Transcript REIMBURSEMENT ISSUES

Chapter 11
Care of the Patient with
an Endocrine Disorder
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Overview of Anatomy and
Physiology
• Endocrine glands and hormones
 The endocrine system is composed of a series of
ductless glands
 It communicates through the use of hormones
• Hormones are chemical messengers that travel though
the bloodstream to their target organ
*Exocrine=glands that secrete through ducts
(sebaceous, sudoriferous)
*Endocrine= ductless glands; release secretions
directly into bloodstream
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Slide 2
Overview of Anatomy and Physiology
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Works closely with nervous system
Both control homeostasis
Small amount of hormone is very powerful
Too much or too little of one hormone can affect
other hormones (interrelated)
• Controlled by negative feedback system
• Information continually exchanged between target
organ and pituitary gland
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Slide 3
Overview of Anatomy and
Physiology
• Pituitary gland—“master gland”; works closely with
hypothalamus
 Anterior pituitary gland (6 hormones)
• TSH (growth and secretion of thyroid)
• FSH (growth of ovarian follicle, production of estrogen in females,
and production of sperm in males)
• GH (also called somatropic hormone; accelerates the growth of the
body)
• ACTH (growth and secretion of adrenal cortex)
• LH (stimulates ovulation and formation of corpus luteum in
menstruation cycle)
• PROLACTIN (secretion of milk and influences maternal behavior)
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Slide 4
Posterior Pituitary
 Posterior pituitary gland (2 hormones)
• Oxytocin (maintains water balance by increasing the reabsorption
of water by the kidneys)
• ADH (vasopressin) maintains water balance by increasing the
reabsorption of water by the kidneys.
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Categorized Based on Function:
TROPIC- target other endocrine structures to increase
their growth and secretions
SEX- influence reproductive changes
ANABOLIC- stimulate the process of building tissues.
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Slide 5
Overview of Anatomy and
Physiology
• Thyroid gland
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Butterfly shaped
Thyroxine (T3), Triiodothronine (T4), Calcitonin
Requires iodine for function
Control metabolism, growth and development,
nervous system activity
 Controlled by TSH released by pituitary gland
• Parathyroid gland
 4 glands in posterior surface of thyroid
 PTH; regulates Ca and Phosphorus
Calcium: > levels=impaired heart fx, cardiac arrest
<levels=excitability of nerve cells; increased
muscle stimulation; tetany
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Slide 6
Overview of Anatomy and Physiology
• Adrenal gland
 Adrenal cortex; outer section
• 3 layers; each secrete hormone (steroid)
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Mineralocorticoids, glucocorticoids, sex hormones
 Adrenal medulla; middle section
• Epinephrine (adrenaline), norepinephrine
• Pancreas
 Exocrine and endocrine functions
 Insulin and glucagon
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Slide 7
Figure 11-2
(From Thibodeau, G.A., Patton, K.T. [2008]. Structure and function of the body. [13th ed.]. St. Louis: Mosby.)
Pituitary hormones.
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Slide 8
Overview of Anatomy and
Physiology
• Female sex glands
 Ovaries; estrogen & progesterone
 Placenta; releases estrogen & progesterone during
pregnancy
• Male sex glands
 Testes; testosterone
• Thymus gland
 Thymosin; assists with immunity during infancy
• Pineal gland
 Melatonin; biological clock & inhibits gonadotropic
activity
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Slide 9
Figure 11-1
(From Thibodeau, G.A., Patton, K.T. [2008]. Structure and function of the body. [13th ed.]. St. Louis: Mosby.)
Location of the endocrine glands in the female and male bodies.
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Slide 10
Disorders of the Pituitary Gland
• Acromegaly
 Etiology/pathophysiology
• Overproduction of growth hormone in the adult
• Causes
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Idiopathic hyperplasia of the anterior pituitary gland
Tumor growth in the anterior pituitary gland
• Changes are irreversible
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Slide 11
Disorders of the Pituitary Gland
• Acromegaly (continued)
 Clinical manifestations/assessment
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Enlargement of the cranium and lower jaw
Separation and malocclusion of the teeth
Bulging forehead
Bulbous nose
Thick lips; enlarged tongue; hypertrophy of vocal cords
Generalized coarsening of the facial features
Enlarged hands and feet
Enlarged heart, liver, and spleen
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Slide 12
Disorders of the Pituitary Gland
• Acromegaly (continued)
 Clinical manifestations/assessment (continued)
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Muscle weakness
Hypertrophy of the joints with pain and stiffness
Males—impotence
Females—deepened voice, increased facial hair,
amenorrhea
• Partial or complete blindness with pressure on the optic
nerve due to tumor
• Severe headaches common
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Slide 13
Figure 11-6
(Courtesy of the Group for Research in Pathology Education.)
Right: Coarse facial features typical of acromegaly. Left: Patient’s
face several years before she developed the pituitary tumor.
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Slide 14
Acromegaly
• Assessment
 Subjective; pain, visual disturbances, emotional
reactions
 Objective data; monitor bone enlargement, joint
involvement, vital signs, s/s heart failure
• Diagnosis
 CT, MRI, cranial radiographic evaluation
 Complete ophthalmic exam to determine damage to
optic nerve,
 Lab tests: serum GH level, oral GTT (GH usually falls
during challenge but not in acromegaly)
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Slide 15
Disorders of the Pituitary Gland
• Acromegaly (continued)
 Medical management/nursing interventions
• Pharmacological management
• Given to suppress GH release
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Parlodel
Sandostatin
Analgesics
Cryosurgery (application of extreme cold)
Transsphenoidal removal of tissue
Proton beam therapy (radiation)
Soft, easy-to-chew diet
Prognosis: changes irreversible; prone to complications
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Slide 16
Disorders of the Pituitary Gland
• Gigantism
 Etiology/pathophysiology
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Overproduction of growth hormone
Caused by hyperplasia of the anterior pituitary gland
Occurs in a child before closure of the epiphyses
Results in overgrowth of long bones
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Slide 17
Disorders of the Pituitary Gland
• Gigantism (continued)
 Clinical manifestations/assessment
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Great height
Increased muscle and visceral development
Increased weight
Normal body proportions
Weakness
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Slide 18
Gigantism
 Assessment
• Subjective; patient’s understanding of disease
process/ability to verbalize emotional responses
• Objective; frequent height measurement, use of
adaptive coping mechanisms/family interactions
 Diagnosis
• GH suppression test (glucose loading test); baseline
GH levels high
 Medical management/nursing interventions
• Surgical removal of tumor
• Irradiation of the anterior pituitary gland
Prognosis: shorter than average life span
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Slide 19
Disorders of the Pituitary Gland
• Dwarfism
 Etiology/pathophysiology
• Deficiency in growth hormone; usually idiopathic
• Some cases attributed to autosomal recessive trait
 Clinical manifestations/assessment
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Abnormally short height
Normal body proportion
Appear younger than age
Dental problems due to underdeveloped jaws
Delayed sexual development`
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Slide 20
Disorders of the Pituitary Gland
• Assessment
 Subjective; pt’s understanding of disease process; emotional
response
 Objective; regular ht/wt measurement
• Diagnostic tests
 Radiographic evaluation of wrist for bone age & MRI/CT scan to
r/o pituitary tumor
 Plasma GH levels (will be decreased)
• Medical management/nursing interventions
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Growth hormone injections
Removal of tumor, if present
Major issues with self-esteem
Prognosis: normal life span; prone to
musculoskeletal/cardiovascular problems
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Slide 21
Disorders of the Pituitary Gland
• Diabetes insipidus
 Etiology/pathophysiology
• Transient or permanent metabolic disorder of the
posterior pituitary
• Deficiency of antidiuretic hormone (ADH)
• Primary or secondary
• Significant electrolyte and fluid imbalances
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Slide 22
Disorders of the Pituitary Gland
• Diabetes insipidus
 Clinical manifestations/assessment
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Polyuria; polydipsia
May become severely dehydrated
Lethargic
Dry skin; poor skin turgor
Constipation
 Assessment
• Subjective; embarrassment, not restricting fluids
• Objective; skin turgor, I&O, urine color, daily weight
 Diagnosis
• Urine ADH measurement, urine specific gravity, urine
output, serum Na levels
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Slide 23
Diabetes Insipidus
 Medical management/nursing interventions
• ADH preparations
• Limit caffeine due to diuretic properties
• Prognosis: dependant on etiology, usually dependant
on medication for life, constant medical monitoring
since condition may worsen with time
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Slide 24
Disorders of the Thyroid and
Parathyroid Glands
• Hyperthyroidism
 Etiology/pathophysiology
• Also called Graves’ disease, exophthalmic goiter, and
thyrotoxicosis
• Overproduction of the thyroid hormones
• Exaggeration of metabolic processes
• Exact cause unknown
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Slide 25
Disorders of the Thyroid and
Parathyroid Glands
• Hyperthyroidism (continued)
 Clinical manifestations/assessment
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Edema of the anterior portion of the neck
Exophthalmos
Inability to concentrate; memory loss
Dysphagia
Hoarseness
Increased appetite
Weight loss
Nervousness
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Slide 26
Disorders of the Thyroid and
Parathyroid Glands
• Hyperthyroidism (continued)
 Clinical manifestations/assessment (continued)
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Insomnia
Tachycardia; hypertension
Warm, flushed skin
Fine hair
Amenorrhea
Elevated temperature
Diaphoresis
Hand tremors
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Slide 27
Hyperthyroidism
• Assessment
 Subjective: inability to concentrate, memory loss,
feelings of nervousness, jittery, insomnia
 Objective: rapid pulse, high BP, skin warm/flushed,
amenorrhea, hyperactivity, clumsiness, weight loss
• Diagnosis
 Decrease in TSH levels & elevated T3, T4
 Elevated iodine uptake test
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Slide 28
Disorders of the Thyroid and
Parathyroid Glands
• Hyperthyroidism (continued)
 Medical management/nursing interventions
• Pharmacological management
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Propylthiouracil (PTU)
Methimazole (Tapazole)
Block production of thyroid hormones
• Radioactive iodine (ablation therapy)
• Subtotal thyroidectomy
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Slide 29
Disorders of the Thyroid and
Parathyroid Glands
• Hyperthyroidism (continued)
 Medical management/nursing interventions
(continued)
• Postoperative
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Voice rest; voice checks
Avoid hyperextension of the neck
Tracheotomy tray at bedside
Assess for signs and symptoms of internal and external
bleeding
Assess for tetany
o Chvostek’s and Trousseau’s signs
Assess for thyroid crisis
Prognosis: normal life expectancy; may develop
hypothyroidism due to treatment
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Slide 30
Disorders of the Thyroid and
Parathyroid Glands
• Hypothyroidism
 Etiology/pathophysiology
• Insufficient secretion of thyroid hormones
• Slowing of all metabolic processes
• Failure of thyroid or insufficient secretion of thyroidstimulating hormone from pituitary gland
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Slide 31
Disorders of the Thyroid and
Parathyroid Glands
• Hypothyroidism (continued)
 Clinical manifestations/assessment
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Hypothermia; intolerance to cold
Weight gain
Depression
Impaired memory; slow thought process
Lethargic
Anorexia
Constipation
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Slide 32
Disorders of the Thyroid and
Parathyroid Glands
• Hypothyroidism (continued)
 Clinical manifestations/assessment
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Decreased libido
Menstrual irregularities
Thin hair
Skin thick and dry
Enlarged facial appearance
Low, hoarse voice
Bradycardia
Hypotension
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Slide 33
Hypothyroidism
• Assessment
 Subjective: depression, paranoia, impaired memory,
irritability, coping mechanisms
 Objective: skin, hair, facial features, voice,
bradycardia, decreased BP, weakness, menorrhagia
• Diagnosis
 Physical exam
 Lab tests: TSH, T3, T4,
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Slide 34
Disorders of the Thyroid and
Parathyroid Glands
• Hypothyroidism (continued)
 Medical management/nursing interventions
• Pharmacological management
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Synthroid
Levothyroid
Proloid
Cytomel
• Symptomatic treatment
• Prognosis: require medication for life
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Slide 35
Disorders of the Thyroid and
Parathyroid Glands
• Simple goiter
 Etiology/pathophysiology
• Enlarged thyroid due to low iodine levels
• Enlargement is caused by the accumulation of colloid in
the thyroid follicles
• Usually caused by insufficient dietary intake of iodine
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Slide 36
Disorders of the Thyroid and
Parathyroid Glands
• Simple goiter (continued)
 Clinical manifestations/assessment
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Enlargement of the thyroid gland
Dysphagia
Hoarseness
Dyspnea
 Assessment
 Medical management/nursing interventions
• Pharmacological management
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Potassium iodide
• Diet high in iodine
• Surgery—thyroidectomy
• Prognosis: normal life expectancy
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Slide 37
Figure 11-10
(Courtesy of L. V. Bergman & Associates, Inc., Cold Springs, New York.)
Simple goiter.
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Slide 38
Disorders of the Thyroid and
Parathyroid Glands
• Cancer of the thyroid
 Etiology/pathophysiology
• Malignancy of thyroid tissue; very rare
 Clinical manifestations/assessment
• Firm, fixed, small, rounded mass or nodule on thyroid
 Assessment
 Diagnosis; thyroid needle biopsy
 Medical management/nursing interventions
• Total thyroidectomy
• Thyroid hormone replacement
• If metastasis is present: radical neck dissection;
radiation, chemotherapy, and radioactive iodine
• Prognosis: dependant on tumor type
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Slide 39
Disorders of the Thyroid and
Parathyroid Glands
• Hyperparathyroidism
 Etiology/pathophysiology
• Overactivity of the parathyroid, with increased
production of parathyroid hormone
• Hypertrophy of one or more of the parathyroid glands
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Slide 40
Disorders of the Thyroid and
Parathyroid Glands
• Hyperparathyroidism (continued)
 Clinical manifestations/assessment
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Hypercalcemia
Skeletal pain; pain on weight-bearing
Pathological fractures
Kidney stones
Fatigue
Drowsiness
Nausea
Anorexia
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Slide 41
Disorders of the Thyroid and
Parathyroid Glands
• Hyperparathyroidism (continued)
 Assessment
 Diagnosis
• X-ray-skeletal decalcification; PTH increased, serum
phosphorus low, calcium high
 Medical management/nursing interventions
• Removal of tumor
• Removal of one or more parathyroid glands
• Prognosis: good with proper treatment unless due to
carcinoma
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Slide 42
Disorders of the Thyroid and
Parathyroid Glands
• Hypoparathyroidism
 Etiology/pathophysiology
• Decreased parathyroid hormone
• Decreased serum calcium levels
• Inadvertent removal or destruction of one or more
parathyroid glands during thyroidectomy
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Slide 43
Disorders of the Thyroid and
Parathyroid Glands
• Hypoparathyroidism (continued)
 Clinical manifestations/assessment
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Neuromuscular hyperexcitability
Involuntary and uncontrollable muscle spasms
Tetany
Laryngeal spasms
Stridor
Cyanosis
Parkinson-like syndrome
Chvostek’s and Trousseau’s signs
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Slide 44
Disorders of the Thyroid and
Parathyroid Glands
• Hypoparathyroidism (continued)
 Assessment
 Diagnosis
• Decreased serum calcium and PTH, increased serum
phosphorus
 Medical management/nursing interventions
• Pharmacological management
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Calcium gluconate or intravenous calcium chloride
• Vitamin D
• Prognosis: fairly normal lifestyle and expectancy
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Slide 45
Disorders of the Adrenal Glands
• Adrenal hyperfunction (Cushing’s syndrome)
 Etiology/pathophysiology
• Plasma levels of adrenocortical hormones are
increased
• Hyperplasia of adrenal tissue due to overstimulation by
the pituitary gland
• Tumor of the adrenal cortex
• Adrenocorticotropic hormone (ACTH) secreting tumor
outside the pituitary
• Overuse of corticosteroid drugs
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Slide 46
Disorders of the Adrenal Glands
• Adrenal hyperfunction (Cushing’s syndrome)
(continued)
 Clinical manifestations/assessment
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Moonface
Buffalo hump
Thin arms and legs
Hypokalemia; proteinuria
Increased urinary calcium excretion
Susceptible to infections
Depression
Loss of libido
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Slide 47
Disorders of the Adrenal Glands
• Adrenal hyperfunction (Cushing’s syndrome)
(continued)
 Clinical manifestations/assessment
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Ecchymoses and petechiae
Weight gain
Abdominal enlargement
Hirsutism in women
Menstrual irregularities
Deepening of the voice
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Slide 48
Disorders of the Adrenal Glands
• Adrenal hyperfunction (Cushing’s syndrome)
(continued)
 Assessment
 Diagnosis
• Clinical appearance and lab tests; high cortisol levels,
CT/ultrasound to r/o adrenal/pituitary tumor
 Medical management/nursing interventions
• Treat causative factor
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Adrenalectomy for adrenal tumor
Radiation or surgical removal for pituitary tumors
• Lysodren
• Dietary recommendations:
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Low-sodium
High-potassium
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Slide 49
Disorders of the Adrenal Glands
• Adrenal hypofunction (Addison’s disease)
 Etiology/pathophysiology
• Adrenal glands do not secrete adequate amounts of
glucocorticoids and mineralocorticoids
• May result from
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Adrenalectomy
Pituitary hypofunction
Long-standing steroid therapy
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Slide 50
Disorders of the Adrenal Glands
• Adrenal hypofunction (Addison’s disease)
(continued)
 Clinical manifestations/assessment
• Usually not detected until 90% cortex destroyed
• Related to imbalances of hormones, nutrients, and
electrolytes
• Nausea; anorexia
• Postural hypotension
• Headache
• Disorientation
• Abdominal pain; lower back pain
• Anxiety
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Slide 51
Disorders of the Adrenal Glands
• Adrenal hypofunction (Addison’s disease)
(continued)
 Clinical manifestations/assessment
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Darkly pigmented skin and mucous membranes
Weight loss
Vomiting
Diarrhea
Hypoglycemia
Hyponatremia
Hyperkalemia
Assess for adrenal crisis
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Slide 52
Disorders of the Adrenal Glands
• Adrenal hypofunction (Addison’s disease)
(continued)
 Assessment
 Diagnosis
• Decreased serum Na, increased K+, decreased
glucose, cortisol/aldosterone levels low
 Treatment
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Restore fluid and electrolyte balance
Replacement of adrenal hormones
Diet high in sodium and low in potassium
Adrenal crisis
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IV corticosteroids in a solution of saline and glucose
Prognosis: fair with proper treatment
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Slide 53
Disorders of the Adrenal Glands
• Pheochromocytoma
 Etiology/pathophysiology
• Chromaffin cell tumor; usually found in the adrenal
medulla
• Causes excessive secretion of epinephrine and
norepinephrine
 Clinical manifestations/assessment
• Hypertension
 Diagnosis: urinary metanephrines (catecholamine
metabolites) elevated
 Medical management/nursing interventions
• Surgical removal of tumor
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Slide 54
Disorders of the Pancreas
• Diabetes mellitus
 Etiology/pathophysiology
• A systemic metabolic disorder that involves improper
metabolism of carbohydrates, fats, and proteins
• Insulin deficiency
• Risk factors
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Heredity
Environment and lifestyle
Viruses
Malignancy or surgery of pancreas
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Slide 55
Disorders of the Pancreas
• Diabetes mellitus (continued)
 Types of diabetes mellitus
• Type I—insulin dependent (IDDM)
• Type II—non-insulin dependent (NIDDM)
 Clinical manifestations/assessment
• Type I and type II
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“3 Ps”
o Polyuria
o Polydipsia
o Polyphagia
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Slide 56
Disorders of the Pancreas
• Diabetes mellitus (continued)
 Clinical manifestations/assessment (continued)
• Type I
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Sudden onset
Weight loss
Hyperglycemia
Under 40 years old
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Slide 57
Disorders of the Pancreas
• Diabetes mellitus (continued)
 Clinical manifestations/assessment (continued)
• Type II
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Slow onset
May go undetected for years
“3 Ps” are usually mild
If untreated, may have skin infections and arteriosclerotic
conditions
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Slide 58
Disorders of the Pancreas
• Diabetes mellitus (continued)
 Diagnostic tests
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Fasting blood glucose (FBG)
Oral glucose tolerance test (OGTT)
2-hour postprandial blood sugar
Patient self-monitoring of blood glucose (SMBG)
Glycosylated hemoglobin (HbA1c)
C-peptide test
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Slide 59
Disorders of the Pancreas
• Diabetes mellitus (continued)
 Medical management/nursing interventions
• Diet
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A goal of nutritional therapy is to achieve a blood glucose
level of <126 mg/dL
Balanced diet should include proteins, carbohydrates,
and fats
Type II—may be controlled by diet alone
Type I—diet is calculated and then the amount of insulin
required to metabolize it is established
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Slide 60
Disorders of the Pancreas
• Diabetes mellitus (continued)
 Medical management/nursing interventions
(continued)
• Diet (continued)


American Diabetes Association (ADA) diet
o Seven exchanges
o Quantitative diet
Need three regular meals with snacks between meals
and at bedtime to maintain constant glucose levels
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 61
Disorders of the Pancreas
• Diabetes mellitus (continued)
 Medical management/nursing interventions
(continued)
• Exercise



Promotes movement of glucose into the cell
Lowers blood glucose
Lowers insulin needs
• Stress of acute illness and surgery



Extra insulin may be required
Increased risk of ketoacidosis (hyperglycemia)
Glucose must be monitored closely
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 62
Disorders of the Pancreas
• Diabetes mellitus (continued)
 Medical management/nursing interventions
(continued)
• Medications

Insulin
o Classified by action: Regular; Lente and NPH;
Ultralente
o Classified by type: beef/pork: Humulin/Novolin
o Injection sites should be rotated to prevent scar
tissue formation
o Sliding scale
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Slide 63
Figure 11-16
(From Potter, P.A., Perry, A.G. [2003]. Basic nursing: essentials for practice. [5th ed.]. St. Louis: Mosby.)
A, Rotation of sites for insulin injections.
B, Injection diagram to track rotation of injection sites.
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Slide 64
Disorders of the Pancreas
• Diabetes mellitus (continued)
 Medical management/nursing interventions
(continued)
• Medications

Oral hypoglycemic agents
o Stimulate islet cells to secrete more insulin
o Only for type II diabetes mellitus
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 65
Disorders of the Pancreas
• Diabetes mellitus (continued)
 Medical management/nursing interventions
(continued)
• Patient teaching




Good skin care
Report any skin abnormalities to physician
Special foot care is crucial
o Do not trim toenails—go to podiatrist
o No hot water bottles or heating pads
Assess for symptoms of hypoglycemia
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 66
Disorders of the Pancreas
• Diabetes mellitus (continued)
 Medical management/nursing interventions
(continued)
• Acute complications


Coma
o Diabetic ketoacidosis
o Hyperglycemic hyperosmolar nonketotic
o Hypoglycemic reaction
Infection
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 67
Disorders of the Pancreas
• Diabetes mellitus (continued)
 Medical management/nursing interventions
(continued)
• Long-term complications



Diabetic retinopathy
Cardiovascular problems
Renal failure
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 68
Nursing Process
• Nursing diagnoses










Knowledge, deficient
Self-esteem, risk for situational low
Sensory and perceptual alterations: visual
Fluid volume, deficient, risk for
Infection, risk for
Sexual dysfunction
Body image, disturbed
Coping, ineffective
Nutrition, imbalanced
Activity intolerance
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Slide 69
Chapter 21
Hormones and Steroids
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70
Chapter 21
Lesson 21.1
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71
Learning Objectives


Describe the use of antidiabetic medications
Identify preparations that act on the uterus
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72
Overview



Hormones and steroids
Natural and synthetic preparations
Used to replace and/or increase natural
chemicals in the body
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73
Endocrine System



Regulation and coordination of body systems
Endocrine glands
Pituitary, thyroid, parathyroid, adrenal glands,
pancreas, testes, ovaries, and placenta
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74
Endocrine System
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75
Male Reproductive System
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76
Female Reproductive System
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77
Antidiabetic Drugs




Diabetes mellitus: chronic disorder of
metabolism
Insulin: necessary for the metabolism and
use of glucose in the body
Pancreas
Type 1 and type 2 diabetes
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78
Insulin
Action
 Lowers blood glucose levels by helping
glucose move into target tissues
Uses
 Treatment of type 1 diabetes
Table 21-1
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79
Insulin (cont.)
Adverse Reactions
 Lipodystrophy, local itching, swelling, erythema
 Hypoglycemia: serum glucose less than 60
mg/dL
Drug Interactions
 Insulin antagonists
 Anabolic steroids and alcohol may increase the
hypoglycemic effects of insulin
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80
Insulin (cont.)
Nursing Implications
 Assessment: polyuria, polyphagia, polydipsia,
weight loss, blurred vision, and fatigue
 Hyperglycemia: systemic acidosis
 Conditions that alter requirements for insulin
Patient Teaching
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81
Oral Hypoglycemics
Action

Stimulate insulin release from pancreatic beta cells;
decrease insulin resistance
Uses


Monotherapy versus combination therapy
Six classes






Sulfonylureas, 1st and 2nd generation
Biguanides
Alpha-glucosidase inhibitors
Meglitinides
Thiazolidinediones
Incretins
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82
Oral Hypoglycemics (cont.)
Adverse Reactions
 Hypoglycemia; allergic reactions
Drug Interactions
 Displacement; potentiation
 Thiazides oppose the secretion of insulin
from beta cells and decrease the
effectiveness of sulfonylureas
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83
Oral Hypoglycemics (cont.)
Nursing Implications
 Assessment: health history; renal and liver
function; sulfa allergies
Patient Teaching
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Selected Drugs Used with
Pregnancy and Delivery
Overview
 Antepartum, intrapartum, and postpartum




Tocolytics
Oxytocics
Uterine relaxants
Abortifacients
Drug Table 21-4
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85
Selected Drugs Used with
Pregnancy and Delivery (cont.)
Action and Uses
 Abortifacients stimulate uterine contractions and
cause the uterus to empty
 Oxytocic agents and ergot preparations cause
the uterus to contract
 Uterine relaxants act on beta-adrenergic
receptors to stop smooth-muscle contraction in
the uterus
 Tocolytics are used to stop preterm labor
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Selected Drugs Used with
Pregnancy and Delivery (cont.)
Adverse Reactions




Abortifacients: cramping and pain
Tocolytics: visual disturbance, malaise, nausea,
and confusion
Oxytocics: dysrhythmias, edema, fetal bradycardia,
anxiety, redness of skin during administration,
nausea, vomiting, anaphylaxis, postpartum
hemorrhage, cyanosis, and dyspnea
Ergots: nausea and vomiting, allergic reactions,
bradycardia, hypotension, hypertension,
cerebrospinal symptoms, and spasms
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87
Selected Drugs Used with
Pregnancy and Delivery (cont.)
Drug Interactions
 Vasoconstrictors and local anesthetics
increase the effectiveness of oxytocics
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88
Selected Drugs Used with
Pregnancy and Delivery (cont.)
Nursing Implications and Patient Teaching
 Assessment
 Diagnosis
 Planning
 Implementation: nursing care and monitoring
during drug administration
 Evaluation
 Patient and family teaching: adverse effects of
ergonovine
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89
Question 1
____________________ are chemicals that
are made in an organ or gland and carried
through the bloodstream to another part of
the body.
1.
2.
3.
4.
Steroids
Hormones
Androgens
Estrogens
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90
Question 2
Which of the following are NOT part of the
endocrine system?
1.
2.
3.
4.
Pituitary gland
Adrenal glands
Placenta
Sweat glands
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91
Question 3
A lack of insulin can increase the production
of free fatty acids. There may be an increase
in glucagon and other hormones and a
decrease in pH. This is called:
1.
2.
3.
4.
Lipodystrophy.
Ketoacidosis.
Hyperglycemia.
Hypoglycemia.
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92
Chapter 21
Lesson 21.2
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93
Learning Objectives




Compare and contrast the action of adrenal and
pituitary hormones
Describe at least five adverse reactions that
may result from the use of glucocorticoid and
mineralocorticoid steroids
Compare the actions of various male and
female hormones
List the indications for the use of thyroid
preparations
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94
Pituitary and Adrenocortical
Hormones




Pituitary gland: “master gland”
Adenohypophysis
Neurohypophysis
Hormone production, control growth,
electrolyte balance, water retention or loss,
and reproductive cycle
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95
Pituitary Hormones
Anterior Pituitary Hormones
 HCG
 LH and FSH
 STH
 ACTH
Drug Table 21-5
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Anterior Pituitary Hormones
(cont.)
Adverse Reactions (systemic or local reaction)





Menotropins: enlarged ovaries; multiple births when
used for fertilization
Clomiphene: abdominal discomfort, ovarian
enlargement, blurred vision, nervousness, nausea and
vomiting, vasomotor flushes
Chorionic gonadotropins: headache, irritability,
restlessness, fatigue, and edema
Somatotropin: antibody stimulation
ACTH: adrenal gland
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Posterior Pituitary Hormones





ADH
Vasopressin may cause abdominal cramps,
anaphylaxis, bronchial constriction, circumoral
pallor, diarrhea, flatus, intestinal hyperactivity,
headache, sweating, tremors, urticaria, uterine
cramps, vertigo, vomiting; large doses may
produce death
Oxytocin
ACTH
Drug Table 21-6
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98
Adrenocortical Hormones
Actions
 Manufactures glucocorticoids,
mineralocorticoids, and small amounts of sex
hormones
Uses
 Adrenal insufficiency (Addison disease)
 Reduce inflammation in allergic or
immunologic responses; treat hematologic
and malignant diseases
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99
Adrenocortical Hormones (cont.)
Adverse Reactions
 Table 21-7
Drug Interactions
 Increase effects of barbiturates, sedatives,
narcotics, and certain anticoagulants
 Decrease effects of insulin, oral
hypoglycemics, Coumadin, isoniazid, aspirin,
and broad-spectrum antibiotics
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100
Adrenocortical Hormones (cont.)
Nursing Implications and Patient Teaching













Frequent medical monitoring
Avoid smoking
Alcohol use: ulcer development
Risk for infection
Increase dose during times of stress
Signs and symptoms of adrenal insufficiency
Do not stop drug abruptly
MedicAlert bracelet
Immunization considerations
Diet
Storage of drug
Drug interactions
Dosage schedule, missed dosage
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101
Sex Hormones



Production influenced by the anterior pituitary
Male: testosterone; androgens
Female: estrogen; progesterone
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102
Androgens
Actions

Development of secondary sex characteristics; tissue
building
Uses

Hypogonadism, hypopituitarism, dwarfism, eunuchism,
cryptorchidism, oligospermia, and male androgen
deficiency
Adverse Reactions

Edema due to sodium retention, acne, hirsutism, male
pattern baldness, cholestatic hepatitis with jaundice,
buccal irritation, nausea and vomiting, diarrhea
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103
Androgens (cont.)
Drug Interactions



Increased effects – anticoagulants, antidiabetic agents,
and other drugs
Decreased effects – barbiturates
Concurrent use with corticosteroids increase edema
Nursing Implications

Assessment, diagnosis, planning, implementation, and
evaluation
Drug Table 21-9
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104
Androgens (cont.)
Patient and Family Teaching
 Administration
 Response time
 Diet
 Symptoms to report
 Administration considerations
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Female Sex Hormones



Estrogens
Progestins
Table 21-10
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106
Estrogens
Action and Uses

Used for hormone replacement therapy in menopause
and other conditions (ovarian failure); infertility workups; palliative breast cancer treatment
Adverse Reactions
Drug Interactions
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107
Progestins
Action
Uses

Contraception, control excessive uterine bleeding,
treatment of secondary amenorrhea, dysmenorrhea,
premenstrual tension, and control of pain in
endometriosis
Drug Interactions
Nursing Implications and Patient Teaching
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108
Oral Contraceptives
Combination Drugs: Estrogen and Progestin

Table 21-11
Action

Prevent ovulation
Use

Contraception
Adverse Reactions

Estrogen excess, progestin excess, androgen excess,
estrogen deficiency, progestin deficiency
Contraindications for Oral Contraceptives
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109
Thyroid Hormones
Thyroid Supplements or Replacements
Action

Increase metabolic rate: increase tissue oxygen
consumption, body temperature, heart and respiratory
rate, cardiac output, and carbohydrate, lipid, and protein
metabolism; influence the development of the skeletal
system
Uses

Replacement therapy for several conditions
Table 21-12
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110
Thyroid Hormones (cont.)
Adverse Reactions
 Dysrhythmias, hypertension, tachycardia,
hand tremors, headache, insomnia,
nervousness, diarrhea, vomiting, weight loss,
menstrual irregularities, rash, glycosuria,
hyperglycemia, increase prothrombin time,
and increase serum cholesterol levels
Drug Interactions
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111
Thyroid Hormones (cont.)
Nursing Implications and Patient Teaching
 Assessment, diagnosis, planning,
implementation, evaluation
 Administration
 Drug action/expected outcomes
 Drug interactions: diabetes; anticoagulants;
checking with health care provider
 Signs/symptoms of hyperthyroidism and
hypothyroidism
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112
Antithyroid Products
Action

Stop the production of thyroid hormones
Uses

Treatment of hyperthyroidism; to improve
hyperthyroidism in preparation for surgery or
radioactive iodine therapy
Adverse Reactions
Drug Interactions
Nursing Implications and Patient Teaching
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113
Williams' Basic Nutrition & Diet
Therapy
14th Edition
Chapter 20
Diabetes Mellitus
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114
Lesson 20.1: Diabetes Mellitus
as a Metabolic Disorder


Diabetes mellitus is a metabolic disorder of glucose
metabolism with many causes and forms.
A consistent, sound diet is a major keystone of
diabetes care and control.
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115
Introduction (p. 400)




11% of U.S. adults have diabetes
Seventh leading cause of death in the United States
Historically, victims died at young age
With proper care, people with diabetes can live long,
fulfilling lives
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116
Nature of Diabetes (p. 400)

Defining factor




Glucose is primary source of energy for the body
Insulin is needed to be taken out of blood and
transferred into cells
People with diabetes either do not produce insulin
or cannot effectively use insulin produced
Diabetes: group of metabolic diseases
characterized by hyperglycemia
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117
Classification of Diabetes Mellitus
and Glucose Intolerance (p. 400)

Type 1 diabetes mellitus



Accounts for 5% to 10% of cases
Previously called insulin-dependent or juvenileonset diabetes
Severe, unstable form
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118
Classification of Diabetes Mellitus and
Glucose Intolerance (cont’d) (p. 401)

Type 1 diabetes mellitus (cont’d)



Caused by autoimmune destruction of pancreatic
cells
Can occur at any age
Requires exogenous insulin
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119
Type 2 Diabetes Mellitus (p. 401)




Accounts for 90% to 95% of cases
Previously called adult-onset or non–insulindependent diabetes
Initial onset usually after age 40 years
Now being diagnosed in children
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120
Type 2 Diabetes Mellitus (cont’d)
(p. 402)




Strong genetic link
Prevalent in older, obese people
Caused by insulin resistance or defect
Usually treated with diet, exercise
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121
Gestational Diabetes (p. 402)



Temporary form of disease occurring in pregnancy
Presents complications for mother and fetus/infant
Must be carefully monitored and controlled
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122
Other Types of Diabetes (p. 404)

Causes




Genetic defect
Pancreatic conditions or disease
Endocrinopathies: imbalance with other hormones
in the body
Drug/toxin induced or chemical induced
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123
Impaired Glucose Tolerance
(p. 404)



Above normal fasting blood glucose but not high
enough to be diabetes
A risk factor for type 2 diabetes
Underlying conditions often present
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124
Symptoms of Diabetes (p. 404)

Initial signs





Increased thirst
Increased urination
Increased hunger
Unusual weight loss (type 1)
Unusual weight gain (type 2)
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125
Symptoms of Diabetes (cont’d)
(p. 405)

Laboratory test results




Glycosuria (sugar in urine)
Hyperglycemia (elevated blood sugar)
Abnormal glucose tolerance tests
Progressive results



Water, electrolyte imbalance
Ketoacidosis
Coma
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126
The Metabolic Pattern of
Diabetes (p. 405)

Energy supply and control of blood glucose


Diabetes is especially related to metabolism of
carbohydrate and fat
It is important to control blood glucose within
normal levels of 70 to 110 mg/dl
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127
Case Study

Mr. Jones is a 45-year-old black male. He is 25 lbs
overweight. He also has a family history of diabetes.
His most recent lab work reveals an elevated fasting
blood sugar, elevated total cholesterol, and low HDL
level.
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128
Case Study (cont’d)

List Mr. Jones’ risk factors for type 2 diabetes.
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129
Case Study (cont’d)

What other screening tools could be used for
diabetes?
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130
Case Study (cont’d)

What are some signs and symptoms that Mr. Jones
may be experiencing?
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131
The Metabolic Pattern of
Diabetes (cont’d) (p. 405)

Sources of blood glucose



Dietary intake
Glycogen from liver and muscles
Uses of blood glucose



For immediate energy needs: glycolysis
Change to glycogen for storage: glycogenesis
Convert to fat for longer-term storage: lipogenesis
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132
Pancreatic Hormone Control
(p. 405)

Islets of Langerhans produce:



Insulin
Glucagon
Somatostatin
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133
Islets of Langerhans (p. 407)
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134
Insulin (p. 405)

Controls blood sugar






Helps transport glucose into cells
Helps change glucose to glycogen and store it in
liver, muscles
Stimulates changes of glucose to fat for storage as
body fat
Inhibits breakdown of tissue fat and protein
Promotes uptake of amino acids by skeletal
muscles
Influences burning of glucose for energy
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135
Glucagon (p. 407)



Acts in a manner opposite to insulin
Breaks down stored glycogen and fat
Raises blood glucose as needed to protect brain
during sleep or fasting
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136
Somatostatin (p. 407)



A “referee” for several other hormones
Inhibits secretion of insulin, glucagon, and other GI
hormones
Also produced in other parts of the body (e.g.,
hypothalamus)
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137
Abnormal Metabolism in
Uncontrolled Diabetes (p. 407)

When insulin activity insufficient, imbalances
occur in:



Glucose
Fat
Protein
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138
Glucose (p. 407)



Glucose normally absorbed into pancreatic cells,
triggering secretion of insulin
Glucose taken up into cells
Without insulin, cells starved for glucose
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139
Fat (p. 407)



Without insulin, fat tissue formation decreases
Fat tissue breakdown increases
Intermediate products of fat breakdown, ketones,
accumulate in body
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140
Protein (p. 408)

Without insulin, protein also broken down to secure
energy
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141
Long-Term Complications
(p. 408)




Retinopathy: leading cause of new cases of
blindness age 20 to 74
Nephropathy: leading cause of end-stage
renal disease
Neuropathy: nervous system damage in legs
and feet
Heart disease


Dyslipidemia: Elevated triglyceride, decreased
high-density lipoprotein cholesterol
Hypertension: A major comorbid condition
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142
General Management of
Diabetes (p. 409)




Early detection
Prevention of complications
Glucose tolerance test
Goals of care



Maintaining optimal nutrition
Avoiding symptoms
Preventing complications
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General Management of
Diabetes (cont’d) (p. 411)

Self-care skills


People with diabetes must treat themselves
Basic elements of diabetes management



Healthy diet
Physical activity
Ensure adequate insulin
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Special Objectives During
Pregnancy (p. 411)



Usually involves team of specialists
Careful monitoring of mother with diabetes
Preventing fetal damage
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Lesson 20.2: Care for the Person
with Diabetes Mellitus



Daily self-care skills enable a person with diabetes to
remain healthy and reduce risks for complications.
Blood glucose monitoring is a critical practice for
blood glucose control.
A personalized care plan balancing food intake,
exercise, and insulin regulation is essential to
successful diabetes management.
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Medical Nutrition Therapy for
Individuals with Diabetes (p. 411)

Individuals with prediabetes



Promote healthy food choices
Increase physical activity
Achieve and maintain moderate weight loss
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Medical Nutrition Therapy for Individuals
with Diabetes (cont’d) (p. 411)

Individuals with diabetes

Blood glucose levels as safely as possible
 Lipid and lipoprotein profile
 Blood pressure levels
 Prevent, or at least slow, the rate of chronic
complications
 Address individual nutrition needs
 Maintain the pleasure of eating
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Additional Considerations
(p. 411)

Additional considerations


For youth with type 1 diabetes, youth with type 2
diabetes, pregnant and lactating women, and
older adults with diabetes, to meet the nutrition
needs of these unique times in the life cycle
Provide self-management training for safe conduct
of exercise, including the prevention and treatment
of hypoglycemia and diabetes treatment during
acute illness
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Total Energy Balance (p. 411)

Normal growth and weight management



Type 1 in childhood: use normal height/weight
charts
Type 2 in adulthood: major goal is often weight
reduction/control
Energy intake


Balances with needs for growth/development,
physical activity, desirable lean weight
Negative balance if weight loss is goal
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Nutrient Balance (p. 412)

Carbohydrate





Starch and sugar: Complex and simple
carbohydrates
Glycemic index
Fiber
Sugar substitutes: Nutritive and nonnutritive
Glycemic index


Measure of a food’s ability to raise blood glucose
level
Carbohydrates differ
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Nutrient Balance (cont’d) (p. 412)

Fiber


Sugar substitute sweeteners


Nutritive and nonnutritive allowed in moderation
Protein


Normal consumption encouraged
About 10% to 35% of total energy
Fat

No more than 7% of kilocalories from saturated fat
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Food Distribution (p. 414)






Eat even amounts of food at regular intervals
Maintain even blood glucose supply
Snacks may be needed
Adjust eating according to activity level and stress
Regulate glycemic response according to physical
activity and exercise
Drug therapy
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Daily Activity Schedule (p. 414)



Food distribution must be adjusted to activities
Especially important for children and adolescents
Stressful event can counteract insulin activity
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Exercise (p. 414)



Recommendation: 150 min/week of moderateintensity aerobic activity
Helps those with type 2 DM control blood glucose
and prevent cardiovascular disease, other risks
For those using insulin, energy needs of exercise
must be covered in food distribution plan
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Drug Therapy (p. 415)


Affects food distribution
Patient must adjust diet, medications, exercise as
needed
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Diet Management (p. 415)


General planning according to type of diabetes
Develop plan to meet individual needs: living
situation, background, food habits
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Diet Management (cont’d)
(p. 415)

Carbohydrate counting



Count carbohydrates for a meal
Inject appropriate amount of insulin to process
glucose
Food exchange system

Organizes food into groups
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Special Concerns (p. 416)







Special diet food items: usually not needed
Alcohol: occasional cautious use allowed
Hypoglycemia: prepare for possibility
Illness: adjust food and insulin accordingly
Travel: consult with dietitian first
Eating out: plan ahead and choose restaurants wisely
Stress: antagonistic to insulin
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Diabetes Education Program
(p. 419)

Goal: person-centered self-care



Patients taking more active role in their care
Diabetes requires daily survival skills
Diabetes Self-Management Education
(DSME)

Support informed decision-making
 Self-care behaviors
 Problem-solving
 Active collaboration with health care team
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Necessary Skills (p. 419)




Healthy eating
Being active
Monitoring
Medications





Insulin
Oral hypoglycemic agents
Problem-solving
Health coping
Reducing risk
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Case Study (cont’d)


The physician sends Mr. Jones for nutritional
counseling.
What are your recommendations for him?
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Resources (p. 422)



American Diabetes Association
American Dietetic Association
American Association of Diabetes Educators
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Staff Education (p. 422)


Success of diabetes education programs depends on
sensitivity and training of staff
Continuing education essential
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