nursing of adults with medical & surgical conditions endocrine disorders
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Acromegaly
Etiology/Pathophysiology– Overproduction of growth hormone in the
adult– Idiopathic hyperplasia of the anterior
pituitary gland• No known cause
– Tumor growth in the anterior pituitary gland– Changes are irreversible
Acromegaly Signs & Symptoms
– Enlargement of the cranium and lower jaw
– Separation and malocclusion of the teeth
– Bulging forehead– Bulbous nose– Thick lips– Enlarged tongue– Generalized coarsening
of the facial features– Enlarged hands and feet– Enlarged heart, liver, and
spleen
Acromegaly
– Muscle weakness– Hypertrophy of the joints with pain and
stiffness– Males – impotence– Females – deepened voice, increased facial
hair, amenorrhea– Partial or complete blindness with pressure
on the optic nerve due to tumor– Severe headaches
Acromegaly Treatment
– Medications• Parlodel• Sandostatin
– Inhibit production of growth hormone
– Cryosurgery• Destroy tissue by freezing
– Transphenoidal removal of tissue
– Proton beam therapy• Low doses of radiation
– Soft easy to chew diet– Analgesics
Giantism
Etiology/Pathophysiology– Overproduction of growth hormone– Caused by hyperplasia of the anterior
pituitary gland– Occurs in a child before closure of the
epiphyses– Other causes
• Genetic disorders• Disturbances in sex hormone production
Giantism
Signs & Symptoms– Great height– Increased muscle and visceral
development– Increased weight– Normal body proportions– Weakness
Giantism
Treatment– Surgical removal of tumor– Irradiation of the anterior pituitary gland
• Requires replacement of pituitary hormones
Dwarfism
Signs & Symptoms– Abnormally short
height– Normal body
proportion– Appear younger than
age– Dental problems due
to underdeveloped jaws
– Delayed sexual development
Diabetes Insipidus
Etiology/Pathophysiology– Transient or permanent metabolic disorder
of the posterior pituitary– Deficiency of antidiuretic hormone– Primary– Secondary
• Head injury; intracranial tumor, aneurysm, or infarct; encephalitis or meningitis
Diabetes Insipidus Signs & Symptoms
– Polyuria• Urine very dilute• May exceed 10 L in 24 hours
– Polydipsia• Craves cold water• Up to 40 L of fluid daily
– May become severly dehydrated– Lethergic– Dry skin– Poor skin tugor– Constipation
Diabetes Insipidus
Treatment– ADH preparations
• Vasopressin• IV, SQ, nasal spray
– Limit caffeine due to diuretic properties
Graves’ Disease
Etiology/Pathophysiology– Overproduction of the thyroid hormones– Exaggeration of metabolic processes– Exact cause unknown– Risk factors
• Physical or emotional stress• Pregnancy• Adolescence• Infection• Genetic• Autoimmune
Graves’ Disease Signs & Symptoms
– Edema of the anterior portion of the neck
• Enlargement of the thyroid
– Exphtalmos• Bulging of the eyeballs due to
periorbital edema
– Inablility to concentrate– Memory loss– Dysphagia– Hoarsness– Increased appetite– Weight loss– Nervousness
Graves’ Disease
– Insomnia– Tachycardia– Hypertension– Warm, flushed skin– Fine hair– Amenorrhea– Elevated temperature– Diaphoresis– Hand tremors
Graves’ Disease
Treatment– Medications
• Propylthiouracil• Methimazole
– Block production of thyroid hormones
– Radioactive iodine• Destroys part of thyroid tissue
– Subtotal thyroidectomy• Part of thyroid is removed
Graves’ Disease– Post-Op
• Voice rest• Voice checks• Avoid hyperextention of neck• Tracheotomy tray at bedside• Assess for s/s of internal and external bleeding
– High risk of hemorrhage
• Assess for tetany– May occur due to accidental removal of parathyroid glands– Decreases serum calcium levels– Chvostek’s Sign
» Abnormal spasm of facial muscles elicited by light tap on the facial nerve
– Trousseau’s Sign» Carpal spasm induced by inflation of B/P cuff on the upper
arm for 3 minutes
Graves’ Disease
• Thyroid Crisis– Caused by manipulation of thyroid– Releases large amounts of thyroid hormones– Usually occurs within first 12 hrs– Exaggerated symptoms of hyperthyroidism– Can be fatal if untreated
Hypothyroidism
Etiology/Pathophysiology– Insufficient secretion of thyroid hormones– Slowing of all metabolic processes– Failure of thyroid or insufficient secretion of
TSH from pituitary gland– Myxedema
• Adults
– Cretinism• Newborns; congenital
Hypothyroidism Signs & Symptoms
– Depends on degree of thyroid hormone deficiency
– Hypothermia– Intolerance to cold– Weight gain– Depression– Impaired memory– Slow thought process– Lethargic – Anorexia– Constipation
Hypothyroidism
– Decreased libido– Menstrual irregularities– Thin hair– Skin thick and dry– Enlarged facial
appearance– Low hoarse voice– Bradycardia– Hypotension
Hypothyroidism
Treatment– Medications
• Synthroid• Levothyroid• Proloid• Cytomel
– Symptomatic treatment
Simple Goiter
Etiology/Pathophysiology– Enlarged thyroid due to low iodine levels– Enlargement is caused by the
accumulation of colloid in the thyroid follicles
– Usually cause by insufficient dietary intake of iodine
Cancer of the Thyroid
Treatment– Total thyroidectomy– Thyroid hormone replacement– If metastasis is present:
• Radical neck dissection• Radiation therapy, chemotherapy, and
radioactive iodine
Hyperparathyroidism
Etiology/Pathophysiology– Overactivity of the parathyroid, with
increased production of parthormone– Hypertrophy of one or more of the
parathyroid glands• Usually due to an adenoma
Hyperparathyroidism Signs & Symptoms
– Hypercalcemia• Calcium leaves the bones and enters the bloodstream
– Skeletal pain
– Pain on weight bearing
– Pathological fractures
– Kidney stones
– Fatigue
– Drowsiness
– Nausea
– Anorexia
Hypoparthyroidism
Etiology/Pathophysiology– Decreased parathyroid hormone– Decreased serum calcium levels– Inadvertent removal or destruction or one
or more gland during thyroidectomy
Hypoparthyroidism Signs & Symptoms
– Neuromuscular hyperexcitability– Involuntary and uncontrollable muscle spasms– Tetany– Laryngeal spasms– Stridor– Cyanosis– Parkinson-like syndrome
• Bizarre posturing• Spastic movements
– Chvosteck’s sign &Trousseau’s sign
Hypoparthyroidism
Treatment– Calcium gluconate or calcium chloride IV
• Must be given very slowly due to irritation of vessel
• Rate should not exceed 1 ml/min• Can precipitate cardiac arrest
– Vitamin D• Increases absorption of calcium
Adrenal HyperfunctionCushing’s Syndrome
Etiology/Pathophysiology– Plasma levels of adrenocortical hormones
are increased– Hyperplasia of adrenal tissue due to
overstimulation by the pituitary gland– Tumor of the adrenal cortex– ACTH secreting tumor outside the pituitary– Overuse of corticosteriod drugs
Adrenal HyperfunctionCushing’s Syndrome
Signs & Symptoms– Moonface– Buffalo hump– Thin arms and legs– Hypokalemia– Proteinuria– Increased urinary calcium excretion– Susceptible to infections– Depression– Loss of libido
Adrenal HyperfunctionCushing’s Syndrome
– Ecchymoses and petechiae– Weight gain– Abdominal enlargement– Hirsutism in women
• Exessive hair in a masculine distribution
– Menstrual irregularities– Deepening of the voice
Adrenal HyperfunctionCushing’s Syndrome
Treatment– Treat causative factor
• Adrenalectomy for adrenal tumor• Radiation or surgical removal for pituitary
tumors
– Lysodren• Cytotoxic agent to decrease production of
adrenal steroids
– Low sodium, high potassium diet
Adrenal HypofunctionAddison’s Disease
Etiology/Pathophysiology– Adrenal glands do not secrete adequate
amounts of glucocorticoids and mineralocorticoids
– May result from• Adrenalectomy• Pituitary hypofunction• Long standing steroid therapy
Adrenal HypofunctionAddison’s Disease
Signs & Symptoms– Related to imbalances of hormones, nutrients, and
electrolytes:– Nausea– Anorexia– Postural hypotension– Headache– Disorientation
• Abdominal pain• Lower back pain
– Anxiety
Adrenal HypofunctionAddison’s Disease
– Darkly pigmented skin and mucous membranes
– Weight loss– Vomiting – Diarrhea– Hypoglycemia– Hyponatremia– Hyperkalemia
Adrenal HypofunctionAddison’s Disease
– Adrenal Crisis• Sudden, severe drop in B/P• Nausea & vomiting• Extremely high temperature• Cyanosis• Death
Adrenal HypofunctionAddison’s Disease
Treatment– Restore fluid and electrolyte balance– Replacement of adrenal hormones
• Florinef
– Diet high in sodium and low in potassium– Adrenal Crisis
• IV corticosteroids in a solution of saline and glucose
Diabetes MellitusType I and Type II
Etiology/Pathophysiology– Unknown
Risk Factors– Heredity
• Blood relatives of people who have DM (esp Type II) are more likely to develop DM
– Environment and lifestyle• Overweight, sedentary lifestyle are more prone to Type I DM
– Viruses• Chickenpox-type viruses have been associated with the
development of Type I DM
– Malignancy or Surgery of Pancreas• Decreased functioning ability
Diabetes MellitusType I and Type II
Pathophysiology– Insulin deficiency
• May be decreased or none
– Insulin is secreted by the beta cells in the islets of Langerhans
– Insulin is necessary for the cells to combine O2 and glucose to produce energy
– If insulin is not present or is reduced, glucose accumulates in the blood and is excreted in the urine
– The body then uses proteins and fat for energy which can cause acidosis
Diabetes MellitusType I and Type II
Classifications– Type I
• Insulin Dependent (IDDM)
– Type II• Non-insulin Dependent (NIDDM)
Signs & Symptoms– Type I & Type II
• Polyuria• Polydypsia• Polyphagia
Diabetes MellitusType I and Type II
– Type I• Sudden onset• Weight loss• Hyperglycemia• Under 40 years old
– Type II• Slow onset• May go undetected for years• “3 P’s” are usually mild• Untreated may have skin infections &
arteriosclerotic conditions
Diabetes MellitusType I and Type II
Diagnostic Tests– Urine glucose and acetone
• Neither are normally in urine• Glucose in urine means the blood glucose has
exceeded the “renal threshold”
– Blood glucose• Venipuncture or capillary• Glucose is always present in the blood• Amount can fluctuate according to how much and what
type of foods have been eaten• Normal values
– 70-110 mg/dl
– Oral glucose tolerance test• Fasting (NPO for at least 8 hours)• Fasting blood sugar is drawn• Glucose drink administered• Blood drawn at 1 hr, 2 hrs, and 3 hrs after drink
– 1hr: elevated– 2hr: essentially normal– 3hr: within normal limits
– 2 hour post-parandial blood sugar• Blood sugar drawn 2 hours after a normal meal• Values should be within normal limits
– Glycohemoglobin• Glucose in hemoglobin• Elevation means that the patient’s blood sugar levels were
consistantly high for 6-8 weeks previously• Values
– Non-diabetic adult: 2.2-4.8%– Good diabetic control: 2.5-5.9%– Fair diabetic control: 6-8%– Poor diabetic control above 8%
Treatment– Diet
• The cornerstone of treatment• Usually based on caloric needs (pt. size, activity, etc)• Type II may be controlled by diet alone• Type I diet is calculated and then the amount of insulin required to
metabolize it is established• ADA diet (American Diabetes Association)
– 7 Exchanges» Free calories» Vegetables» Fruits» Bread» Meat» Fats» Milk
– Quantitative Diet» Carbohydrates – 45-50% of calories» Proteins – 10-20% of calories» Fats – no more than 30% of calories
• Need 3 regular meals with snacks between meals and at bedtime to maintain constant glucose levels
Carbohydrate Counting Adults with Type 2 diabetes generally need to limit
carbohydrates to no more than 45-60 grams per meal and 15-30 grams for a snack.
Eat three meals a day with one to three snacks. Try to eat around the same times every day.
Avoid skipping meals. Follow the food guide pyramid. Pay attention to
carbohydrate choices. Stay within your recommended serving ranges.
Limit foods that are high in added sugars and fats. If you do consume foods with added sugar, be sure to count them into your carbohydrate choices.
Avoid drinking high sugar beverages such as regular sodas, fruit juices, lemonade and punch. All of these can be substituted with diet, low calorie, low sugar or light alternatives.
These foods count as one (1) carbohydrate choice:
1 oz dinner roll
1 cup (8 oz) milk
1/2 cup beans
1 slice bread
1 cup (8 oz) soy milk
1/2 cup corn
1/2 cup cooked cereal
8 oz yogurt (no added sugar)
1/2 cup green peas
3/4 cup dry cereal (varies)
1 taco
3 oz baked potato
2 - 4" pancakes
1 slice thin crust pizza
1 cup winter squash
1/2 cup pasta or potato salad
1 cup bean or noodle soup
1/2 cup canned fruit
1/2 cup pasta
1 granola bar
1/4 cup dried fruit
1/3 cup rice
3 graham cracker squares
1 cup berries
1 - 6" tortilla
1/2 cup sugar free pudding
1/2 medium grapefruit
1 - 4" waffle
10-15 potato chips
3 prunes
3 cups popcorn
1/2 cup ice cream
12-15 cherries or grapes
4-5 crackers
1 - 3" cookie
1 small apple or orange
1 small muffin
1 Tbsp syrup, honey, or sugar
1 cup melon
15 pretzels
1/3-1/2 cup fruit juice
2 Tbsp raisins
These foods count as two (2) carbohydrate choices:
1 - 8 to 11 oz frozen dinner
1 hamburger with bun
1 - 2-oz English muffin
1 cup lasagna (3" x 4" piece)
1 - 2-oz hamburger or hotdog bun
1 cup macaroni and cheese
1 cup sweetened yogurt
1 slice thick crust pizza
1 - 7" meat burrito
1/2 large bag light popcorn
1 medium banana or pear
1 small bagel
1 cup chili
1 cup casserole
– Insulin• Classified by Action
– Regular» Fast acting» Peek action 2-4 hours» Duration 5-8 hours
– Lente & NPH» Intermediate acting» Peek action 4-12 hours» Duration 18-24 hours
– Ultralente» Long acting» Peek action 12-18 hours» Duration 28-36 hours
• Classified by Type– Beef/Pork
» derived from the pancreas of a pig or cow
– Humulin/Novolin» synthetic human insulin
• Regular Insulin is the ONLY form that can be given IV!
• Should be administered at room temperature• Should be discarded after open for 3 months• Standardized Dose
– 100 units/ml (U100)– Use ONLY insulin syringes
• Administer subcutaneous
Insulin Injection Sites• Injection Sites
– Should be rotated to prevent scar tissue formation
» Insulin is not well absorbed in scar tissue
– Sites » Lateral surface of
the upper arms» Abdomen just
below the rib cage» Buttocks» Anterior surface of
thighs
• Sliding Scale– Insulin is given according to blood glucose levels– Regular insulin is only type that should be given to
scale– Scales will vary on different patients, physicians, etc.– Sample Scale
» Blood Sugar Insulin 200-225 2 units 226-250 3 units 251-275 4 units 276-300 5 units above 300 Call MD
– Oral hypoglycemic agents• Stimulate islet cells to secrete more insulin
• Must have some production of insulin by pancreas
• Only for Type II DM
• NOT insulin
• Side Effects– hypoglycemia
• Types– Orinase short acting 6-12 hours
– Tolinase interm. acting 12-24 hours
– Diabinease long acting up to 60 hours
– Hygiene• Prevention more than treatment• Decreased resistance to infection• Wounds heal more slowly• Proper care of feet
– Clean
– Nail care
– Proper fitting shoes
– No heating pads
– Do NOT trim nails - MD only
– Exercise• Promotes movement of glucose into the cell by
changing the cell permeability• Lowers blood glucose• Lowers insulin needs
Insulin Reaction– Hypoglycemia– May be due to a sudden drop to below
normal or may be due to a sudden drop from extremely high to normal
– Pathophysiology• Too little circulating glucose
– Cause• Too much insulin OR not enough food
– Signs and Symptoms• Trembling• Perspiration• Irrritability• Dizziness• Muscle weakness• Headache• Blurred vision• Hunger• Confusion• Comatose• Convulsions
– Treatment• Increase blood glucose
– High calorie drink
» Orange juice
» Cola
– Concentrated sugar
» Candy
» Jelly
– Then complex foods
» Carbohydrates
» Proteins
– If unconsious
» 50% dextrose IV
Diabetic Acidosis/Ketoacidosis– Hyperglycemia– Usually occurs in Type I (IDDM)– Cause
• Lack of insulin• Accumulation of glucose and wastes from fat and
protein metabolism
– Signs & Symptoms• Polyuria• Polydipsia• Polyphagia• Nausea & vomiting• Weakness• Headache• Flushed face• Late Symptoms
– Sweet fruity breath– Hypotension– Tachycardia– Kussmaul’s Respirations
» Loud, deep and rapid resp. followed by apnea– BS may be as high as 1000mg/dl
Chronic Complications– Macrovascular changes
• Caused by atherosclerosis• Intermittent claudication• Stroke• Gangrene• Coronary artery disease
– Microvascular changes• Caused by changes in the capillaries• Eyes
– diabetic retinopathy– cateracts
• Kidneys– nephropathy
• Infection– High BS levels cause poor circulation and decreased sensation
• CNS disturbances– Metabolic imbalances affects the sensory and motor fibers
Other Complications– Surgery
• Stresses the body
• Pts. who required no insulin, may now require insulin
• Pts. who were on insulin, will probably require increased doses
– Tests• NPO
• Need to consider how long they will be NPO and what type insulin they are taking
– “Sick Days”• Increased risk of ketoacidosis (hyperglycemia)
• Glucose must be monitored closely
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