NGRTCI Endocrine System Disorders Lecture

transcript

JOFRED M. MARTINEZ, MAN, RN

Insufficient hormone activity Excess hormone activity

• Gland hypofunction • Gland hyperfunction

• Lack of tropic or stimulating hormone • Excess tropic or stimulating hormone

• Target tissue insensitivity to hormone • Ectopic hormone production

• Self-administration of too much

replacement hormone

NTIDIURETIC HORMONE

XYTOCIN

RESULTS TO…

Neurogenic DI

Nephrogenic DI

Psychogenic DI

RESULTS TO…

CAUSES:

Pituitary surgery

Trauma

Presence of tumor

Drugs (glucocorticoids or alcohol)

CAUSES:

Head trauma, surgery

Oat cell carcinoma of the lungs

Hodgkin’s disease

Medications (diuretics, anesthetics, TCAs)

Hyperplasia of pituitary gland

SIGNS AND SYMPTOMS:

1. Polyuria

2. Signs of dehydration

3. Weakness and fatigue

4. Hypotension

5. Weight loss

6. Untreated results to…

HYPOVOLEMIC SHOCK

SIGNS AND SYMPTOMS:

1.Fluid retention

2.Untreated results to

CEREBRAL EDEMA results to…

INCREASE ICP results to…

SEIZURE ACTIVITY

DIAGNOSTIC PROCEDURE:

1. Urine specific gravity DECREASED

2. Serum sodium INCREASED

3. Water-deprivation test POSITIVE

DIAGNOSTIC PROCEDURE:

1. Urine specific gravity INCREASED

2. Serum sodium DECREASED

NURSING MANAGEMENT:

1. Force fluids

2. Monitor strictly vital signs and intake and

output

3. Administer medications…

DESMOPRESSIN (DDAVP)

Administered INTRANASAL

PITRESSIN (VASOPRESIN TANNATE)

administered IM Z-TRACT

CHLORPROPAMIDE (DIABINESE)

4. Prevent complications…

HYPOVOLEMIC SHOCK

NURSING MANAGEMENT:

1. Restrict fluid (500 to 600 mL per 24

hours)

2. Administer medications…

LOOP DIURETICS (LASIX)

OSMOTIC DIURETICS (MANNITOL)

LITHIUM CARBONATE ( ESKALITH)

PHENYTOIN HCL ( DILANTIN)

3. Monitor strictly vital signs, intake and

output and neuro check

4. Weigh patient daily and assess for

pitting edema

5. Provide meticulous skin care

6. Prevent complications

MEDICATIONS SIDE-EFFECTSNURSING

IMPLICATIONS• Vasopressin (Pitressin):

replaces ADH

• Water retention • Check daily weights and

urine specific gravity.

• Desmopressin (DDAVP):

replaces ADH

• Water loss, dehydration

• Demeclocycline

(Declomycin): reduces

ADH release

• Photosensitivity, allergy,

water loss

• Do not give

demeclocycline with

dairy products or

antacids.

• Assess for early signs of dehydration and maintain

adequate hydration

• Assess neurologic status

• Measure fluid I&O

• Check urine specific gravity

• Record daily client weight

• Monitor client for education need and ability to participate

in health care

• Weigh daily using the same scale at the same time of day

• Institute seizure precautions for children

• Obtain daily serum and urinary sodium and osmolality

levels

• Measure I&O

• Record daily client weight

• Monitor client for education need and ability to participate

• in health care

• Observe changes in client neurologic status

Assess for muscle twitching

Check orientation to time, place, and person

Reduce environmental noise to prevent

overstimulation

• Give ice chips to combat thirst when fluids are restricted

• Provide mouth care often

IN CHILDREN…

IN ADULTS…

DWARFISM acromegaly

Etiology • pituitary tumor or failure of the

pituitary to develop

• infection trauma

• neglect or severe emotional

stress

• malnutrition

• pituitary hyperplasia

• benign pituitary tumor

• hypothalamic dysfunction

Signs and

symptoms

• grow to only 3 to 4 feet

• slowed sexual maturation

• children: mental retardation

• adults: weakness, hypoglycemia,

sexual dysfunction, skin

changes, and increased risk for

cardiovascular and

cerebrovascular disease

• nose, jaw, brow, hands, and feet

enlarge

• tongue becomes thick

• kyphosis

• visual disturbances

• headaches

• erectile dysfunction and

amenorrhea

DWARFISM acromegaly

Diagnostic

• growth hormone stimulation test

• MRI

• radiographic studies

• Serum growth hormone levels

are measured

Treatment • children: administration of growth

hormone

• surgery

• Bromocriptine (Parlodel)

• Octreotide (Sandostatin)

• Hypophysectomy or radiation

• lifelong replacement of thyroid

hormone, corticosteroids, and

sex hormones

Nursing

management

• assessment of mental status,

ability to cope with the effects of

the disorder, and understanding

of the treatment plan.

• assess safety in relation to

impaired eyesight, chewing,

swallowing, and sleep apnea

• monitor serum glucose levels

MEDICATIONS SIDE-EFFECTS NURSING IMPLICATIONS

Bromocriptine

(Parlodel): reduces

growth hormone

release

• Dizziness, hypotension,

nausea

• Monitor blood pressure,

serum growth hormone.

Octreotide

(Sandostatin):

supresses growth

hormone

• Uncommon: dizziness,

nausea, constipation

• Teach patient self

administration.

Somatropin

(Humatrope):

replaces growth

hormone

• Insulin resistance,

hypothyroidism

• Monitor growth; teach

patient self-administration.

• Promote self-esteem

• Support confidence by capitalizing on idol worship in adolescents

• Encourage participation in a support group

• Promote coping

RESULTS TO…

• Most tumors of the pituitary gland are benign adenomas.

• Benign tumors in the brain can cause visual disturbances,

symptoms of increased pressure in the brain, and symptoms related

to hormone imbalances.

• Treatment for is usually hypophysectomy.

• Radiation is used, either alone or as an adjunct to surgery.

PREOPERATIVE CARE

• Ensure that the patient understands the physician’s explanation of surgery.

• Perform and document a baseline neurological assessment.

• Prepare the patient for what to expect following surgery. Instruct the patient to avoid any

actions that increase pressure on the surgical site, such as coughing, sneezing, nose

blowing, straining to move bowels, or bending from the waist.

• Instruct the patient in deep breathing exercises or use of an incentive spirometer.

POSTOPERATIVE CARE

• Perform routine neurological assessments

• check urine for specific gravity

• If a patient has had transsphenoidal surgery, nasal packing are left in place and not

removed unless ordered by the physician.

• Monitor the dressing for signs of cerebrospinal fluid (CSF) leakage.

• Avoid any actions that increase pressure on the surgical site.

• Obtain orders for stool softeners and antitussives as needed.

• Tooth brushing is avoided until the incision line is healed.

• The patient may use floss and mouth rinses.

• The patient is placed on hormone replacement therapy following hypophysectomy.

POSTOPERATIVE CARE

• Pituitary hormones are generally given. These may include thyroid hormone,

glucocorticoids, intranasal desmopressin, and sex hormones.

• Instruct the patient about how to administer the hormones, as well as side effects to report.

A. PREDISPOSING FACTORS

1. Goiter belt area

2. Increase intake of goitrogenic foods

• cabbage, turnips, radish, strawberry, carrots, sweet potato, broccoli, all nuts

3. Goitrogenic drugs

a. Anti Thyroid Agent – Prophylthiuracil (PTU)

b. Lithium Carbonate

c. ASA (Aspirin)

d. Cobalt

e. Phenylbutazones (NSAIDs)

B. SIGNS AND SYMPTOMS

1. Enlarged thyroid gland

2. Mild dysphagia

3. Mild restlessness

C. DIAGNOSTIC PROCEDURES

1. Decreased serum T3 and T4

2. Thyroid Scan –enlarged thyroid gland

3. Thyroid Stimulating Hormone (TSH) – increased

CONFIRMATORY DIAGNOSTIC TEST

D. NURSING MANAGEMENT

1. Enforce complete bed rest

2. Administer medications as ordered

a. LUGOL’S SOLUTION / SSKI

ADMINISTER VIA STRAW TO PREVENT

STAINING OF TEETH

Medications to be taken via straw:

LUGOL’S, IRON, TETRACYCLINE, NITROFURANTOIN

b. THYROID HORMONES

• LEVOTHYROXINE (SYNTHROID)

• LIOTHYRONINE (CYTOMEL)

• THYROID EXTRACTS

Nursing management when giving thyroid hormones:

1. Instruct client to take in the morning to prevent insomnia

2. Monitor vital signs especially heart rate because drug causes tachycardia and

palpitations

3. Monitor side effects insomnia, tachycardia, palpitations, hypertension, heat intolerance

4. Increase dietary intake of foods rich in iodine

• seaweeds

• seafood’s like oyster, crabs, clams and lobster but not shrimps because it contains

lesser amount of iodine.

• iodized salt, best taken raw because it is easily destroyed by heat

5. Assist in SUBTOTAL THYROIDECTOMY

• All body systems are DECREASED except

WEIGHT & MENTRUATION

• All body systems are INCREASED except

WEIGHT & MENTRUATION

• DECREASED CNS: drowsiness, memory

losses (FORGETFULNESS)

• DECREASED VS: hypotension, bradypnea,

bradycardia, hypothermia

• DECREASED GI motility:

CONSTIPATION

• DECREASED appetite but with WEIGHT

GAIN results to INCREASED SERUM

CHOLESTEROL LEVELS results to

HYPERTENSION, MI, CHF, STROKE

• DECREASED metabolism causes decreased

perspiration w/c results to DRY SKIN &

COLD INTOLERANCE

• INCREASED menorrhagia

• INCREASED CNS: tremors, insomnia

• INCREASED VS: hypertension, tachypnea,

tachycardia, hyperthermia

• INCREASED GI motility: DIARRHEA

• INCREASED appetite but with WEIGHT

• INCREASED metabolism causes increased

perspiration w/c results to MOIST SKIN &

HEAT INTOLERANCE

• DECREASED amenorrhea

EXPOTHALMOS

Pathognomonic Sign

DIAGNOSTIC TESTS:

1. Serum T3 and T4 is DECREASED

2. Serum Cholesterol is INCREASED

3. RAIU is DECREASED

DIAGNOSTIC TESTS:

1. Serum T3 and T4 is INCREASED

2. RAIU is INCREASED

3. Thyroid Scan - reveals an ENLARGED

THYROID GLAND

NURSING MANAGEMENT:

output to determine presence of:

•MYXEDEMA COMA is a severe form of

hypothyroidism is characterized by severe

hypotension, bradycardia, bradypnea,

hypoventilation, hyponatremia, hypoglycemia

leading to progressive stupor and coma.

NURSING MANAGEMENT:

output to determine presence of:

•THYROID STORM is a severe form of

hyperthyroidism is characterized by severe

hypertension, tachycardia, tachypnea,

hyperventilation, hyperpyrexia, altered

neurologic or mental state, which frequently

appears as delirium psychosis, somnolence, or

NURSING MANAGEMENT FOR MYXEDEMA

Assist in mechanical ventilation

Administer thyroid hormones as ordered

Force fluids

NURSING MANAGEMENT FOR

THYROTOXICOSIS

Cool quiet environment

O2 inhalation

IV fluids (hypertonic)

Antithyroid agents

2. Force fluids

3. Administer isotonic fluid solution as ordered

4. Administer medications:

Thyroid Hormones

LEVOTHYROXINE

LEOTHYRONINE

THYROID EXTRACTS

5. Provide dietary intake that is LOW IN

CALORIES

6. Provide comfortable and warm environment

Antithyroid Agents

PROPHYTHIORACIL (PTU)

METHYMAZOLE (TAPAZOLE)

Side effects: AGRANULOCYTOSIS

• increase lymphocytes and monocytes,

fever and chills, sore throat, leukocytosis

BETA-BLOCKERS

PROPANOLOL (INDERAL)

ATENOLOL (TENORMIN)

3. Provide dietary intake that is INCREASED

IN CALORIES.

NURSING MANAGEMENT:

8. Provide client health teaching and discharge

planning concerning:

a. Avoid precipitating factors leading to

myxedema coma

• stress

• infection

• cold intolerance

• use of anesthetics, narcotics, and

sedatives

• prevent complications (myxedema

coma, hypovolemic shock

• hormonal replacement therapy for

lifetime

• importance of follow up care

NURSING MANAGEMENT:

5. Comfortable and cold environment

6. Maintain side rails

7. Provide bilateral eye patch to prevent drying

of the eyes.

8. Assist in surgical procedures:

SUBTOTAL THYROIDECTOMY

• Before thyroidectomy administer LUGOL’S

SOLUTION, SSKI, POTASSIUM IODIDE to

decrease bleeding and hemorrhage.

Levothyroxine

(Synthroid):

replaces T3 and T4

• Tachycardia, insomnia,

nervousness, weight loss

• Monitor vital signs and

thyroid laboratory results.

Propylthiouracil

(PTU): inhibits

synthesis of thyroid

hormones

• Nausea, vomiting,

agranulocytosis

• Monitor WBC and

differential, thyroid function.

Methimazole

(Tapazole): inhibits

synthesis of thyroid

hormones

• Rash, agranulocytosis

• Alert physician to medications taken that can alter results

of diagnostic tests, especially estrogen, salicylates,

amphetamines, antibiotics, corticosteroids, and mercurial

diuretics

• Modify client activity to accommodate fatigue

• Promote independence in self-care activities

• Provide extra layers of clothing or extra blanket

• Monitor body temperature and report decreases from

baseline

• Provide foods high in fiber

• Monitor respiratory rate, depth, pattern, pulse oximetry,

and arterial blood gas

• Orient client to time, place, and events

• Monitor for increasing severity of decreased LOC, VS

changes, and increasing difficulty in arousal

• Position a newborn with a goiter with the neck

hyperextended to aid breathing; provide supplemental

oxygen; and have a tracheostomy set immediately

available in case tracheal compression by the goiter

requires emergency ventilation.

• Monitor VS especially heart rate and rhythm

• Monitor serum albumin, hemoglobin, and lymphocyte

• levels

• Encourage a diet high in calories, proteins, and

carbohydrates

• Encourage six meals per day

• Weigh at least weekly

• Assess for visual changes: photophobia, decreased

acuity, or ability to close eyes

• If exophthalmos is present, protect eyes with glasses,

wet with artificial tears, elevate head of bed at night;

avoid sleeping in a prone position and wear a patch at

night if eyelids do not fully close

• Assess level of mentation for impending storm

• May cause nausea so limit oral intake 2 hours before and

after treatment

• Take acetaminophen for sore throat, which may occur a

few days after the treatment

• I 131 is eliminated in urine over 4–5 days so drink a lot of

fluid, void frequently and flush twice, and thoroughly

clean up any spilled urine

• Wash laundry separately if the treated person has

sweated heavily, such as after exercise

• Keep an arm’s length from anyone who will be in contact

with you for more than 2 hours in every 4-hour period;

especially if in contact with children and pregnant

women.

• Small amount found in saliva so avoid kissing and any

sharing of food, fluids, or utensils

• After I 131 treatment, women should not get pregnant or

breast-feed for 6 months

• Report palpitations, chest pain, or dizziness

1. Watch out for signs of thyroid storm/ thyrotoxicosis

HYPERTHERMIA, TACHYCARDIA, AGITATION

a. Administer medications as ordered

ANTI PYRETICS, BETA-BLOCKERS

b. Monitor strictly vital signs, input and output and neuro check.

c. Maintain side rails

d. Provide TSB

2. Watch out for accidental removal of parathyroid gland that may

lead to HYPOCALCEMIA (TETANY)

Signs and Symptoms:

(+) TROUSSEAU’S SIGN (+) CHVOSTEK SIGN

Watch out for arrhythmia, seizure give CALCIUM GLUCONATE IV slowly

as ordered.

CHvostek’s sign is assessed near the CHeek.

3. Watch out for accidental laryngeal damage which may lead to

HOARSENESS OF VOICE

Nursing Management:• encourage client to talk/speak immediately after operation and

notify physician

4. Signs of bleeding

Nursing Management:• check the soiled dressings at the back or nape area.

5. Hormonal replacement therapy for lifetime

6. Importance of follow up care

ETIOLOGY:

1. Subtotal thyroidectomy

2. Atrophy of parathyroid gland

due to:

a. inflammation

b. tumor

c. trauma

ETIOLOGY:

1. Hyperplasia of parathyroid gland

2. Over compensation of

parathyroid gland due to vitamin

D deficiency

a. Children: RICKETTS

b. Adults: OSTEOMALACIA

SIGNS AND SYMPTOMS:

1. ACUTE TETANY• tingling sensation, paresthesia,

numbness, dysphagia, POSITIVE

TROUSSEAU'S SIGN, POSITIVE

CHVOSTEK’S SIGN,

laryngospasm/broncospasm,

seizure, arrhythmia

2. CHRONIC TETANY• photophobia and cataract

formation, loss of tooth enamel,

anorexia, nausea and vomiting,

agitation and memory loss

SIGNS AND SYMPTOMS:

1. Bone pain especially at back

2. Kidney stones

a. renal colic

b. cool moist skin

3. Anorexia, nausea and vomiting

4. Agitation and memory

impairment

DIAGNOSTIC PROCEDURES

1. Serum Calcium is DECREASED

2. Serum Phosphate is DECREASED

3. X-ray of long bones reveals a

decrease in bone density

4. CT Scan – reveals degeneration

of basal ganglia

RISK FACTORS:

1. Serum Calcium is INCREASED

2. Serum Phosphate is DECREASED

3. X-ray of long bones reveals bone

demineralization

NURSING MANAGEMENT:

1. Administer medications as

ordered such as:

A. ACUTE TETANY

CALCIUM GLUCONATE

IV SLOWLY

B. CHRONIC TETANY

• Oral Calcium supplements

• Calcium Gluconate

• Calcium Lactate

• Calcium Carbonate

C. Vitamin D for absorption of

calcium

NURSING MANAGEMENT:

1. Force fluids to prevent kidney

stones

2. Strain all the urine using gauze

pad for stone analysis

3. Provide warm sitz bath

4. Administer medication:

MORPHINE SULFATE (DEMEROL)

5. Encourage increase intake of

foods rich in phosphate but low

in calcium

NURSING MANAGEMENT:

2. Avoid precipitating stimulus such

as glaring lights and noise

3. Encourage increase intake of

foods rich in calcium

a. anchovies

b. salmon

c. green turnips

4. Institute seizure and safety

precaution

5. Encourage client to breathe

using paper bag to produce mild

respiratory acidosis result.

6. Prepare TRACHEOSTOMY SET at

bedside for presence of

laryngospasm

7. Prevent complications

8. Hormonal replacement therapy

for lifetime

9. Importance of follow up care.

NURSING MANAGEMENT:

6. Provide acid ash in the diet to

acidify urine and prevent

bacterial growth

7. Assist/supervise in ambulation

8. Maintain side rails

9. Prevent complications (seizure

and arrhythmia)

10. Assist in surgical procedure

known as PARATHYROIDECTOMY

11. Hormonal replacement therapy

for lifetime

12. Importance of follow up care.

Cheeses

Yogurt

Sardines

Oysters

Salmon

Cauliflower

Green leafy vegetables

Calcium gluconate:

replaces calcium

• Dysrhythmia, cardiac arrest,

constipation

• Monitor vital signs and ECG

during IV therapy.

• Do not take PO calcium with

other medications.

Alendronate

(Fosamax): inhibits

resorption of bone;

keeps calcium in

• Abdominal pain, constipation,

diarrhea, nausea

• Do not take with calcium

supplements or caffeine.

• Monitor serum calcium

• If client complains of paresthesias suggestive of

hypocalcemia check for Chvostek and Trousseau’s signs

• Report signs of impending tetany immediately

• Make certain a tracheostomy set and IV calcium

gluconate or calcium chloride is immediately available

• Hypercalcemic crisis:

Monitor VS, CVP, and output hourly while

administering high-volume IV normal saline (NS)

Administer medications to lower serum calcium

Assess for early signs of hypocalcemia, which are

indicative of overtreatment

• A pheochromocytoma is an uncommon tumor that arises from

the chromaffin cells of the adrenal medulla.

• The tumor autonomously secretes catecholamines (epinephrine

and norepinephrine) in excessive amounts.

• The cause of pheochromocytoma is unknown.

• About 5% of cases are hereditary.

• Patients with a pheochromocytoma have exaggerated fight or flight

symptoms.

The patient should avoid caffeine and medications for 2 days

before and during the test.

• During hypertensive crisis, client should be in ICU to

allow for needed cardiac, BP, and neurological

monitoring

• Manage postoperative pain because untreated it can

cause hypertension

• Avoid activities that increase intra-abdominal pressure

RISK FACTORS:

1. Atrophy of adrenal glands

2. Fungal infections

RISK FACTORS:

1. Hyperplasia of adrenal gland

SIGNS AND SYMPTOMS:

1. HYPOGLYCEMIA

2. Decrease tolerance to stress

3. HYPONATREMIA

• hypotension

• signs of dehydration

• weight loss

4. HYPERKALEMIA

• agitation

• diarrhea

• arrhythmia

5. Decrease libido

6. Loss of pubic and axillary hair

7. BRONZE LIKE SKIN PIGMENTATION

SIGNS AND SYMPTOMS:

1. Increase susceptibility to infections

2. HYPERNATREMIA

• Hypertension, edema, weight

gain, MOON FACE APPEARANCE

AND BUFFALO HUMP, obese trunk,

pendulous abdomen, thin

extremities

3. HYPOKALEMIA

• Weakness and fatigue,

constipation, U wave upon ECG

(T wave hyperkalemia)

5. Hirsutism

6. Acne and striae

7. Easy bruising

8. INCREASE MASCULINITY AMONG

FEMALES

RISK FACTORS:

1. Atrophy of adrenal glands

2. Fungal infections

RISK FACTORS:

1. Hyperplasia of adrenal gland

DIAGNOSTIC PROCEDURES:

1. FBS is DECREASED

2. Plasma cortisol is DECREASED

3. Serum sodium is DECREASED

4. Serum potassium is INCREASED

NURSING MANAGEMENT:

1. Monitor strictly vital signs, input

and output to determine

presence of ADDISONIAN CRISIS

Addisonian crisis characterized by:

a. severe hypotension

b. hypovolemic shock

c. hyponatremia leading to

progressive stupor and coma

DIAGNOSTIC PROCEDURES:

1. FBS is INCREASED

2. Plasma cortisol is INCREASED

3. Serum sodium is INCREASED

4. Serum potassium is DECREASED

NURSING MANAGEMENT:1. Monitor strictly vital signs and

intake and output

2. Weigh patient daily and assess for

pitting edema

3. Measure abdominal girth daily and

notify physician

4. Restrict sodium intake

a. Spinarolactone – potassium

sparing diuretic

NURSING MANAGEMENT FOR

ADDISONIAN CRISIS:

1. Assist in mechanical ventilation,

2. Administer ISOTONIC FLUID

SOLUTION as ordered

3. Force fluids

ordered:

CORTICOSTEROIDS:

a. DEXAMETHASONE (DECADRONE)

b. PREDNISONE

c. HYDROCORTISONE (CORTISON)

NURSING MANAGEMENT:

7. Prevent complications (DM)

8. Assist in surgical procedure

(BILATERAL ADRENALECTOMY)

9. Hormonal replacement for

lifetime

10. Importance of follow up care

Phenoxybenzamine

(Dibenzyline):

blocks action of

epinephrine at alpha

receptors in

pheochromocytoma

• Orthostatic hypotension • Monitor vital signs.

Hydrocortisone:

replaces cortisol in

adrenal insufficiency

• Cushing’s effects • Teach patient to take with

food and not to discontinue

abruptly.

Fludrocortisone

(Florinef): replaces

aldosterone in

adrenal insufficiency

• Fluid retention, heart failure,

hypokalemia

• Monitor daily weights, vital

signs, and serum

potassium.

• Interventions to promote fluid balance and monitor for

fluid deficit — Weigh daily, record I&O

• Assess VS every 1–4 hours

• Kayexalate may be needed if severe hyperkalemia is

present

• Monitor blood glucose levels every 4 hours for

hypoglycemia.

• Manage activity intolerance with gradual increases in

self-care activities

• Alert client to strategies to minimize anxiety and stress

• Monitor for electrolyte imbalances, hyperglycemia, and

opportunistic infections

• Provide a diet low in sodium, high in potassium, limited in

calories and with increased amounts of calcium and

vitamin D

• Provide measures to prevent skin breakdown

• Assist the client in avoiding pathologic fractures

• Monitor and manage potential for Addisonian crisis,

which can result from withdrawal of exogenous

• Monitor for electrolyte imbalances, hyperglycemia, and

opportunistic infections

• Provide a diet low in sodium, high in potassium, limited in

calories and with increased amounts of calcium and

vitamin D

• Provide measures to prevent skin breakdown

• Assist the client in avoiding pathologic fractures

1. Instruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon to mimic the

normal diurnal rhythm

3. Monitor side effects

a. HYPERTENSION

b. EDEMA

c. HIRSUTISM

d. INCREASED SUSCEPTIBILITY TO INFECTION

e. MOON FACE APPEARANCE

Always slowly taper corticosteroid therapy to avoid adrenal crisis.

5. Provide dietary intake, INCREASE CALORIES, CARBOHYDRATES, PROTEIN but

DECREASE IN POTASSIUM

7. Provide client health teaching and discharge planning

a. avoid precipitating factor leading to Addisonian crisis:

• stress

• infection

• sudden withdrawal to steroids

b. prevent complications

• Addisonian crisis

• hypovolemic shock

c. hormonal replacement for lifetime

d. importance of follow up care

PREOPERATIVE CARE

• Monitor the patient for electrolyte imbalance and hyperglycemia.

• To prevent adrenal crisis, glucocorticoids are administered because removal of the

adrenals causes a sudden drop in adrenal hormones.

POSTOPERATIVE CARE

• The patient is closely monitored for changes in fluid and electrolyte balance and adrenal

crisis.

• Patients must take replacement glucocorticoid and

• mineralocorticoid hormones for the remainder of their life.

Chronic illness that damages the islet cells:

• pancreatitis

• cystic fibrosis

Prolonged use of some drugs:

• steroid hormones

• phenytoin (Dilantin)

• thiazide diuretics

• thyroid hormone

Symptoms of diabetes plus casual plasma glucose

concentration equal to or greater than 200 mg/Dl

Fasting plasma glucose greater than or

equal to 126 mg/dL

2-hour postload glucose equal to or greater than 200

mg/dL during an oral glucose tolerance test

• Normal plasma glucose level is less than 100 mg/dL.

• When the fasting plasma glucose (drawn after at least 8 hours

without eating) is 126 mg/dL, diabetes is diagnosed.

• If the fasting plasma glucose is between 100 and 125 mg/dL, the

patient has impaired fasting glucose (IFG).

• A normal HbA1c is 4% to 6%.

• Diabetes is diagnosed if the CPG is 200 mg/dL, with symptoms of

diabetes.

• An OGTT measures blood glucose at intervals after the patient

drinks a concentrated carbohydrate drink.

• Diabetes is diagnosed when the blood glucose level is 200 mg/dL

after 2 hours.

• A result between 140 and 199 mg/dL at 2 hours diagnoses

impaired glucose tolerance (IGT).

INCIDENCE RATE:

•10% general population

INCIDENCE RATE:

•90% general population

RISK FACTORS:

2.Race

3.Heredity

4.Autoimmune reaction

5. Related to viruses

6. Drugs

a. Lasix

b. Steroids

7. Related to CARBON

TETRACHLORIDE TOXICITY

RISK FACTORS:

2.Race

3.Heredity

4. OBESITY – because obese

persons lack insulin receptor

binding sites

5. Sedentary lifestyle (lack of

exercise, increased intake of

carbohydrates)

6. Hypertension

7. Triglyceride level of ≥250 mg/dL

SIGNS AND SYMPTOMS:

1. Polyuria

2. Polydypsia

3. Polyphagia

4. Glucosuria

5. WEIGHT LOSS

7. Blurring of vision

8. Increase susceptibility to

infection

9. Delayed/poor wound healing

SIGNS AND SYMPTOMS:

1. Usually asymptomatic

2. Polyuria

3. Polydypsia

4. Polyphagia

5. Glucosuria

6. WEIGHT GAIN

TREATMENT:

1. Insulin therapy

2. Diet

3. Exercise

COMPLICATIONS:

1. DIABETIC KETOACIDOSIS (DKA)

TREATMENT:

1. Oral Hypoglycemic agents

2. Diet

3. Exercise

COMPLICATIONS:

1. HYPEROSMOLAR NON-KETOTIC

COMA (HHNKC)

RISK FACTORS:

1. Hyperglycemia

2. STRESS

3. Infection

RISK FACTORS:

1.Increased osmolarity

(severe dehydration)

SIGNS AND SYMPTOMS:1. Polyuria

2. Polydypsia

3. Polyphagia

4. Glucosuria

5. Weight loss

7. Blurring of vision

8. Acetone breath odor

9. KUSSMAUL’S RESPIRATION

10. CNS depression leading to coma

SIGNS AND SYMPTOMS:

1. Headache and dizziness

2. Restlessness

3. Seizure activity

4. Decrease LOC – DIABETIC COMA

DIAGNOSTIC PROCEDURES:1. FBS is INCREASED

2. BUN is INCREASED

3. Creatinine is INCREASED

4. Hct is INCREASED

NURSING MANAGEMENT:

1. Assist in mechanical ventilation

2. Administer hypotonic solutions to

counteract dehydration and

3. Monitor strictly vital signs, intake

and output and blood sugar

levels

ordered

a. Insulin therapy (regular acting

insulin/rapid acting insulin

peak action of 2 – 4 hours)

b. Sodium Bicarbonate to

counteract acidosis

c. Antibiotics to prevent infection

NURSING MANAGEMENT:

1. Assist in mechanical ventilation

2. Administer hypotonic solutions to

counteract dehydration and

3. Monitor strictly vital signs, intake

and output and blood sugar

levels

ordered

a. Insulin therapy (regular acting

insulin peak action of 2–4 hrs.)

b. Antibiotics to prevent infection

A. SOURCES OF INSULIN

1. Animal sources

• Rarely used because it can cause severe allergic reaction

• Derived from beef and pork

2. Human Sources

• Frequently used type because it has less antigenicity property

thus less allergic reaction

3. Artificial Compound Insulin

B. TYPES OF INSULIN

1. RAPID ACTING INSULIN (CLEAR)

• Regular acting insulin (IV only)

• Peak action is 2 – 4 hours

2. INTERMEDIATE ACTING INSULIN (CLOUDY)

• Non Protamine Hagedorn Insulin (NPH)

3. LONG ACTING INSULIN (CLOUDY)

• Ultra Lente

NURSING MANAGEMENT FOR INSULIN INJECTIONS

1. Administer at room temperature to prevent development of

lipodystrophy (atrophy, hypertrophy of subcutaneous tissues)

2. Place in refrigerator once opened

3. Avoid shaking insulin vial vigorously instead gently roll vial between

palm to prevent formation of bubbles

4. Use gauge 25 – 26 needle

5. Administer insulin either 45◦ – 90◦ depending on amount of clients

tissue deposit

6. No need to aspirate upon injection

NURSING MANAGEMENT FOR INSULIN INJECTIONS

7. Rotate insulin injection sites to prevent development of

lipodystrophy

8. Most accessible route is the abdomen

9. When mixing 2 types of insulin aspirate first the clear insulin before

cloudy to prevent contaminating the clear insulin and promote

proper calibration.

10. Monitor for signs of local complications such as allergic reactions,

LIPODYSTROPHY, INSULIN WANING, SOMOGYI PHENOMENON,

DAWN PHENOMENON

C. NURSING MANAGEMENT

1. Administer insulin and OHA therapy as ordered

2. Monitor for peak action of insulin and OHA and notify physician

3. Monitor strictly vital signs, intake and output and blood sugar levels

4. Monitor for signs of hypoglycemia and hyperglycemia

• administer simple sugars

• for hypoglycemia (cold and clammy skin) give simple sugars

• for hyperglycemia (dry and warm skin)

5. Provide nutritional intake of diabetic diet that includes:

carbohydrates 50%, protein 30% and fats 20% or offer

alternative food substitutes

6. Instruct client to exercise best after meals when blood glucose is

rising

7. Monitor signs for complications

8. Institute foot care management

a. instruct client to avoid walking barefooted

b. instruct client to cut toenails straight

c. instruct client to avoid wearing constrictive garments

d. encourage client to apply lanolin lotion to prevent skin

breakdown

e. assist in surgical wound debridement (give analgesics 15 – 30

mins prior to surgery)

9. Instruct client to have an annual eye and kidney exam

10. Monitor for signs of DKA and HONKC

D. COMPLICATIONS

1. MACROVASCULAR COMPLICATIONS

• Coronary artery disease

• Cerebrovascular disease

• Peripheral vascular disease

2. MACROVASCULAR COMPLICATIONS

• Diabetic retinopathy

• Diabetic nephropathy

• Diabetic neuropathy

Hormone Hypofunction Hyperfunction

Antidiuretic hormone Diabetes insipidus SIADH

Growth hormone Dwarfism Acromegaly, gigantism—bone

and tissue overgrowth

Thyroid hormone Hypothyroidism Hyperthyroidism—increased

metabolism

Epinephrine Rare Pheochromocytoma—

hypertension

Parathyroid hormone Hypoparathyroidism—low

serum calcium, osteoporosis,

tetany

Hyperparathyroidism—high

calcium, weakness

Cortisol Addison’s disease—sodium

and water loss

Cushing’s syndrome—sodium

and water retention,

hyperglycemia

NGRTCI Endocrine System Disorders Lecture

Health & Medicine