Transcript Endocrine Disorders

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