle.

When potassium level increases, we see progressive cardiac changes, including:

• Bradycardia

• Tall ‘T’ waves on an ECG

• Atrial standstill (lack of ‘P’ waves on an ECG)

• Progressive widening of the QRS complex

• Sine wave formation

• Asystole

So how do we manage hyperkalaemia?

There are several ways we treat hyperkalaemia in the Addisonian crisis patient. These include:

• Administering intravenous fluid therapy to dilute circulating potassium levels.

• Administering calcium gluconate, protects the heart from the effects of hyperkalaemia but does not actually lower the potassium level itself.

• Administering glucose reduces blood potassium levels by stimulating the body to release insulin, driving potassium from the bloodstream into cells.

• Administering neutral insulin reduces blood potassium levels by driving it into cells. As hypoglycaemia can result, glucose is typically given at the same time.

What else is important in the crisis patient?

As well as identifying and managing hyperkalaemia, we also need to think about:

• Slow correction of hyponatraemia (maximum rate 0.5mmol/kg/hour)

• Cardiovascular monitoring

• Correcting hypovolaemia/dehydration

• Performing an ACTH stimulation test (before administering any steroids!)

• Administering steroids

• Providing supportive care.

#5: How to perform a low-dose dexamethasone suppression test

The LDDST is another test we commonly perform in patients with hypercortisolism. We use this to diagnose the condition - it can also give us some idea of whether our patient has adrenal-dependent or pituitary-dependent disease.

This is a longer test, taking 8 hours to complete. These patients generally need to be in for the day during their sampling, and again, the veterinary nurse is ideally placed to admit these patients and perform this test.

Here’s how you do it:

1. Collect a baseline blood sample into a serum or serum gel tube.

2. Administer 0.01-0.015mg/kg of dexamethasone intravenously.

3. Set a timer for 4 hours and place it on the patient’s kennel.

4. Obtain a second blood sample into a serum or serum gel tube 4 hours after dexamethasone administration.

5. Set a timer for a further 4 hours and place it on the patient’s kennel.

6. Obtain the final blood sample into a serum or serum gel tube 8 hours after dexamethasone administration.
   
   

So there you go - 5 practical skills to perform in your endocrine patients! From performing those dynamic tests in the diagnosis of Cushing’s and Addison’s to placing sampling lines and administering insulin CRIs to your DKA cases, there is SO much we can do to support these patients.

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