Diabetes and endocrine nursing

In short

Diabetes and endocrine nursing is the medical-surgical care of patients whose hormone-producing glands — pancreatic islets, thyroid, parathyroid, adrenals and pituitary — are over- or under-functioning. It matters because India has roughly 10 crore people with diabetes and an even larger group — about 13.6 crore — with prediabetes (ICMR-INDIAB), so a nurse on any ward will manage insulin, glucose monitoring and foot risk daily, whatever the admitting diagnosis. The topic is examined in INC/university Medical-Surgical Nursing II papers (endocrine unit), in NORCET, AIIMS, JIPMER, state staff-nurse and ESIC recruitment tests, and in interview rounds at Apollo, Fortis, Manipal, AIIMS and district hospitals. Clinically it governs the three true endocrine emergencies — hypoglycaemia, diabetic ketoacidosis and thyroid storm — where nursing action within minutes decides the outcome. It is also the main nursing contribution to NPCDCS/NP-NCD screening and health-and-wellness-centre work under Ayushman Bharat.

Explained

Endocrine physiology a nurse must hold

• Hormone axis: hypothalamus → releasing hormone → anterior pituitary → trophic hormone (TSH, ACTH, GH, FSH/LH, prolactin) → target gland → hormone → negative feedback switches the axis off.
• Posterior pituitary stores ADH (vasopressin) and oxytocin made in the hypothalamus — it is a storage, not a synthesis, site.
• Pancreatic islets: beta cells → insulin (lowers glucose, anabolic); alpha cells → glucagon (raises glucose); delta cells → somatostatin.
• Insulin actions: moves glucose into muscle and fat (GLUT-4), stores glycogen, stops lipolysis and ketogenesis, drives K⁺ into cells — hence insulin lowers serum potassium.
• Counter-regulatory hormones: glucagon, adrenaline, cortisol, growth hormone — they raise glucose, explaining stress hyperglycaemia, the dawn phenomenon and steroid-induced diabetes.
• Thyroid: TSH → T3/T4 (needs iodine) → raises basal metabolic rate; calcitonin lowers calcium. Parathormone raises serum calcium; its loss after thyroidectomy causes tetany.
• Adrenal cortex: gluco­corticoid (cortisol), mineralocorticoid (aldosterone — Na⁺ retention, K⁺ loss), androgens. Medulla: adrenaline/noradrenaline (phaeochromocytoma).

Diabetes mellitus — classification and diagnosis

• Definition: a group of metabolic disorders with chronic hyperglycaemia from defective insulin secretion, insulin action, or both.
• Type 1: autoimmune beta-cell destruction, absolute deficiency, usually young, lean, ketosis-prone, insulin-dependent for life.
• Type 2: insulin resistance plus progressive secretory failure; ~90–95% of cases; central obesity, family history; Indians develop it a decade earlier and at a lower BMI (the "thin-fat Indian" phenotype).
• Gestational diabetes (GDM): hyperglycaemia first detected in pregnancy. India's national guideline uses a single-step 75 g oral glucose load irrespective of the last meal, with a 2-hour value ≥140 mg/dL (DIPSI method, in the Ministry of Health GDM guideline) — this differs from the IADPSG/ADA three-value criteria, so quote the one the question asks for.
• Other types: MODY (monogenic), fibrocalculous pancreatic diabetes, drug-induced (steroids, antipsychotics, thiazides), endocrinopathies (Cushing, acromegaly), post-pancreatectomy.
• Diagnostic thresholds (ADA, also used by RSSDI/ICMR): fasting plasma glucose ≥126 mg/dL; 2-h post-75 g glucose ≥200 mg/dL; HbA1c ≥6.5%; random ≥200 mg/dL with classic symptoms. Prediabetes: FPG 100–125, 2-h 140–199, HbA1c 5.7–6.4%.
• Classic presentation: polyuria, polydipsia, polyphagia, weight loss, fatigue, blurred vision, recurrent infection, slow healing, pruritus vulvae/balanitis.
• Targets (individualised; frail elderly are kept looser): HbA1c <7%, fasting 80–130 mg/dL, post-prandial <180 mg/dL, BP <130/80, statin for most adults over 40.

Nursing management of diabetes — the four pillars plus education

1. Diet: carbohydrate 50–60% of energy with complex carbohydrates and 25–30 g fibre, protein 15–20%, fat <30% (saturated <10%), consistent carbohydrate timing with insulin. Practical Indian counselling: smaller rice portion, add dal/curd/vegetables, prefer whole wheat/millets (ragi, jowar, bajra), avoid fruit juice and "sugar-free" sweets eaten freely.
2. Exercise: 150 minutes/week moderate aerobic plus resistance twice weekly; check glucose before and after; take 15 g carbohydrate if <100 mg/dL; avoid exercise at peak insulin action and when ketones are present; inspect footwear and feet after activity.
3. Monitoring: self-monitoring of blood glucose (SMBG) with glucometer — side of the fingertip, first drop wiped if hands washed with soap not possible, rotate sites; HbA1c every 3 months until stable then 6-monthly; urine ketones in type 1 when glucose >250 mg/dL or during illness; CGM where affordable.
4. Pharmacology — nurse's angle:
   • Metformin (biguanide): first line, no hypoglycaemia alone, GI upset, B12 deficiency on long use; hold before contrast studies and in renal impairment/sepsis (lactic acidosis risk).
   • Sulphonylureas (glimepiride, gliclazide): cause hypoglycaemia and weight gain — give with the meal, warn about skipped meals.
   • DPP-4 inhibitors (sitagliptin, teneligliptin), SGLT2 inhibitors (dapagliflozin, empagliflozin — genital mycotic infection, volume depletion, euglycaemic DKA), GLP-1 receptor agonists (liraglutide, semaglutide — nausea, weight loss), pioglitazone (oedema, heart failure), acarbose (flatulence; hypoglycaemia on acarbose must be treated with glucose, not sucrose).
   • Insulins: rapid-acting (lispro, aspart — onset 10–15 min, peak 1–2 h), regular/short (30 min, peak 2–4 h), intermediate NPH (1–2 h, peak 6–12 h, cloudy), long-acting glargine/detemir/degludec (flat, 20–42 h), premixed 30/70. Strength in India is almost entirely U-100; U-40 vials persist in some places, so the syringe must match the vial.
   • Injection technique: subcutaneous at 90° with a 4–6 mm pen needle (no pinch needed for short needles), rotate within one anatomical site — abdomen fastest, then arm, thigh, buttock; when mixing, draw clear (regular) before cloudy (NPH); never shake insulin; roll cloudy insulin; never mix glargine with any insulin; store unopened vials at 2–8 °C, in-use pen at room temperature up to ~28 days, never freeze, never leave on a window sill.
   • Lipohypertrophy from non-rotation causes erratic absorption — palpate sites at every review.
5. Education and follow-up: sick-day rules (never omit insulin, test 4-hourly, take fluids, check ketones), sharps disposal, carrying 15 g glucose and an identity card, annual dilated fundus examination, urine albumin-creatinine ratio, lipids, foot examination at every visit, vaccination, pre-conception counselling, smoking and alcohol cessation.

Acute complications — the emergencies

• Hypoglycaemia (<70 mg/dL): autonomic signs first — sweating, tremor, palpitation, hunger, anxiety; then neuroglycopenic — confusion, slurred speech, behaviour change, seizure, coma. Beta-blockers mask the warning signs.
  • Conscious: "rule of 15" — 15 g fast carbohydrate (3–4 teaspoons sugar/glucose in water, 100–150 mL fruit juice), recheck in 15 minutes, repeat if still low, then give a complex carbohydrate snack.
  • Unconscious / unable to swallow: nothing by mouth; IV 25% dextrose 50–100 mL (or 50% dextrose 25–50 mL) through a secure large vein, or glucagon 1 mg IM/SC; recheck glucose, find the cause, continue dextrose infusion for sulphonylurea overdose (prolonged, needs admission).
• Diabetic ketoacidosis (DKA): triad of hyperglycaemia (usually >250 mg/dL), ketosis and metabolic acidosis (pH <7.3, bicarbonate <15–18 mEq/L, anion gap >10–12). Precipitants: infection, missed insulin, new-onset type 1, MI, surgery. Signs: Kussmaul breathing, acetone breath, dehydration, abdominal pain, vomiting, drowsiness.
  • Nursing priorities in order: fluid → insulin → potassium, with hourly monitoring. Isotonic saline first (commonly 1 L in the first hour, then titrated), regular insulin infusion ~0.1 unit/kg/h (bolus optional per protocol), add dextrose when glucose falls to ~200–250 mg/dL so the infusion can continue to clear ketones.
  • Potassium is the trap: serum K⁺ looks normal or high while total body K⁺ is depleted; insulin drives it into cells. Withhold insulin until K⁺ >3.3 mEq/L, add KCl once urine output is established, and keep continuous ECG monitoring.
  • Hourly: glucose, urine output (catheterise only if indicated), neurological status, vitals; 2–4 hourly electrolytes and venous blood gas. Watch for cerebral oedema (headache, falling consciousness) in children with rapid correction.
• Hyperosmolar hyperglycaemic state (HHS): type 2, elderly, glucose often >600 mg/dL, osmolality >320 mOsm/kg, minimal ketosis, no significant acidosis, profound dehydration and altered sensorium, mortality higher than DKA. Fluid replacement is the mainstay; correct slowly to avoid cerebral oedema; insulin requirement lower.
• Lactic acidosis: suspect in metformin plus renal failure/sepsis.

Chronic complications and the diabetic foot

• Microvascular: retinopathy (non-proliferative → proliferative; leading preventable blindness — annual dilated screening, laser/anti-VEGF), nephropathy (microalbuminuria → overt proteinuria → CKD; ACE inhibitor/ARB, BP control, avoid nephrotoxics), neuropathy (distal symmetrical sensory "glove-and-stocking", painful neuropathy, autonomic — gastroparesis, postural hypotension, silent MI, erectile dysfunction, neurogenic bladder).
• Macrovascular: coronary artery disease (often silent), stroke, peripheral arterial disease.
• Others: infections (TB, UTI, candidiasis, mucormycosis in poorly controlled/steroid-treated patients), periodontal disease, frozen shoulder, non-alcoholic fatty liver.
• Diabetic foot — the highest-yield nursing content: neuropathy (loss of protective sensation) + ischaemia + deformity + trauma → ulcer → infection → amputation.
  • Screening at every visit: inspect between toes, test with a 10 g (5.07) Semmes-Weinstein monofilament at defined plantar sites, vibration with 128 Hz tuning fork, ankle reflexes, pedal pulses, ankle-brachial index.
  • Education: wash and dry daily especially between toes, inspect with a mirror, moisturise but not between toes, cut nails straight across, never walk barefoot even indoors, no hot water bottles or chemical corn removers, break in new footwear gradually, check footwear for stones, report any blister/colour change/discharge the same day.
  • Ulcer care: offloading is as important as dressing; debridement, culture-directed antibiotics, glycaemic control, revascularisation if ischaemic, multidisciplinary clinic. Wagner grading 0–5 is the usual exam classification.

Thyroid, parathyroid, adrenal and pituitary nursing

• Hypothyroidism: fatigue, cold intolerance, weight gain, constipation, bradycardia, dry coarse skin, hoarseness, menorrhagia, delayed relaxation of reflexes; high TSH, low free T4. Levothyroxine on an empty stomach, 30–60 min before breakfast, with water, away from calcium/iron/antacids; start low in the elderly and cardiac patients (angina risk). Myxoedema coma: hypothermia, hypoventilation, hyponatraemia, bradycardia, coma — passive warming, IV levothyroxine, hydrocortisone, ventilatory support, treat precipitant.
• Hyperthyroidism (Graves disease, toxic nodule): weight loss with good appetite, heat intolerance, sweating, tremor, palpitation/atrial fibrillation, diarrhoea, insomnia, exophthalmos, goitre; low TSH, high free T4/T3. Carbimazole/methimazole or propylthiouracil (warn: sore throat and fever = possible agranulocytosis, stop and report), beta-blocker for symptoms, radioiodine, or surgery. Nursing: cool quiet room, high-calorie high-protein diet with extra fluids, eye care (lubricant drops, head elevation, dark glasses), daily weight and pulse.
• Thyroid storm: fever >38.5 °C, tachycardia, arrhythmia, agitation/delirium, vomiting, heart failure — cooling, oxygen, IV fluids, propranolol, antithyroid drug then iodine (iodine at least one hour after the antithyroid drug), hydrocortisone, treat the trigger.
• Thyroidectomy nursing: pre-op render euthyroid (Lugol's iodine shrinks vascularity); post-op semi-Fowler with head and neck supported, avoid neck flexion/hyperextension, keep suction, oxygen and a tracheostomy set at the bedside, inspect dressing and behind the neck for bleeding, assess voice hourly (recurrent laryngeal nerve), watch for airway obstruction/stridor (haematoma), hypocalcaemic tetany at 24–72 h — Chvostek and Trousseau signs, perioral numbness, carpopedal spasm — have 10% calcium gluconate ready, and thyroid storm.
• Goitre and iodine: iodine deficiency disorders are prevented by the National Iodine Deficiency Disorders Control Programme; iodised salt must carry at least 15 ppm iodine at consumer level under the Food Safety and Standards Act, 2006 regulations.
• Cushing syndrome: cortisol excess (commonest cause is exogenous steroids) — moon face, buffalo hump, truncal obesity with thin limbs, purple striae, thin skin, hypertension, hyperglycaemia, hypokalaemia, osteoporosis, immunosuppression, mood change. Nursing: infection precautions, skin and fall protection, Na⁺ restriction with K⁺-rich diet, glucose monitoring, never stop steroids abruptly.
• Addison disease / adrenal insufficiency: weakness, weight loss, anorexia, hyperpigmentation, postural hypotension, hyponatraemia with hyperkalaemia, hypoglycaemia; lifelong hydrocortisone plus fludrocortisone, double the dose in illness, carry a steroid card. Addisonian crisis: shock, vomiting, abdominal pain, fever — rapid IV normal saline with dextrose and IV hydrocortisone, no delay for test results.
• Pituitary: SIADH — too much ADH, dilutional hyponatraemia, concentrated urine, weight gain without oedema → fluid restriction, hypertonic saline only for severe symptomatic hyponatraemia, correct slowly (osmotic demyelination). Diabetes insipidus — too little ADH (or renal resistance), dilute polyuria of several litres with low specific gravity, intense thirst → desmopressin, free access to water, strict intake-output and daily weight. Acromegaly/gigantism (GH excess) and hypopituitarism; post-hypophysectomy nursing: avoid coughing/straining/bending, watch for CSF rhinorrhoea (halo sign, salty postnasal drip) and transient DI.
• Phaeochromocytoma: paroxysmal hypertension with headache, sweating, palpitation; do not palpate the abdomen; alpha-blockade before beta-blockade pre-operatively.

Indian standards, programmes and legal frame

• NP-NCD (formerly NPCDCS) under the National Health Mission: population-based screening of everyone aged 30 and above for diabetes, hypertension and three cancers, delivered through Ayushman Bharat Health and Wellness Centres with ASHA/ANM/CHO teams; NCD clinics at CHC and district level supply free metformin, glimepiride and insulin under the Free Drugs Initiative.
• Ayushman Bharat PM-JAY covers ₹5 lakh per family per year for secondary and tertiary hospitalisation (not outpatient diabetes care); the 2024 extension covers citizens aged 70 and above. Many states run their own schemes in parallel.
• Insulin, pen needles and glucometer strips are notified drugs/devices; prices of several insulins are capped under the Drugs (Prices Control) Order by NPPA — check the current ceiling before quoting a figure.
• Practice frame: Indian Nursing Council curriculum and the ICN/INC Code of Ethics; informed consent for procedures; biomedical waste — used needles and lancets in the white translucent puncture-proof container, never recapped, as per the Bio-Medical Waste Management Rules, 2016 (as amended); glucometer QC and calibration logs under NABH standards.
• Insulin is a high-alert medication: NABH/ICN practice requires independent double-check of dose, never using the abbreviation "U" (write "units"), and a dedicated insulin syringe — never a tuberculin or 2 mL syringe.

Key points

• Type 1 vs Type 2 - absolute insulin deficiency, ketosis-prone, insulin essential vs insulin resistance with relative deficiency, ketosis uncommon.
• Diagnosis - FPG ≥126, 2-h ≥200, HbA1c ≥6.5%, or random ≥200 with symptoms; confirm unless clearly symptomatic.
• HbA1c - mean glycaemia of the last 2–3 months; unreliable in anaemia, haemoglobinopathy, recent transfusion, pregnancy, CKD.
• Rule of 15 - 15 g fast carbohydrate, recheck in 15 minutes, repeat if still <70 mg/dL, then a complex-carbohydrate snack.
• Unconscious hypoglycaemia - nothing orally; IV 25% dextrose or glucagon 1 mg IM.
• DKA order of treatment - fluid, then insulin, then potassium; never insulin if K⁺ <3.3 mEq/L.
• DKA dextrose rule - add dextrose at ~200–250 mg/dL so insulin can keep running to clear ketones.
• HHS - very high glucose, hyperosmolality, no significant ketoacidosis, elderly, fluid is the mainstay.
• Insulin mixing - clear before cloudy; never mix glargine; roll, don't shake.
• Site rotation - within one anatomical region; abdomen absorbs fastest; non-rotation causes lipohypertrophy.
• Metformin - no hypoglycaemia alone, hold for contrast and renal impairment, long-term B12 loss.
• Sulphonylurea hypoglycaemia - prolonged and recurrent; admit and infuse dextrose.
• Levothyroxine - empty stomach, 30–60 min before food, away from calcium and iron.
• Antithyroid drugs - sore throat with fever means possible agranulocytosis; stop and report.
• Post-thyroidectomy - airway, bleeding behind the neck, hoarseness, tetany at 24–72 h; calcium gluconate and tracheostomy set ready.
• Addison vs Cushing electrolytes - Addison: low Na⁺, high K⁺, low glucose; Cushing: high Na⁺, low K⁺, high glucose.
• SIADH vs DI - SIADH: concentrated urine, dilutional hyponatraemia, restrict fluid; DI: dilute polyuria, give desmopressin and water.
• Foot rule - 10 g monofilament screening plus "never barefoot"; offloading matters as much as the dressing.

Formulas and examples

Example 1 — HbA1c to average glucose. A 52-year-old man's HbA1c is 9.2%.

• eAG = (28.7 × 9.2) − 46.7 = 264.04 − 46.7 = 217.3 mg/dL.
• Interpretation: average glucose about 217 mg/dL over 2–3 months — far above the <7% (eAG ≈ 154 mg/dL) target. Nursing action: review adherence, injection sites, diet, and screen for complications.

Example 2 — DKA bedside numbers. Glucose 648 mg/dL, Na⁺ 130 mEq/L, Cl⁻ 96 mEq/L, HCO₃⁻ 8 mEq/L, BUN 28 mg/dL, pH 7.12, K⁺ 3.1 mEq/L.

• Anion gap = 130 − (96 + 8) = 26 mEq/L → high anion gap metabolic acidosis.
• Osmolality = 2(130) + 648/18 + 28/2.8 = 260 + 36 + 10 = 306 mOsm/kg.
• Corrected Na⁺ = 130 + 1.6 × (648 − 100)/100 = 130 + 1.6 × 5.48 = 130 + 8.77 = 138.8 mEq/L → the "low" sodium is dilutional.
• K⁺ is 3.1, below 3.3 — hold the insulin, start KCl with the saline, continuous ECG; then begin insulin. This is the single most-marked step in the question.

Example 3 — insulin infusion and syringe dose. A 70 kg patient in DKA is ordered regular insulin 0.1 unit/kg/h from a bag of 50 units in 50 mL normal saline.

• Dose = 0.1 × 70 = 7 units/h. Bag concentration = 50 units ÷ 50 mL = 1 unit/mL → rate = 7 mL/h.
• Later the same patient is prescribed 14 units of U-100 insulin subcutaneously: volume = 14 ÷ 100 = 0.14 mL = 14 markings on a U-100 insulin syringe — read units, never mL, and double-check with a second nurse.

Example 4 — correction dose and carbohydrate ratio. Type 1 patient, 60 kg, total daily dose 36 units, pre-lunch glucose 280 mg/dL, target 120 mg/dL, meal 60 g carbohydrate.

• Correction factor = 1800 ÷ 36 = 50 mg/dL per unit → correction = (280 − 120)/50 = 160/50 = 3.2 ≈ 3 units.
• Carbohydrate ratio = 500 ÷ 36 = 13.9 ≈ 14 g per unit → meal dose = 60 ÷ 14 = 4.3 ≈ 4 units.
• Total rapid-acting dose before lunch = 3 + 4 = 7 units, given 10–15 minutes before eating.

Example 5 — fluid resuscitation drip rate. 1,000 mL normal saline over 1 hour with a macro set of drop factor 15 drops/mL.

• Drops/min = (1,000 × 15)/60 = 250 drops/min — impossible to count, so this must run on an infusion pump or by pressure infusion; document the volume actually delivered hourly.

Where it is used

• Hospital medical and ICU wards: insulin infusions, hourly glucose charts, DKA and HHS protocols, perioperative glycaemic control at AIIMS, PGIMER, Apollo, Fortis, Manipal, CMC Vellore.
• Diabetes educator and diabetic-foot clinic roles: certified diabetes educator posts with RSSDI/Dr. Mohan's/Madras Diabetes Research Foundation; podiatry and offloading footwear services; insulin-start and pump/CGM counselling.
• Community and public health nursing: NP-NCD screening camps, HWC-based population screening by CHO/ANM, follow-up of defaulters, GDM screening at every antenatal visit under the national GDM guideline.
• Surgical and specialty nursing: pre- and post-thyroidectomy, adrenalectomy and hypophysectomy care; steroid-dependent patients needing stress-dose cover; dialysis units with diabetic CKD.
• Industry and corporate roles: medical/clinical nurse advisers with Novo Nordisk, Sanofi, Eli Lilly, Biocon, USV, Abbott; glucometer and CGM companies (Accu-Chek, OneTouch, FreeStyle Libre) for training and adherence programmes.
• Teaching and quality: medical-surgical nursing faculty, NABH insulin high-alert-medication audits, hypoglycaemia incident reporting and root-cause analysis.

Interview questions

• Q: A patient on insulin is sweaty, tremulous and confused at 3 a.m.; what do you do first? A: Check capillary glucose while keeping the airway safe; if conscious and able to swallow give 15 g oral glucose and recheck in 15 minutes, if unconscious give IV 25% dextrose or glucagon 1 mg IM — treat first, document after.
• Q: In DKA, why is potassium given even when the serum level is normal? A: Total body potassium is severely depleted; insulin and fluids drive K⁺ into cells, so the serum level falls fast and can cause fatal arrhythmia unless replacement starts early.
• Q: Why is dextrose added when the glucose falls to about 200–250 mg/dL in DKA? A: Insulin must continue to clear ketones and close the anion gap, and dextrose prevents hypoglycaemia while that happens.
• Q: How does HHS differ from DKA in nursing priority? A: HHS has far greater fluid deficit with little ketoacidosis, so aggressive but carefully paced fluid replacement and slow osmolality correction take priority over insulin.
• Q: When you draw up regular and NPH insulin in one syringe, which comes first and why? A: Air into NPH, air into regular, then draw regular (clear) first — so cloudy NPH suspension never contaminates the clear regular vial.
• Q: Why must a 2 mL syringe never be used for insulin? A: It is calibrated in mL, not units, and cannot measure 0.1 mL accurately — a tenfold dosing error is possible; insulin is a high-alert drug needing a U-100 insulin syringe and a double check.
• Q: How do you teach foot care to a labourer with neuropathy? A: Daily washing and inspection including between toes, moisturise except between toes, never barefoot even indoors, well-fitting closed footwear checked for stones, nails cut straight, and report any blister or discharge the same day.
• Q: What will you watch for in the first 48 hours after thyroidectomy? A: Airway obstruction and bleeding behind the neck, hoarseness or weak voice from recurrent laryngeal nerve injury, hypocalcaemic tetany with Chvostek and Trousseau signs, and thyroid storm — with suction, oxygen, a tracheostomy set and calcium gluconate at hand.
• Q: Why is iodine given at least an hour after the antithyroid drug in thyroid storm? A: Iodine given first would be used as substrate for new hormone synthesis; the antithyroid drug must block synthesis before iodine is used to inhibit release.
• Q: A patient on long-term prednisolone stops it suddenly before surgery — what do you expect? A: Acute adrenal (Addisonian) crisis — hypotension, vomiting, abdominal pain, hyponatraemia and hyperkalaemia; treat with IV normal saline with dextrose and IV hydrocortisone immediately.
• Q: How do you distinguish SIADH from diabetes insipidus at the bedside? A: SIADH gives low urine output with concentrated urine, weight gain and dilutional hyponatraemia; DI gives large volumes of dilute urine, thirst, weight loss and rising sodium.
• Q: Why is HbA1c sometimes a misleading target in Indian patients? A: Iron-deficiency anaemia, haemoglobinopathies such as thalassaemia trait, recent transfusion, pregnancy and CKD all distort it, so correlate with SMBG or CGM readings.
• Q: Which oral agent is withheld before a contrast CT and why? A: Metformin — contrast-associated renal impairment can precipitate lactic acidosis; withhold and restart only after renal function is confirmed normal.

Common mistakes

• Treating an unconscious hypoglycaemic patient by mouth, or taking time to confirm the glucose before acting.
• Starting insulin before fluids in DKA, or giving insulin while K⁺ is below 3.3 mEq/L.
• Stopping the insulin infusion when the glucose normalises while the anion gap is still open — the ketosis is untreated.
• Measuring insulin in a tuberculin or 2 mL syringe, writing "U" instead of "units", or ignoring a U-40 vial with a U-100 syringe.
• Rotating injection sites across regions (abdomen one day, thigh the next) instead of within one region, which makes absorption unpredictable.
• Writing "ketoacidosis" into an HHS answer, or quoting DKA treatment for hypoglycaemia under exam pressure.
• Confusing Addison with Cushing electrolytes, and SIADH with DI fluid orders — the treatments are exact opposites.
• Soaking diabetic feet in hot water, moisturising between the toes, or using a sharp blade for corns during "foot care" demonstrations.
• Giving levothyroxine with breakfast, calcium or iron, which blunts absorption and keeps TSH high.

Related topics

Cardiovascular nursing · Wound care and pressure injuries · Fluid, electrolyte and acid-base balance · Pharmacology and drug calculations · Community health nursing and national health programmes · Nutrition and dietetics in disease.