Nursing Endocrine
Content
ENDOCRINE
I.
Anatomy and Physiology (illustration ) A. The endocrine system, together with the neurological system, functions as the communication system for the body B. Endocrine glands secrete hormones 1. Secreted in very small amounts 2. Alters the rate of many physiologic activities a. reproduction b. metabolism c. growth and development d. neurological and mental functions 3. Secreted into the blood 4. Regulated by several methods a. autonomic nervous system b. changes in concentrations of specific substances in plasma c. feedback system C. Glands Pituitary (illustration 1 illustration 2 ) 1. Lies in sella turcica above the sphenoid bone 2. Consists of two lobes connected by the hypothalamus 3. Regulates the other endocrine glands by stimulating target organs 4. Controlled by releasing and inhibiting hormones from the hypothalamus Thyroid gland (illustration ) 1. Located at the level of the cricoid cartilage in front of the trachea 2. Two highly vascular lobes 3. Controls the rate of the body metabolism Parathyroid glands - parathormone (PTH) 1. Four small glands located near the thyroid gland 2. Controls calcium and phosphorus metabolism Adrenal glands (illustration ) 1. Two small glands lying in the retroperitoneal region 2. Functions a. cortex - promotes organic metabolism, regulates sodium and potassium, response to stress, preadolescent growth spurt b. medulla - stimulation of sympathetic nervous system, responds to stress
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Pancreas - insulin, glucagon secretion into the blood, an endocrine function (illustration ) 1. Lies retroperitoneally, with the head of the gland in the duodenal cavity and the tail lying against the spleen 2. Excretion of enzymes and bicarbonate that aid digestion and controls carbohydrate metabolism as an exocrine function I. Gonads - ovaries, estrogen, progesterone, inhibin - decreases secretion of follicle-stimulating hormone (FSH); testes, testosterone 1. Located: two ovaries are situated in the lower abdomen on each side of the uterus. The testes are the pair of male sex organs that form within the abdomen but descend into the scrotum 2. Responsible for secondary sex characteristics and reproductive function General Concepts C. Endocrine glands must maintain homeostasis of about 50 billion cells.
H.
D.
Endocrine glands are ductless, and secrete many hormones
directly into the blood or lymph.
Endocrine Glands and their Secretions
3.
These hormones regulate growth; maturation; reproduction; metabolism; the balances of electrolytes, water, and nutrients; and the balances of behavior and energy F. Concentration in the bloodstream of most hormones is maintained at a constant level. If the hormone concentration rises, further production of that hormone is inhibited (also known as "feedback control") G. Unlike the endocrine, exocrine glands secrete their products through duct(s) into the body's cavities or onto its surface. Exocrine glands produce sweat (sweat glands), skin oils (sebaceous glands), mucus (mucous membranes), and digestive juices (for example, the pancreas in its exocrine function). Disorders of the Anterior Pituitary C. Hypopituitarism 1. Definition - underactivity of the front (anterior) pituitary gland a. classifications of pituitary tumors 1. functioning: hormone present in insufficient quantities 2. non-functioning: hormone absent 2. Etiology - most common cause: neoplasms, usually benign 3. Findings - result from hormone deficiency (hypogonadism) a. hypogonadism, female: 1. amenorrhea 2. infertility 3. decreased libido 4. breast and uterine atrophy 5. loss of axillary and pubic hair 6. vaginal dryness b. hypogonadism, male 1. decreased libido 2. impotence 3. small, soft testicles 4. loss of axillary and pubic hair c. hypothyroidism (because pituitary regulates thyroid glands by thyroid stimulating hormone (TSH)) d. hypoadrenalism (because pituitary regulates adrenal glands by ACTH production)
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e. may see signs of increased intracranial pressure (ICP) Diagnostics a. history and physical exam b. neuro-ophthalmological exam c. x-rays of pituitary fossa
radioimmunoassays of anterior pituitary hormones e. computerized tomogram (CT) scan Management a. expected outcome: hormone deficiency corrected b. hormone replacement therapy
d.
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corticosteroid therapy
CARE OF THE CLIENT WITH INCREASED INTRACRANIAL PRESSURE 1. 2. 3. 4. 5. 6. 7. 8. Monitor neuro vital signs as ordered Maintain fluid restriction as ordered Raise head of bed at 30-45 degrees Prevent any activities that increase ICP such as straining at stool, coughing, vomiting, any restrictive clothing around neck, neck rotation, flexion, extension, anxiety Observe for herniation syndrome Monitor intracranial pressure Administer oxygen as ordered Seizure precautions 2. thyroid hormone replacement 3. sex hormone replacement c. surgical removal of tumor Nursing interventions a. provide for care of the client with increased ICP 2. care of the client undergoing surgery monitor for desired effects of administered medications as ordered provide emotional support with referral to support groups teach client 1. medications desired effects and side effects 2. need for lifelong hormone replacement therapy and regular checks of sirum levels
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b. c. d.
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Hyperpituitarism 1. Definition - anterior pituitary secretes too much growth hormone and/or ACTH 2. Etiology a. usually caused by benign neoplasm
b. c.
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growth hormone overproduction: acromegaly ACTH overproduction leads adrenal gland to overproduce cortisone: Cushing's syndrome
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Findings a. may see signs of increased ICP b. acromegaly: excess longitudinal bone growth c. prognathism d. coarse facial features e. prominent forehead and orbital ridge f. large, broad, spade-like hands g. arthritis, kyphosis Diagnostics a. history and physical exam b. computerized tomogram (CT) scan c. plasma hormone levels: increased growth hormone, ACTH Management
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a. expected outcome: remove tumor and restore hormonal balance b. surgical removal of tumor c. irradiation of gland d. pharmacologic: growth hormone suppressant: bromocriptine (parlodel) Nursing interventions a. provide
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care of the client with increased ICP 2. care of the client undergoing surgery 3. care of the client undergoing radiation therapy 4. emotional support b. assess for signs of diabetes insipidus, since removal of a pituitary tumor may injure the posterior pituitary glands and decrease antidiuretic hormone (ADH) secretions c. teach client that treatment usually produces hypopituitarism so lifelong hormone replacement therapy with regular check-ups are required Disorders of the Posterior Pituitary C. Diabetes insipidus 1. Posterior pituitary gland makes too little antidiuretic hormone (ADH). Body loses too much water in the urine; plasma osmolality and sodium levels increase. 2. Etiology can include tumor, trauma, inflammation, or psychogenic causes. 3. Findings a. excessive thirst (polydipsia) b. polyuria: as much as 20 liters per day with specific gravity below 1.006 c. nocturia signs of dehydration e. constipation Diagnostics a. water deprivation tests: inability to concentrate urine b. osmotic stimulation c. administration of vasopressin (pitressin) or desmopressin acetate (stimate) d. computerized tomogram (CT) scan Management a. expected outcomes: to correct underlying cause and restore hormonal balance b. pharmacotherapy 1. desmopressin acetate (stimate) 2. vasopressin (pitressin) - antidiuretic hormone 3. lypressin (diapid) 4. chloropropamide (chloronase) 5. clofibrate (claripex) 6. carbamazapine (mazepine) c. IV fluid replacement therapy d. surgical removal of tumor Nursing interventions a. monitor for findings of dehydration; measure urine; specific gravity b. administer medications as ordered c. monitor fluids and give IV fluids as ordered d. measure intake and output e. weigh client daily
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care of the client with increased ICP care of the client undergoing surgery teach client 1. to record intake and output 2. about medications and side effects 3. to check urine specific gravity 4. the need to wear disease identification jewelry Disorders of the Thyroid Gland C. Hypothyroidism 1. Definition - an underactive thyroid resulting in a lessened secretion of thyroid hormone a. deficiency of thyroid hormones causing decreased metabolic rate 1. affects more women 2. age group: 30 to 50 years of age g. h.
f.
b.
classifications 1. cretinism: hypothyroidism in children 2. hypothyroidism without myxedema: mild thyroid failure 3. hypothyroidism with myxedema: severe thyroid failure; usually seen in older adults 4. myxedema coma 1. most severe type of hypothyroidism 2. precipitated by stress 3. findings include: 1. hypothermia hypoventilation 4. altered LOC leading to coma potentially life threatening condition
2. 3.
bradycardia
4. 2. Etiology a. b. c. d. Findings a. b. c.
thyroid surgery treatment for hyperthyroid condition overdosage of thyroid medications deficiency in dietary iodine cognitive impairment constipation, fatigue, depression intolerance to cold coarse, dry skin; periorbital edema; thick, brittle nails bradycardia; increased diastolic pressure menstrual changes - increased menstrual flow loss of the outer one-third of eyebrows weight gain fluid retention
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d. e.
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Diagnostics TESTS OF THYROID FUNCTION
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Blood tests 1. Serum Thyroxine (T4) 2. Thyroid-Binding Globulin (TBG) 3. Serum Triiodothyronine (T3) T3 Resin Uptake 5. Free Thyroid Index (FTI) 6. Thyrotropin, Thyroid-Stimulating Hormone (TSH) 7. Thyrotropin-Releasing Hormone (TRH) stimulation test 8. Thyroid autoantibodies Radiologic and imaging tests 1. Radioactive Iodine Uptake (RAIU) I 131 uptake 2. Thyroid scan 3. Thyroid ultrasound a. history and physical exam increased TSH decreased serum T3 and T4 anemia decreased basal metabolic rate (BMR) elevated cholesterol and triglycerides
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hypoglycemia Management a. expected outcomes: to restore hormonal balance and prevent complications b. administer synthetic thyroid hormone: levothyroxine sodium (levothroid)
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myxedema coma: 1. IV fluids as ordered 2. correct hypothermia 3. give synthetic thyroid hormone Nursing interventions a. give medications as ordered b. watch client for signs of myxedema c. provide restful environment d. teach client 1. how to conserve energy 2. how to avoid stress 3. about the medications and side effects - synthyroid is to be taken in the morning on an empty stomach at least one hour before any other medications or vitamins or ingestion of milk 4. the importance of lifelong therapy e. protect client from cold
c.
B.
Hyperthyroidism (Graves' disease, thyrotoxicosois) 1. Definition - overactive thyroid over secretes hormones, and causes increased basal metabolic rate or hyperactivity of thyroid as a primary disease state 2. Etiology - considered autoimmune response a. women affected more than men b. age group: 30 to 50 years 3. Findings a. hyperphagia, weight loss, diarrhea b. heat intolerance c. exophthalmos
d. e.
f. g. h. i. j.
tachycardia
palpitations increased systolic BP difficulty concentrating irritability hyperactivity thin, brittle hair, pliable nails: plummer's nails k. diaphoresis l. insomnia m. reduced tolerance for stress
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Diagnostics a. history and physical exam: palpable thyroid enlargement: (goiter) b. elevated serum T3 and T4 levels c. elevated radioactive iodine uptake d. presence of thyroid autoantibodies e. decreased TSH (thyroid-stimulating hormone; comes from pituitary) levels Complication: thyrotoxic crisis (thyroid storm) a. rare but potentially fatal b. breakdown of body's tolerance to chronic hormone excess c. state of extreme hypermetabolism d. precipitating factors: stress, infection, pregnancy e. findings include: 1. systolic hypertension 2. hyperthermia
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angina infarction or heart failure extreme anxiety even psychosis
Management a. expected outcomes: to reduce the excess hormone secretion and to prevent complications
b.
pharmacologic
PHARMACOLOGIC INTERVENTIONS FOR THYROID DISORDERS 1. 2. 3. Propythiouracil (PTU) Methimazole (TAPAZOLE) Saturated solution of potassium iodide Radioactive iodine (131I) Levothyroxine sodium (SYNTHROID) Liothyronine sodium (CYTOMEL) Strong iodine solution (Lugol's solution) IV sodium iodide Propranolol (Inderal) sodium131I 2. antithyroid agents: propylthiouracil (PTU) 3. beta-adrenergic blocking agents: propranolol (inderol) 4. iodides: useful adjunct c. surgical: thyroidectomy: partial or total removal of thyroid gland d. diet high in calories, protein, carbohydrates 7. Nursing interventions a. monitor vital signs, especially blood pressure and heart rate b. provide quiet, restful, cool environment c. monitor diet therapy d. provide extra fluids e. provide emotional support f. administer medications as ordered g. teach client 1. about medications and side effects 2. stress avoidance measures 3. energy conservation measures h. care of the client undergoing surgery Disorders of the Parathyroid Gland B. Hypoparathyroidism 1. Definition - parathyroid produces too little parathormone; results in hypocalcemia 2. Etiology unknown a. possibly an autoimmune disorder b. most often results from surgical removal of parathyroid glands 3. Findings (mild to severe order) a. neuromuscular 1. irritability 2. personality changes 3. muscular weakness or cramping 4. numbness of fingers 5. tetany 6. carpopedal spasms 7. laryngospasms 8. seizures b. dry, scaly skin c. hair loss d. abdominal cramping
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Diagnostics TESTS OF PARATHYROID FUNCTION
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Parathyroid hormone (PTH) Serum calcium, total Serum calcium, ionized Serum phosphate
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history and physical exam b. positive Chvostek's sign c. positive Trousseau's sign (carpopedal spasm as inflated BP cuff is released) d. decreased serum calcium e. increased serum phosphate Management a. expected outcomes: to restore hormonal balance and prevent complications b. calcium replacement therapy: ideal serum calcium level 8.6mg/dl c. vitamin D preparations facilitate uptake of calcium d. calcium-rich diet Nursing interventions a. monitor carefully for signs of tetany
a.
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place airway, suction and tracheotomy tray at bedside institute seizure precautions administer medications as ordered teach client 1. about medications and side effects 2. signs of vitamin D toxicity 3. to consume more calcium and get vitamin D from sun exposure to skin 4. to reduce phosphorus intake: minimize intake of fish, eggs, cheese and cereals Hyperparathyroidism 1. Definition - parathyroid secretes too much parathormone; results in increased serum calcium (hypercalcemia) 2. Etiology a. benign growth in parathyroid b. secondarily as result of kidney disease or osteomalacia c. incidence increases dramatically in both sexes after age 50 3. Findings a. many clients are asymptomatic b. gastrointestinal: constipation, nausea, vomiting, anorexia c. skeletal: bone pain and demineralization d. irritability e. muscle weakness and fatigue c. d. e.
b.
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1. 2. 3. 4.
Diagnostics
TESTS OF PARATHYROID FUNCTION
Parathyroid hormone (PTH) Serum calcium, total Serum calcium, ionized Serum phosphate a. b. c. d. history and physical exam elevated serum calcium decreased serum phosphate level x-rays reveal bone demineralization
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Management
PHARMACOLOGIC INTERVENTIONS FOR HYPERPARATHYROIDISM 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Hydration with 0.9% normal saline solution Diuretics Plicamycin Didronel Glucocorticoids Phosphate as antihypercalcemic agent Calcitonin Estrogen Etidronate disodium Phosphate-binding antacid Calcium supplement
11. Vitamin D a. expected outcomes: to restore hormonal balance and prevent complications b. surgery: removal of parathyroid glands - parathyroidectomy 6. Nursing interventions a. care of the client undergoing surgery b. after surgery observe for signs of hypocalcemia c. after surgery, teach client to consume diet rich in calcium Disorders of the Adrenal Gland B. Addison's disease 1. Definition a. adrenal cortex secretes too little adrenocorticotropic hormone (ACTH) decreases secretion of other adrenal products: mineralocorticoid, glucocorticoids, and sex hormones c. relatively rare Etiology - autoimmune adrenalitis Findings a. acute adrenal insufficiency (Addisonian crisis) 1. severe headache or back pain 2. severe generalized muscle weakness 3. diarrhea or constipation 4. confusion 5. lethargy 6. severe hypotension 7. circulatory collapse b. adrenal insufficiency 1. vague complaints or findings 2. fatigue 3. muscle weakness 4. vague abdominal complaints: anorexia, nausea, vomiting 5. personality changes 6. skin pigmentation Diagnostics a. history and physical exam b. ACTH stimulation test: low cortisol level c. low blood levels of sodium and glucose and high levels of potassium d. 24-hour urine collection: decreased levels of free cortisol Management
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Test of Adrenal Function 4.
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Blood and Urine Tests B. Dexamethasone suppression test for cortisol levels C. Fasting prephlebotomy for cortisol plasma level D. 17-hydroxycorticosterone (Porter-Silber test) 17-OCHS E. 17-ketosteroids F. Aldosterone G. Urinary cortisol level H. Renin level ACTH I. Captopril test Radiologic and Imaging: Angiography of Adrenals a. expected outcome: to return to hormonal balance b. Addisonian crisis 1. emergency management of circulatory collapse c.
2. intravenous hydrocortisone chronic insufficiency 1. glucocorticoid replacement therapy: hydrocortisone (cortef)
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mineralocorticoid replacement therapy: fludrocortisone acetate (florinef acetate) 3. diet high in protein, carbohydrates, and sodium Nursing interventions during hospitalization a. administer medications as ordered b. manipulate the environment to reduce stressors c. preserve the client's energy by assisting with ADL as indicated d. monitor diet therapy e. measure intake and output and observe for signs of hyponatremia, hyperkalemia, and hypoglycemia. f. teach client 1. about medications and side effects 2. the need for lifelong hormone-replacement therapy 3. the need for medical-alert jewelry 4. how to conserve energy 5. how to avoid or minimize stress 6. guidelines for diet: high sodium
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Here's how to remember hyponatremia: "hypo" means "beneath" and "Na" is the chemical abbreviation for sodium. And if "K" is the chemical abbreviation for potassium, what's "hypokalemia"? B. Cushing's syndrome 1. Definition: adrenal gland secretes too much cortisol 2. Etiology a. average age of onset 20 to 40 years of age b. affects women more often than men c. primary syndrome caused by tumor of adrenal cortex d. secondary syndrome caused by an ACTH-producing tumor of pituitary e. long term steroid therapy 3. Findings a. personality changes b. hypertension
c. d.
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metabolic alkalosis weight gain, buffalo hump, truncal obesity change in libido moon face muscle weakness virilization in women, amenorrhea, or menstrual irregularities osteoporosis acne or hyperpigmentation
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Diagnostics a. history and physical exam b. blood tests show 1. increased levels of cortisol, 2. increased sodium and glucose, 3. decreased potassium c. 24-hour urine collection: 1. elevated free cortisol 2. elevated 17-ketosteroids
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3. elevated 17-hydroxycorticosterone Management a. expected outcome: to restore hormonal balance b. surgery for adrenal or pituitary tumor c. irradiation therapy d. pharmacologic e. adrenal enzyme inhibitors that block enzymes needed for cortisol synthesis 1. aminogluthemide 2. metyrapone
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3. mitotane f. potassium supplements g. high protein diet with sodium restriction Nursing interventions a. administer medications as ordered b. monitor diet therapy c. monitor for signs of hypokalemia, hypernatremia d. teach client CARE OF CLIENT ON STEROID THERAPY
Teach client to: 1. 2. 3. 4. 5. 6. 7. 8. Never discontinue medications abruptly- could precipitate acute crisis. Take medication with breakfast - corresponds to biorhythms and reduces gastric irritation. Take higher dose in AM and lower doses in PM. Always take medication with a meal or a snack. Carry extra medication on self during travel. Adjust medications during periods of acute or chronic stress such as pregnancy or infections; contact health care provider. Wear medical identification jewelry or carry medical card . Avoid other people with infections or shopping malls, grocery stores, etc in times when the flu or colds are most evident. 1. the need for lifelong treatment 2. about medications and side effects 3. the need for medical alert jewelry surgical treatment may cause adrenal or pituitary insufficiency
C.
e. Pheochromocytoma 1. Definition Adrenal medulla secretes too much epinephrine and norepinephrine (called the catecholamines). Causes excessive stimulation of the sympathetic nervous system 2. Etiology a. generally benign tumor of the adrenal medulla b. curable, but fatal if untreated 3. Findings a. severe stress response b. panic metabolic state c. hypertensive crisis d. headache, usually severe e. orthostatic hypotension f. tachycardia g. pallor or flushing h. diaphoresis i. palpitations j. anxiety, high and sustained k. hyperglycemia l. dysrhythmias
When reading the stem of the question, give special attention to words such as: BEST, MOST, LEAST, FIRST, PRIORITY, INITIAL.
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Diagnostics increased BMR b. computerized tomogram (CT) scan c. 24-hour urine collection: increased urinary catecholamines Management a. expected outcomes: to remove the tumor and correct the imbalance
a.
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surgical removal of the tumor: scheduled only after client has been normotensive for at least one week c. antihypertensive agents as needed preop d. alpha-adrenergic blocking agent and beta adrenergic blocking agent (beta blockers): phentolamine (regitine), nitroprusside (nitropress), propranolol (inderal) e. tyrosine inhibitors: alphamethylparatyrosine decreases circulating catecholamines f. antidysrhythmic agents as needed preop Nursing interventions a. monitor vital signs, especially blood pressure b. administer medications as ordered c. provide care of the client undergoing surgery
b.
d.
if bilateral adrenalectomy performed, lifelong steroid therapy
required
CARE OF CLIENT ON STEROID THERAPY
Teach client to:
1. 2. 3. 4. 5. 6. 7. 8. Never discontinue medications abruptly- could precipitate acute crisis. Take medication with breakfast - corresponds to biorhythms and reduces gastric irritation. Take higher dose in AM and lower doses in PM. Always take medication with a meal or a snack. Carry extra medication on self during travel. Adjust medications during periods of acute or chronic stress such as pregnancy or infections; contact health care provider. Wear medical identification jewelry or carry medical card . Avoid other people with infections or shopping malls, grocery stores, etc in times when the flu or colds are most evident. e. 2. teach client i. about medications and side effects ii. need for lifelong followup
Disorders of the Pancreas 1. Diabetes mellitus 4. Definition - a condition in which the pancreas produces too little insulin, or cells stop responding to insulin; results in hyperglycemia a. type 1 diabetes mellitus: genetic, auto-immune respones; severe insulin deficiency from beta cells stop production of insulin b. type 2 diabetes mellitus: obesity; cells stop responding to insulin
Be cautious of “absolute” words: ONLY, MUST, ALWAYS, NEVER which signal that the option is wrong.
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Diagnostics
TESTS FOR DIABETES MELLITUS (FUNCTION OF PANCREAS)
Glucose Tolerance Test (GTT) Glycated Hemoglobin (Glycohemoglobin, Glycosylated Hemoglobin, HbA) - gives average glucose level for prior two to three months Blood glucose - fasting C-Peptide Assay (Connecting Peptide Assay) Fructosamine Assay Blood glucose monitoring - finger sticks Serum glucose and osmolarity Serum sodium and potassium BUN and creatinine
10. Urine glucose and ketone monitoring 11. Urine specific gravity a. history and physical exam b. fasting blood sugar: elevated serum glucose levels c. oral glucose tolerance test (GTT) d. after meal, serum glucose is elevated - post-prandial glucose e. glycosylated hemoglobin test (A1c test) Data collection a. hyperglycemia b. the 3 "polys" of diabetes mellitus: polydipsia, polyuria, polyphagia c. additional findings: fatigue, hunger, weight loss d. blurred vision e. slow wound healing
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It's oversimplified, but if it helps you, think of the relation between insulin and glucose as a see-saw. When one is higher, the other tends to be lower. 4. Management a. diet therapy and weight loss i. the total number of calories is individualized according to the client's weight ii. as prescribed by the care provider, the client may be advised to follow dietary guidelines for Americans (food guide pyramid) or individualized food exchanges from the American Diabetic Association b. exercise i. lowers glucose level and improves circulation ii. decreases total cholesterol and triglycerides iii. instruct client to monitor glucose before exercising iv. before exercise, clients who require insulin should eat a carbohydrate snack with protein to prevent hypoglycemia c. insulin i. used in type 1 diabetes mellitus (DM) and type 2 DM, if needed for better control of blood glucose levels ii. regular insulin, the only insulin that is given IV, is used for ketoacidosis iii. check other medications the client is taking iv. illness, infections, and stress increase the need for insulin v. instruct client about the importance of rotating injection within one region (the abdomen absorbs insulin the most rapidly) vi. insulin administration: see Pharmacology section of this course vii. insulin pens, jet injectors, and insulin pumps are used to administer insulin d. oral antidiabetic medications i. prescribed for clients with type 2 DM ii. monitor blood glucose levels iii. check other medications the client is taking iv. instruct the client to recognize manifestations for hypoglycemia and hyperglycemia v. pancreas transplant vi. islet cell transplant vii. blood glucose monitoring - with different self-check systems Medications a. type 1 DM: insulin therapy b. type 2 DM: oral hypoglycemic agents Complications a. hypoglycemia (insulin shock) i. blood sugar falls below 50 mg / dl ii. caused by too much insulin, too little food, or excessive physical activity iii. may result from delayed meals, exercise, or vomiting
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rapid onset v. findings of insulin shock 1. diaphoresis; cold, clammy skin 2. anxiety, tremor, slurred speech 3. weakness 4. nausea 5. mental confusion, personality changes, altered LOC 6. headache vi. management of hypoglycemia 1. if client is conscious, give oral sugar: hard candy, honey, Karo syrup, jelly, cola 2. if unconscious: give one mg glucagon IM, IV or subcutaneous (SC); or 20 to 50 ml 50% dextrose IV push diabetic ketoacidosis (DKA) - an acute complication i. results from severe insulin deficiency ii. findings 1. blood sugar levels > 350 mg/dl 2. elevated ketone levels: sweet odor to breath may also have odor of someone drinking alcohol 3. metabolic acidosis: Kussmaul's respirations, flushed appearance, dry skin 4. thirst 5. polyuria 6. drowsiness 7. anorexia, vomiting 8. may lead to shock and coma 9. usual causes: 1. undiagnosed diabetes mellitus 2. inadequacy of prescribed therapy for diabetes mellitus 3. physical stress such as surgery, illness, or trauma in person with diabetes mellitus 4. caused by increased gluconeogenesis from amino acids and glycogenolysis in the liver 10. management: 1. correct fluid depletion - IV fluids 2. correct electrolyte depletion - replacement particularly of potassium 3. correct metabolic acidosis - insulin IV hyperglycemic, hyperosmolar nonketotic coma (HHNKC) i. potentially fatal ii. findings 1. severe hyperglycemia; usually > 600 mg/dl plasma hyperosmolarity dehydration altered LOC - decreased 5. absence of ketoacidosis iii. usually precipitated by physical stress such as an infection; iv. in non-diabetics can be due to tube feedings without supplemental water, or too rapid rate of infusion for parenteral nutrition v. occurs more often in the elderly, typically vi. expected: to correct fluid depletion, insulin deficiency, and electrolyte imbalance other chronic complications i. diabetic triopathy 1. retinopathy 3. 4. neuropathy macrovascular disease in the 1. coronary artery
iv.
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d.
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nephropathy
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2. peripheral vascular Nursing interventions a. give medications as ordered b. monitor for findings of hyperglycemia or hypoglycemia c. help client monitor blood glucose d. refer client to dietician for planing of meals e. support client emotionally f. teach client i. the importance of balanced, consistent daily focus of diet, medication and exercise ii. self blood-glucose monitoring iii. dietary exchange system or refer to appropriate resources iv. about medications and side effects
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vii. viii.
foot care early reporting of complications of 1. ketoacidosis 2. insulin shock 3. long term issues about insulin administration about the need to: 1. eat more before strenuous exercise 2. carry extra rapid-absorbing carbohydrate on person at all times 3. wear medical-alert jewelry 4. have regular eye exams 5. consider emergency care for insulin shock
About Insulin
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In the pancreas's islets of Langerhans, beta cells secrete insulin-the islet-cell hormone of major physiological importance; Without sufficient insulin, the body develops diabetes mellitus. Exploration of a number of new delivery systems for insulin is ongoing. Implanted insulin delivery systems, in combination with a glucose sensor may create an "artificial pancreas." Exercise increases the body's metabolic rate to result in a decrease in blood sugar and an increase in insulin sensitivity. Signs of hypoglycemia often occur. Illness can disrupt metabolic control and raise blood sugar, which results in an increased need for insulin. Insulin-dependent clients should be well controlled for at least one week prior to any surgery. Special care for any client with either type of diabetes mellitus should be taken to monitor blood glucose during and after surgery and adjust insulin accordingly.
About the Thyroid
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Following neck surgery, potentially life-threatening complications such as laryngeal edema and tracheal obstruction can occur. Monitor for respiratory distress. Following thyroid surgery, many clients suffer transient hypocalcemia from hyporfunction or removal of the parathyroids. Monitor for signs of tetany for up to three days after surgery.
About the Parathyroid
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Positive Chvostek's sign: contraction of facial muscle near mouth occurs when light tap is given over facial nerve in front of ear. Positive Trousseau's sign: carpopedal spasm results during the deflation of a blood pressure cuff that has been inflated for at least one minute.
Calcitonin Corpus luteum Hashimoto's thyroiditis
Hyperplasia Medullary carcinoma Microangiopathy NPH insulin Papillary adenoma Polyphagia Endocrine
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Adrenal glands Endocrine system Pancreas and its relation to the duodenum Pituitary gland and hypothalamus Pituitary gland Thyroid gland and related structures
I.
Anatomy and Physiology (illustration ) A. The endocrine system, together with the neurological system, functions as the communication system for the body B. Endocrine glands secrete hormones 1. Secreted in very small amounts 2. Alters the rate of many physiologic activities a. reproduction b. metabolism c. growth and development d. neurological and mental functions 3. Secreted into the blood 4. Regulated by several methods a. autonomic nervous system b. changes in concentrations of specific substances in plasma c. feedback system C. Glands Pituitary (illustration 1 illustration 2 ) 1. Lies in sella turcica above the sphenoid bone 2. Consists of two lobes connected by the hypothalamus 3. Regulates the other endocrine glands by stimulating target organs 4. Controlled by releasing and inhibiting hormones from the hypothalamus Thyroid gland (illustration ) 1. Located at the level of the cricoid cartilage in front of the trachea 2. Two highly vascular lobes 3. Controls the rate of the body metabolism Parathyroid glands - parathormone (PTH) 1. Four small glands located near the thyroid gland 2. Controls calcium and phosphorus metabolism Adrenal glands (illustration ) 1. Two small glands lying in the retroperitoneal region 2. Functions a. cortex - promotes organic metabolism, regulates sodium and potassium, response to stress, preadolescent growth spurt b. medulla - stimulation of sympathetic nervous system, responds to stress
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Pancreas - insulin, glucagon secretion into the blood, an endocrine function (illustration ) 1. Lies retroperitoneally, with the head of the gland in the duodenal cavity and the tail lying against the spleen 2. Excretion of enzymes and bicarbonate that aid digestion and controls carbohydrate metabolism as an exocrine function I. Gonads - ovaries, estrogen, progesterone, inhibin - decreases secretion of follicle-stimulating hormone (FSH); testes, testosterone 1. Located: two ovaries are situated in the lower abdomen on each side of the uterus. The testes are the pair of male sex organs that form within the abdomen but descend into the scrotum 2. Responsible for secondary sex characteristics and reproductive function General Concepts C. Endocrine glands must maintain homeostasis of about 50 billion cells.
H.
D.
Endocrine glands are ductless, and secrete many hormones
directly into the blood or lymph.
Endocrine Glands and their Secretions
3.
These hormones regulate growth; maturation; reproduction; metabolism; the balances of electrolytes, water, and nutrients; and the balances of behavior and energy F. Concentration in the bloodstream of most hormones is maintained at a constant level. If the hormone concentration rises, further production of that hormone is inhibited (also known as "feedback control") G. Unlike the endocrine, exocrine glands secrete their products through duct(s) into the body's cavities or onto its surface. Exocrine glands produce sweat (sweat glands), skin oils (sebaceous glands), mucus (mucous membranes), and digestive juices (for example, the pancreas in its exocrine function). Disorders of the Anterior Pituitary C. Hypopituitarism 1. Definition - underactivity of the front (anterior) pituitary gland a. classifications of pituitary tumors 1. functioning: hormone present in insufficient quantities 2. non-functioning: hormone absent 2. Etiology - most common cause: neoplasms, usually benign 3. Findings - result from hormone deficiency (hypogonadism) a. hypogonadism, female: 1. amenorrhea 2. infertility 3. decreased libido 4. breast and uterine atrophy 5. loss of axillary and pubic hair 6. vaginal dryness b. hypogonadism, male 1. decreased libido 2. impotence 3. small, soft testicles 4. loss of axillary and pubic hair c. hypothyroidism (because pituitary regulates thyroid glands by thyroid stimulating hormone (TSH)) d. hypoadrenalism (because pituitary regulates adrenal glands by ACTH production)
E.
4.
e. may see signs of increased intracranial pressure (ICP) Diagnostics a. history and physical exam b. neuro-ophthalmological exam c. x-rays of pituitary fossa
radioimmunoassays of anterior pituitary hormones e. computerized tomogram (CT) scan Management a. expected outcome: hormone deficiency corrected b. hormone replacement therapy
d.
5.
1.
corticosteroid therapy
CARE OF THE CLIENT WITH INCREASED INTRACRANIAL PRESSURE 1. 2. 3. 4. 5. 6. 7. 8. Monitor neuro vital signs as ordered Maintain fluid restriction as ordered Raise head of bed at 30-45 degrees Prevent any activities that increase ICP such as straining at stool, coughing, vomiting, any restrictive clothing around neck, neck rotation, flexion, extension, anxiety Observe for herniation syndrome Monitor intracranial pressure Administer oxygen as ordered Seizure precautions 2. thyroid hormone replacement 3. sex hormone replacement c. surgical removal of tumor Nursing interventions a. provide for care of the client with increased ICP 2. care of the client undergoing surgery monitor for desired effects of administered medications as ordered provide emotional support with referral to support groups teach client 1. medications desired effects and side effects 2. need for lifelong hormone replacement therapy and regular checks of sirum levels
6.
1.
b. c. d.
D.
Hyperpituitarism 1. Definition - anterior pituitary secretes too much growth hormone and/or ACTH 2. Etiology a. usually caused by benign neoplasm
b. c.
3.
growth hormone overproduction: acromegaly ACTH overproduction leads adrenal gland to overproduce cortisone: Cushing's syndrome
4.
5.
Findings a. may see signs of increased ICP b. acromegaly: excess longitudinal bone growth c. prognathism d. coarse facial features e. prominent forehead and orbital ridge f. large, broad, spade-like hands g. arthritis, kyphosis Diagnostics a. history and physical exam b. computerized tomogram (CT) scan c. plasma hormone levels: increased growth hormone, ACTH Management
6.
a. expected outcome: remove tumor and restore hormonal balance b. surgical removal of tumor c. irradiation of gland d. pharmacologic: growth hormone suppressant: bromocriptine (parlodel) Nursing interventions a. provide
4.
care of the client with increased ICP 2. care of the client undergoing surgery 3. care of the client undergoing radiation therapy 4. emotional support b. assess for signs of diabetes insipidus, since removal of a pituitary tumor may injure the posterior pituitary glands and decrease antidiuretic hormone (ADH) secretions c. teach client that treatment usually produces hypopituitarism so lifelong hormone replacement therapy with regular check-ups are required Disorders of the Posterior Pituitary C. Diabetes insipidus 1. Posterior pituitary gland makes too little antidiuretic hormone (ADH). Body loses too much water in the urine; plasma osmolality and sodium levels increase. 2. Etiology can include tumor, trauma, inflammation, or psychogenic causes. 3. Findings a. excessive thirst (polydipsia) b. polyuria: as much as 20 liters per day with specific gravity below 1.006 c. nocturia signs of dehydration e. constipation Diagnostics a. water deprivation tests: inability to concentrate urine b. osmotic stimulation c. administration of vasopressin (pitressin) or desmopressin acetate (stimate) d. computerized tomogram (CT) scan Management a. expected outcomes: to correct underlying cause and restore hormonal balance b. pharmacotherapy 1. desmopressin acetate (stimate) 2. vasopressin (pitressin) - antidiuretic hormone 3. lypressin (diapid) 4. chloropropamide (chloronase) 5. clofibrate (claripex) 6. carbamazapine (mazepine) c. IV fluid replacement therapy d. surgical removal of tumor Nursing interventions a. monitor for findings of dehydration; measure urine; specific gravity b. administer medications as ordered c. monitor fluids and give IV fluids as ordered d. measure intake and output e. weigh client daily
1.
d.
4.
5.
6.
5.
care of the client with increased ICP care of the client undergoing surgery teach client 1. to record intake and output 2. about medications and side effects 3. to check urine specific gravity 4. the need to wear disease identification jewelry Disorders of the Thyroid Gland C. Hypothyroidism 1. Definition - an underactive thyroid resulting in a lessened secretion of thyroid hormone a. deficiency of thyroid hormones causing decreased metabolic rate 1. affects more women 2. age group: 30 to 50 years of age g. h.
f.
b.
classifications 1. cretinism: hypothyroidism in children 2. hypothyroidism without myxedema: mild thyroid failure 3. hypothyroidism with myxedema: severe thyroid failure; usually seen in older adults 4. myxedema coma 1. most severe type of hypothyroidism 2. precipitated by stress 3. findings include: 1. hypothermia hypoventilation 4. altered LOC leading to coma potentially life threatening condition
2. 3.
bradycardia
4. 2. Etiology a. b. c. d. Findings a. b. c.
thyroid surgery treatment for hyperthyroid condition overdosage of thyroid medications deficiency in dietary iodine cognitive impairment constipation, fatigue, depression intolerance to cold coarse, dry skin; periorbital edema; thick, brittle nails bradycardia; increased diastolic pressure menstrual changes - increased menstrual flow loss of the outer one-third of eyebrows weight gain fluid retention
3.
d. e.
f. g. h. i.
4.
Diagnostics TESTS OF THYROID FUNCTION
A.
Blood tests 1. Serum Thyroxine (T4) 2. Thyroid-Binding Globulin (TBG) 3. Serum Triiodothyronine (T3) T3 Resin Uptake 5. Free Thyroid Index (FTI) 6. Thyrotropin, Thyroid-Stimulating Hormone (TSH) 7. Thyrotropin-Releasing Hormone (TRH) stimulation test 8. Thyroid autoantibodies Radiologic and imaging tests 1. Radioactive Iodine Uptake (RAIU) I 131 uptake 2. Thyroid scan 3. Thyroid ultrasound a. history and physical exam increased TSH decreased serum T3 and T4 anemia decreased basal metabolic rate (BMR) elevated cholesterol and triglycerides
4.
B.
b.
c.
d.
e.
5.
hypoglycemia Management a. expected outcomes: to restore hormonal balance and prevent complications b. administer synthetic thyroid hormone: levothyroxine sodium (levothroid)
f. g.
6.
myxedema coma: 1. IV fluids as ordered 2. correct hypothermia 3. give synthetic thyroid hormone Nursing interventions a. give medications as ordered b. watch client for signs of myxedema c. provide restful environment d. teach client 1. how to conserve energy 2. how to avoid stress 3. about the medications and side effects - synthyroid is to be taken in the morning on an empty stomach at least one hour before any other medications or vitamins or ingestion of milk 4. the importance of lifelong therapy e. protect client from cold
c.
B.
Hyperthyroidism (Graves' disease, thyrotoxicosois) 1. Definition - overactive thyroid over secretes hormones, and causes increased basal metabolic rate or hyperactivity of thyroid as a primary disease state 2. Etiology - considered autoimmune response a. women affected more than men b. age group: 30 to 50 years 3. Findings a. hyperphagia, weight loss, diarrhea b. heat intolerance c. exophthalmos
d. e.
f. g. h. i. j.
tachycardia
palpitations increased systolic BP difficulty concentrating irritability hyperactivity thin, brittle hair, pliable nails: plummer's nails k. diaphoresis l. insomnia m. reduced tolerance for stress
4.
5.
Diagnostics a. history and physical exam: palpable thyroid enlargement: (goiter) b. elevated serum T3 and T4 levels c. elevated radioactive iodine uptake d. presence of thyroid autoantibodies e. decreased TSH (thyroid-stimulating hormone; comes from pituitary) levels Complication: thyrotoxic crisis (thyroid storm) a. rare but potentially fatal b. breakdown of body's tolerance to chronic hormone excess c. state of extreme hypermetabolism d. precipitating factors: stress, infection, pregnancy e. findings include: 1. systolic hypertension 2. hyperthermia
3.
4. 5. 6. 6.
angina infarction or heart failure extreme anxiety even psychosis
Management a. expected outcomes: to reduce the excess hormone secretion and to prevent complications
b.
pharmacologic
PHARMACOLOGIC INTERVENTIONS FOR THYROID DISORDERS 1. 2. 3. Propythiouracil (PTU) Methimazole (TAPAZOLE) Saturated solution of potassium iodide Radioactive iodine (131I) Levothyroxine sodium (SYNTHROID) Liothyronine sodium (CYTOMEL) Strong iodine solution (Lugol's solution) IV sodium iodide Propranolol (Inderal) sodium131I 2. antithyroid agents: propylthiouracil (PTU) 3. beta-adrenergic blocking agents: propranolol (inderol) 4. iodides: useful adjunct c. surgical: thyroidectomy: partial or total removal of thyroid gland d. diet high in calories, protein, carbohydrates 7. Nursing interventions a. monitor vital signs, especially blood pressure and heart rate b. provide quiet, restful, cool environment c. monitor diet therapy d. provide extra fluids e. provide emotional support f. administer medications as ordered g. teach client 1. about medications and side effects 2. stress avoidance measures 3. energy conservation measures h. care of the client undergoing surgery Disorders of the Parathyroid Gland B. Hypoparathyroidism 1. Definition - parathyroid produces too little parathormone; results in hypocalcemia 2. Etiology unknown a. possibly an autoimmune disorder b. most often results from surgical removal of parathyroid glands 3. Findings (mild to severe order) a. neuromuscular 1. irritability 2. personality changes 3. muscular weakness or cramping 4. numbness of fingers 5. tetany 6. carpopedal spasms 7. laryngospasms 8. seizures b. dry, scaly skin c. hair loss d. abdominal cramping
4.
5. 6. 7. 8. 9.
1.
2.
4.
Diagnostics TESTS OF PARATHYROID FUNCTION
1. 2. 3. 4.
Parathyroid hormone (PTH) Serum calcium, total Serum calcium, ionized Serum phosphate
5.
6.
history and physical exam b. positive Chvostek's sign c. positive Trousseau's sign (carpopedal spasm as inflated BP cuff is released) d. decreased serum calcium e. increased serum phosphate Management a. expected outcomes: to restore hormonal balance and prevent complications b. calcium replacement therapy: ideal serum calcium level 8.6mg/dl c. vitamin D preparations facilitate uptake of calcium d. calcium-rich diet Nursing interventions a. monitor carefully for signs of tetany
a.
C.
place airway, suction and tracheotomy tray at bedside institute seizure precautions administer medications as ordered teach client 1. about medications and side effects 2. signs of vitamin D toxicity 3. to consume more calcium and get vitamin D from sun exposure to skin 4. to reduce phosphorus intake: minimize intake of fish, eggs, cheese and cereals Hyperparathyroidism 1. Definition - parathyroid secretes too much parathormone; results in increased serum calcium (hypercalcemia) 2. Etiology a. benign growth in parathyroid b. secondarily as result of kidney disease or osteomalacia c. incidence increases dramatically in both sexes after age 50 3. Findings a. many clients are asymptomatic b. gastrointestinal: constipation, nausea, vomiting, anorexia c. skeletal: bone pain and demineralization d. irritability e. muscle weakness and fatigue c. d. e.
b.
4.
1. 2. 3. 4.
Diagnostics
TESTS OF PARATHYROID FUNCTION
Parathyroid hormone (PTH) Serum calcium, total Serum calcium, ionized Serum phosphate a. b. c. d. history and physical exam elevated serum calcium decreased serum phosphate level x-rays reveal bone demineralization
5.
Management
PHARMACOLOGIC INTERVENTIONS FOR HYPERPARATHYROIDISM 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Hydration with 0.9% normal saline solution Diuretics Plicamycin Didronel Glucocorticoids Phosphate as antihypercalcemic agent Calcitonin Estrogen Etidronate disodium Phosphate-binding antacid Calcium supplement
11. Vitamin D a. expected outcomes: to restore hormonal balance and prevent complications b. surgery: removal of parathyroid glands - parathyroidectomy 6. Nursing interventions a. care of the client undergoing surgery b. after surgery observe for signs of hypocalcemia c. after surgery, teach client to consume diet rich in calcium Disorders of the Adrenal Gland B. Addison's disease 1. Definition a. adrenal cortex secretes too little adrenocorticotropic hormone (ACTH) decreases secretion of other adrenal products: mineralocorticoid, glucocorticoids, and sex hormones c. relatively rare Etiology - autoimmune adrenalitis Findings a. acute adrenal insufficiency (Addisonian crisis) 1. severe headache or back pain 2. severe generalized muscle weakness 3. diarrhea or constipation 4. confusion 5. lethargy 6. severe hypotension 7. circulatory collapse b. adrenal insufficiency 1. vague complaints or findings 2. fatigue 3. muscle weakness 4. vague abdominal complaints: anorexia, nausea, vomiting 5. personality changes 6. skin pigmentation Diagnostics a. history and physical exam b. ACTH stimulation test: low cortisol level c. low blood levels of sodium and glucose and high levels of potassium d. 24-hour urine collection: decreased levels of free cortisol Management
3.
b.
2. 3.
4.
5.
Test of Adrenal Function 4.
5.
Blood and Urine Tests B. Dexamethasone suppression test for cortisol levels C. Fasting prephlebotomy for cortisol plasma level D. 17-hydroxycorticosterone (Porter-Silber test) 17-OCHS E. 17-ketosteroids F. Aldosterone G. Urinary cortisol level H. Renin level ACTH I. Captopril test Radiologic and Imaging: Angiography of Adrenals a. expected outcome: to return to hormonal balance b. Addisonian crisis 1. emergency management of circulatory collapse c.
2. intravenous hydrocortisone chronic insufficiency 1. glucocorticoid replacement therapy: hydrocortisone (cortef)
2.
mineralocorticoid replacement therapy: fludrocortisone acetate (florinef acetate) 3. diet high in protein, carbohydrates, and sodium Nursing interventions during hospitalization a. administer medications as ordered b. manipulate the environment to reduce stressors c. preserve the client's energy by assisting with ADL as indicated d. monitor diet therapy e. measure intake and output and observe for signs of hyponatremia, hyperkalemia, and hypoglycemia. f. teach client 1. about medications and side effects 2. the need for lifelong hormone-replacement therapy 3. the need for medical-alert jewelry 4. how to conserve energy 5. how to avoid or minimize stress 6. guidelines for diet: high sodium
2.
Here's how to remember hyponatremia: "hypo" means "beneath" and "Na" is the chemical abbreviation for sodium. And if "K" is the chemical abbreviation for potassium, what's "hypokalemia"? B. Cushing's syndrome 1. Definition: adrenal gland secretes too much cortisol 2. Etiology a. average age of onset 20 to 40 years of age b. affects women more often than men c. primary syndrome caused by tumor of adrenal cortex d. secondary syndrome caused by an ACTH-producing tumor of pituitary e. long term steroid therapy 3. Findings a. personality changes b. hypertension
c. d.
e.
metabolic alkalosis weight gain, buffalo hump, truncal obesity change in libido moon face muscle weakness virilization in women, amenorrhea, or menstrual irregularities osteoporosis acne or hyperpigmentation
f.
g.
h.
i.
j. 4.
Diagnostics a. history and physical exam b. blood tests show 1. increased levels of cortisol, 2. increased sodium and glucose, 3. decreased potassium c. 24-hour urine collection: 1. elevated free cortisol 2. elevated 17-ketosteroids
5.
3. elevated 17-hydroxycorticosterone Management a. expected outcome: to restore hormonal balance b. surgery for adrenal or pituitary tumor c. irradiation therapy d. pharmacologic e. adrenal enzyme inhibitors that block enzymes needed for cortisol synthesis 1. aminogluthemide 2. metyrapone
6.
3. mitotane f. potassium supplements g. high protein diet with sodium restriction Nursing interventions a. administer medications as ordered b. monitor diet therapy c. monitor for signs of hypokalemia, hypernatremia d. teach client CARE OF CLIENT ON STEROID THERAPY
Teach client to: 1. 2. 3. 4. 5. 6. 7. 8. Never discontinue medications abruptly- could precipitate acute crisis. Take medication with breakfast - corresponds to biorhythms and reduces gastric irritation. Take higher dose in AM and lower doses in PM. Always take medication with a meal or a snack. Carry extra medication on self during travel. Adjust medications during periods of acute or chronic stress such as pregnancy or infections; contact health care provider. Wear medical identification jewelry or carry medical card . Avoid other people with infections or shopping malls, grocery stores, etc in times when the flu or colds are most evident. 1. the need for lifelong treatment 2. about medications and side effects 3. the need for medical alert jewelry surgical treatment may cause adrenal or pituitary insufficiency
C.
e. Pheochromocytoma 1. Definition Adrenal medulla secretes too much epinephrine and norepinephrine (called the catecholamines). Causes excessive stimulation of the sympathetic nervous system 2. Etiology a. generally benign tumor of the adrenal medulla b. curable, but fatal if untreated 3. Findings a. severe stress response b. panic metabolic state c. hypertensive crisis d. headache, usually severe e. orthostatic hypotension f. tachycardia g. pallor or flushing h. diaphoresis i. palpitations j. anxiety, high and sustained k. hyperglycemia l. dysrhythmias
When reading the stem of the question, give special attention to words such as: BEST, MOST, LEAST, FIRST, PRIORITY, INITIAL.
4.
Diagnostics increased BMR b. computerized tomogram (CT) scan c. 24-hour urine collection: increased urinary catecholamines Management a. expected outcomes: to remove the tumor and correct the imbalance
a.
5.
6.
surgical removal of the tumor: scheduled only after client has been normotensive for at least one week c. antihypertensive agents as needed preop d. alpha-adrenergic blocking agent and beta adrenergic blocking agent (beta blockers): phentolamine (regitine), nitroprusside (nitropress), propranolol (inderal) e. tyrosine inhibitors: alphamethylparatyrosine decreases circulating catecholamines f. antidysrhythmic agents as needed preop Nursing interventions a. monitor vital signs, especially blood pressure b. administer medications as ordered c. provide care of the client undergoing surgery
b.
d.
if bilateral adrenalectomy performed, lifelong steroid therapy
required
CARE OF CLIENT ON STEROID THERAPY
Teach client to:
1. 2. 3. 4. 5. 6. 7. 8. Never discontinue medications abruptly- could precipitate acute crisis. Take medication with breakfast - corresponds to biorhythms and reduces gastric irritation. Take higher dose in AM and lower doses in PM. Always take medication with a meal or a snack. Carry extra medication on self during travel. Adjust medications during periods of acute or chronic stress such as pregnancy or infections; contact health care provider. Wear medical identification jewelry or carry medical card . Avoid other people with infections or shopping malls, grocery stores, etc in times when the flu or colds are most evident. e. 2. teach client i. about medications and side effects ii. need for lifelong followup
Disorders of the Pancreas 1. Diabetes mellitus 4. Definition - a condition in which the pancreas produces too little insulin, or cells stop responding to insulin; results in hyperglycemia a. type 1 diabetes mellitus: genetic, auto-immune respones; severe insulin deficiency from beta cells stop production of insulin b. type 2 diabetes mellitus: obesity; cells stop responding to insulin
Be cautious of “absolute” words: ONLY, MUST, ALWAYS, NEVER which signal that the option is wrong.
2.
1. 2. 3. 4. 5. 6. 7. 8. 9.
Diagnostics
TESTS FOR DIABETES MELLITUS (FUNCTION OF PANCREAS)
Glucose Tolerance Test (GTT) Glycated Hemoglobin (Glycohemoglobin, Glycosylated Hemoglobin, HbA) - gives average glucose level for prior two to three months Blood glucose - fasting C-Peptide Assay (Connecting Peptide Assay) Fructosamine Assay Blood glucose monitoring - finger sticks Serum glucose and osmolarity Serum sodium and potassium BUN and creatinine
10. Urine glucose and ketone monitoring 11. Urine specific gravity a. history and physical exam b. fasting blood sugar: elevated serum glucose levels c. oral glucose tolerance test (GTT) d. after meal, serum glucose is elevated - post-prandial glucose e. glycosylated hemoglobin test (A1c test) Data collection a. hyperglycemia b. the 3 "polys" of diabetes mellitus: polydipsia, polyuria, polyphagia c. additional findings: fatigue, hunger, weight loss d. blurred vision e. slow wound healing
3.
It's oversimplified, but if it helps you, think of the relation between insulin and glucose as a see-saw. When one is higher, the other tends to be lower. 4. Management a. diet therapy and weight loss i. the total number of calories is individualized according to the client's weight ii. as prescribed by the care provider, the client may be advised to follow dietary guidelines for Americans (food guide pyramid) or individualized food exchanges from the American Diabetic Association b. exercise i. lowers glucose level and improves circulation ii. decreases total cholesterol and triglycerides iii. instruct client to monitor glucose before exercising iv. before exercise, clients who require insulin should eat a carbohydrate snack with protein to prevent hypoglycemia c. insulin i. used in type 1 diabetes mellitus (DM) and type 2 DM, if needed for better control of blood glucose levels ii. regular insulin, the only insulin that is given IV, is used for ketoacidosis iii. check other medications the client is taking iv. illness, infections, and stress increase the need for insulin v. instruct client about the importance of rotating injection within one region (the abdomen absorbs insulin the most rapidly) vi. insulin administration: see Pharmacology section of this course vii. insulin pens, jet injectors, and insulin pumps are used to administer insulin d. oral antidiabetic medications i. prescribed for clients with type 2 DM ii. monitor blood glucose levels iii. check other medications the client is taking iv. instruct the client to recognize manifestations for hypoglycemia and hyperglycemia v. pancreas transplant vi. islet cell transplant vii. blood glucose monitoring - with different self-check systems Medications a. type 1 DM: insulin therapy b. type 2 DM: oral hypoglycemic agents Complications a. hypoglycemia (insulin shock) i. blood sugar falls below 50 mg / dl ii. caused by too much insulin, too little food, or excessive physical activity iii. may result from delayed meals, exercise, or vomiting
5. 6.
b.
c.
rapid onset v. findings of insulin shock 1. diaphoresis; cold, clammy skin 2. anxiety, tremor, slurred speech 3. weakness 4. nausea 5. mental confusion, personality changes, altered LOC 6. headache vi. management of hypoglycemia 1. if client is conscious, give oral sugar: hard candy, honey, Karo syrup, jelly, cola 2. if unconscious: give one mg glucagon IM, IV or subcutaneous (SC); or 20 to 50 ml 50% dextrose IV push diabetic ketoacidosis (DKA) - an acute complication i. results from severe insulin deficiency ii. findings 1. blood sugar levels > 350 mg/dl 2. elevated ketone levels: sweet odor to breath may also have odor of someone drinking alcohol 3. metabolic acidosis: Kussmaul's respirations, flushed appearance, dry skin 4. thirst 5. polyuria 6. drowsiness 7. anorexia, vomiting 8. may lead to shock and coma 9. usual causes: 1. undiagnosed diabetes mellitus 2. inadequacy of prescribed therapy for diabetes mellitus 3. physical stress such as surgery, illness, or trauma in person with diabetes mellitus 4. caused by increased gluconeogenesis from amino acids and glycogenolysis in the liver 10. management: 1. correct fluid depletion - IV fluids 2. correct electrolyte depletion - replacement particularly of potassium 3. correct metabolic acidosis - insulin IV hyperglycemic, hyperosmolar nonketotic coma (HHNKC) i. potentially fatal ii. findings 1. severe hyperglycemia; usually > 600 mg/dl plasma hyperosmolarity dehydration altered LOC - decreased 5. absence of ketoacidosis iii. usually precipitated by physical stress such as an infection; iv. in non-diabetics can be due to tube feedings without supplemental water, or too rapid rate of infusion for parenteral nutrition v. occurs more often in the elderly, typically vi. expected: to correct fluid depletion, insulin deficiency, and electrolyte imbalance other chronic complications i. diabetic triopathy 1. retinopathy 3. 4. neuropathy macrovascular disease in the 1. coronary artery
iv.
2.
d.
2. 3.
nephropathy
ii.
7.
2. peripheral vascular Nursing interventions a. give medications as ordered b. monitor for findings of hyperglycemia or hypoglycemia c. help client monitor blood glucose d. refer client to dietician for planing of meals e. support client emotionally f. teach client i. the importance of balanced, consistent daily focus of diet, medication and exercise ii. self blood-glucose monitoring iii. dietary exchange system or refer to appropriate resources iv. about medications and side effects
v.
vi.
vii. viii.
foot care early reporting of complications of 1. ketoacidosis 2. insulin shock 3. long term issues about insulin administration about the need to: 1. eat more before strenuous exercise 2. carry extra rapid-absorbing carbohydrate on person at all times 3. wear medical-alert jewelry 4. have regular eye exams 5. consider emergency care for insulin shock
About Insulin
• • • • • • • •
In the pancreas's islets of Langerhans, beta cells secrete insulin-the islet-cell hormone of major physiological importance; Without sufficient insulin, the body develops diabetes mellitus. Exploration of a number of new delivery systems for insulin is ongoing. Implanted insulin delivery systems, in combination with a glucose sensor may create an "artificial pancreas." Exercise increases the body's metabolic rate to result in a decrease in blood sugar and an increase in insulin sensitivity. Signs of hypoglycemia often occur. Illness can disrupt metabolic control and raise blood sugar, which results in an increased need for insulin. Insulin-dependent clients should be well controlled for at least one week prior to any surgery. Special care for any client with either type of diabetes mellitus should be taken to monitor blood glucose during and after surgery and adjust insulin accordingly.
About the Thyroid
• •
Following neck surgery, potentially life-threatening complications such as laryngeal edema and tracheal obstruction can occur. Monitor for respiratory distress. Following thyroid surgery, many clients suffer transient hypocalcemia from hyporfunction or removal of the parathyroids. Monitor for signs of tetany for up to three days after surgery.
About the Parathyroid
• •
Positive Chvostek's sign: contraction of facial muscle near mouth occurs when light tap is given over facial nerve in front of ear. Positive Trousseau's sign: carpopedal spasm results during the deflation of a blood pressure cuff that has been inflated for at least one minute.
Calcitonin Corpus luteum Hashimoto's thyroiditis
Hyperplasia Medullary carcinoma Microangiopathy NPH insulin Papillary adenoma Polyphagia Endocrine
• • • • • •
Adrenal glands Endocrine system Pancreas and its relation to the duodenum Pituitary gland and hypothalamus Pituitary gland Thyroid gland and related structures
