Nursing of Adults with Medical & Surgical Conditions Endocrine Disorders

Nursing of Adults withMedical & 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

• Physical or emotional stress• Pregnancy• Adolescence• Infection• Genetic• Autoimmune

Graves’ Disease Signs & Symptoms

– Edema of the anterior portion of the neck

• Enlargement of the thyroid

– Exphtalmos• Bulging of the eyeballs due to

periorbital edema

– Inablility to concentrate– Memory loss– Dysphagia– Hoarsness– Increased appetite– Weight loss– Nervousness

Graves’ Disease

– Insomnia– Tachycardia– Hypertension– Warm, flushed skin– Fine hair– Amenorrhea– Elevated temperature– Diaphoresis– Hand tremors

Graves’ Disease

Treatment– Medications

• Propylthiouracil• Methimazole

– Block production of thyroid hormones

– Radioactive iodine• Destroys part of thyroid tissue

– Subtotal thyroidectomy• Part of thyroid is removed

Graves’ Disease– Post-Op

• Voice rest• Voice checks• Avoid hyperextention of neck• Tracheotomy tray at bedside• Assess for s/s of internal and external bleeding

– High risk of hemorrhage

• Assess for tetany– May occur due to accidental removal of parathyroid glands– Decreases serum calcium levels– Chvostek’s Sign

» Abnormal spasm of facial muscles elicited by light tap on the facial nerve

– Trousseau’s Sign» Carpal spasm induced by inflation of B/P cuff on the upper

arm for 3 minutes

Chvostek’s Sign

Trousseau’s Sign

Graves’ Disease

• Thyroid Crisis– Caused by manipulation of thyroid– Releases large amounts of thyroid hormones– Usually occurs within first 12 hrs– Exaggerated symptoms of hyperthyroidism– Can be fatal if untreated

Hypothyroidism

Etiology/Pathophysiology– Insufficient secretion of thyroid hormones– Slowing of all metabolic processes– Failure of thyroid or insufficient secretion of

TSH from pituitary gland– Myxedema

• Adults

– Cretinism• Newborns; congenital

Hypothyroidism Signs & Symptoms

– Depends on degree of thyroid hormone deficiency

– Hypothermia– Intolerance to cold– Weight gain– Depression– Impaired memory– Slow thought process– Lethargic – Anorexia– Constipation

Hypothyroidism

– Decreased libido– Menstrual irregularities– Thin hair– Skin thick and dry– Enlarged facial

appearance– Low hoarse voice– Bradycardia– Hypotension

Hypothyroidism

Treatment– Medications

• Synthroid• Levothyroid• Proloid• Cytomel

– Symptomatic treatment

Simple Goiter

Etiology/Pathophysiology– Enlarged thyroid due to low iodine levels– Enlargement is caused by the

accumulation of colloid in the thyroid follicles

– Usually cause by insufficient dietary intake of iodine

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


Signs & Symptoms– Firm, fixed, small, rounded mass or nodule

of 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 HyperfunctionCushing’s Syndrome

Etiology/Pathophysiology– Plasma levels of adrenocortical hormones

are increased– Hyperplasia of adrenal tissue due to

overstimulation by the pituitary gland– Tumor of the adrenal cortex– ACTH secreting tumor outside the pituitary– Overuse of corticosteriod drugs


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


– Ecchymoses and petechiae– Weight gain– Abdominal enlargement– Hirsutism in women

• Exessive hair in a masculine distribution

– Menstrual irregularities– Deepening of the voice


Treatment– Treat causative factor

• Adrenalectomy for adrenal tumor• Radiation or surgical removal for pituitary

tumors

– Lysodren• Cytotoxic agent to decrease production of

adrenal steroids

– Low sodium, high potassium diet

Adrenal HypofunctionAddison’s Disease

Etiology/Pathophysiology– Adrenal glands do not secrete adequate

amounts of glucocorticoids and mineralocorticoids

– May result from• Adrenalectomy• Pituitary hypofunction• Long standing steroid therapy


Signs & Symptoms– Related to imbalances of hormones, nutrients, and

electrolytes:– Nausea– Anorexia– Postural hypotension– Headache– Disorientation

• Abdominal pain• Lower back pain

– Anxiety


– Darkly pigmented skin and mucous membranes

– Weight loss– Vomiting – Diarrhea– Hypoglycemia– Hyponatremia– Hyperkalemia


– Adrenal Crisis• Sudden, severe drop in B/P• Nausea & vomiting• Extremely high temperature• Cyanosis• Death


Treatment– Restore fluid and electrolyte balance– Replacement of adrenal hormones

• Florinef

– Diet high in sodium and low in potassium– Adrenal Crisis

• IV corticosteroids in a solution of saline and glucose

Diabetes MellitusType I and Type II

Etiology/Pathophysiology– Unknown

Risk Factors– Heredity

• Blood relatives of people who have DM (esp Type II) are more likely to develop DM

– Environment and lifestyle• Overweight, sedentary lifestyle are more prone to Type I DM

– Viruses• Chickenpox-type viruses have been associated with the

development of Type I DM

– Malignancy or Surgery of Pancreas• Decreased functioning ability


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


Classifications– Type I

• Insulin Dependent (IDDM)

– Type II• Non-insulin Dependent (NIDDM)

Signs & Symptoms– Type I & Type II

• Polyuria• Polydypsia• Polyphagia


– Type I• Sudden onset• Weight loss• Hyperglycemia• Under 40 years old

– Type II• Slow onset• May go undetected for years• “3 P’s” are usually mild• Untreated may have skin infections &

arteriosclerotic conditions


Diagnostic Tests– Urine glucose and acetone

• Neither are normally in urine• Glucose in urine means the blood glucose has

exceeded the “renal threshold”

– Blood glucose• Venipuncture or capillary• Glucose is always present in the blood• Amount can fluctuate according to how much and what

type of foods have been eaten• Normal values

– 70-110 mg/dl

– Oral glucose tolerance test• Fasting (NPO for at least 8 hours)• Fasting blood sugar is drawn• Glucose drink administered• Blood drawn at 1 hr, 2 hrs, and 3 hrs after drink

– 1hr: elevated– 2hr: essentially normal– 3hr: within normal limits

– 2 hour post-parandial blood sugar• Blood sugar drawn 2 hours after a normal meal• Values should be within normal limits

– Glycohemoglobin• Glucose in hemoglobin• Elevation means that the patient’s blood sugar levels were

consistantly high for 6-8 weeks previously• Values

– Non-diabetic adult: 2.2-4.8%– Good diabetic control: 2.5-5.9%– Fair diabetic control: 6-8%– Poor diabetic control above 8%

Treatment– Diet

• The cornerstone of treatment• Usually based on caloric needs (pt. size, activity, etc)• Type II may be controlled by diet alone• Type I diet is calculated and then the amount of insulin required to

metabolize it is established• ADA diet (American Diabetes Association)

– 7 Exchanges» Free calories» Vegetables» Fruits» Bread» Meat» Fats» Milk

– Quantitative Diet» Carbohydrates – 45-50% of calories» Proteins – 10-20% of calories» Fats – no more than 30% of calories

• Need 3 regular meals with snacks between meals and at bedtime to maintain constant glucose levels

Carbohydrate Counting Adults with Type 2 diabetes generally need to limit

carbohydrates to no more than 45-60 grams per meal and 15-30 grams for a snack.

Eat three meals a day with one to three snacks. Try to eat around the same times every day.

Avoid skipping meals. Follow the food guide pyramid. Pay attention to

carbohydrate choices. Stay within your recommended serving ranges.

Limit foods that are high in added sugars and fats. If you do consume foods with added sugar, be sure to count them into your carbohydrate choices.

Avoid drinking high sugar beverages such as regular sodas, fruit juices, lemonade and punch. All of these can be substituted with diet, low calorie, low sugar or light alternatives.

These foods count as one (1) carbohydrate choice:

1 oz dinner roll

1 cup (8 oz) milk

1/2 cup beans

1 slice bread

1 cup (8 oz) soy milk

1/2 cup corn

1/2 cup cooked cereal

8 oz yogurt (no added sugar)

1/2 cup green peas

3/4 cup dry cereal (varies)

1 taco

3 oz baked potato

2 - 4" pancakes

1 slice thin crust pizza

1 cup winter squash

1/2 cup pasta or potato salad

1 cup bean or noodle soup

1/2 cup canned fruit

1/2 cup pasta

1 granola bar

1/4 cup dried fruit

1/3 cup rice

3 graham cracker squares

1 cup berries

1 - 6" tortilla

1/2 cup sugar free pudding

1/2 medium grapefruit

1 - 4" waffle

10-15 potato chips

3 prunes

3 cups popcorn

1/2 cup ice cream

12-15 cherries or grapes

4-5 crackers

1 - 3" cookie

1 small apple or orange

1 small muffin

1 Tbsp syrup, honey, or sugar

1 cup melon

15 pretzels

1/3-1/2 cup fruit juice

2 Tbsp raisins

These foods count as two (2) carbohydrate choices:

1 - 8 to 11 oz frozen dinner

1 hamburger with bun

1 - 2-oz English muffin

1 cup lasagna (3" x 4" piece)

1 - 2-oz hamburger or hotdog bun

1 cup macaroni and cheese

1 cup sweetened yogurt

1 slice thick crust pizza

1 - 7" meat burrito

1/2 large bag light popcorn

1 medium banana or pear

1 small bagel

1 cup chili

1 cup casserole

– Insulin• Classified by Action

– Regular» Fast acting» Peek action 2-4 hours» Duration 5-8 hours

– Lente & NPH» Intermediate acting» Peek action 4-12 hours» Duration 18-24 hours

– Ultralente» Long acting» Peek action 12-18 hours» Duration 28-36 hours

• Classified by Type– Beef/Pork

» derived from the pancreas of a pig or cow

– Humulin/Novolin» synthetic human insulin

• Regular Insulin is the ONLY form that can be given IV!

• Should be administered at room temperature• Should be discarded after open for 3 months• Standardized Dose

– 100 units/ml (U100)– Use ONLY insulin syringes

• Administer subcutaneous

Insulin Injection Sites• Injection Sites

– Should be rotated to prevent scar tissue formation

» Insulin is not well absorbed in scar tissue

– Sites » Lateral surface of

the upper arms» Abdomen just

below the rib cage» Buttocks» Anterior surface of

thighs

• Sliding Scale– Insulin is given according to blood glucose levels– Regular insulin is only type that should be given to

scale– Scales will vary on different patients, physicians, etc.– Sample Scale

» Blood Sugar Insulin 200-225 2 units 226-250 3 units 251-275 4 units 276-300 5 units above 300 Call MD

Alternate Methods of Insulin Administration

Insulin Pump



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 short acting 6-12 hours

– Tolinase interm. acting 12-24 hours

– Diabinease long acting up to 60 hours

– Hygiene• Prevention more than treatment• Decreased resistance to infection• Wounds heal more slowly• Proper care of feet

– Clean

– Nail care

– Proper fitting shoes

– No heating pads

– Do NOT trim nails - MD only

– Exercise• Promotes movement of glucose into the cell by

changing the cell permeability• Lowers blood glucose• Lowers insulin needs

Insulin Reaction– Hypoglycemia– May be due to a sudden drop to below

normal or may be due to a sudden drop from extremely high to normal

– Pathophysiology• Too little circulating glucose

– Cause• Too much insulin OR not enough food

– Signs and Symptoms• Trembling• Perspiration• Irrritability• Dizziness• Muscle weakness• Headache• Blurred vision• Hunger• Confusion• Comatose• Convulsions

– Treatment• Increase blood glucose

– High calorie drink

» Orange juice

» Cola

– Concentrated sugar

» Candy

» Jelly

– Then complex foods

» Carbohydrates

» Proteins

– If unconsious

» 50% dextrose IV

Diabetic Acidosis/Ketoacidosis– Hyperglycemia– Usually occurs in Type I (IDDM)– Cause

• Lack of insulin• Accumulation of glucose and wastes from fat and

protein metabolism

– Signs & Symptoms• Polyuria• Polydipsia• Polyphagia• Nausea & vomiting• Weakness• Headache• Flushed face• Late Symptoms

– Sweet fruity breath– Hypotension– Tachycardia– Kussmaul’s Respirations

» Loud, deep and rapid resp. followed by apnea– BS may be as high as 1000mg/dl

– Treatment• Regular insulin IV• Fluids and electrolyte replacement• Find cause and educate patient

Chronic Complications– Macrovascular changes

• Caused by atherosclerosis• Intermittent claudication• Stroke• Gangrene• Coronary artery disease

– Microvascular changes• Caused by changes in the capillaries• Eyes

– diabetic retinopathy– cateracts

• Kidneys– nephropathy

• Infection– High BS levels cause poor circulation and decreased sensation

• CNS disturbances– Metabolic imbalances affects the sensory and motor fibers

Other Complications– Surgery

• Stresses the body

• Pts. who required no insulin, may now require insulin

• Pts. who were on insulin, will probably require increased doses

– Tests• NPO

• Need to consider how long they will be NPO and what type insulin they are taking

– “Sick Days”• Increased risk of ketoacidosis (hyperglycemia)

• Glucose must be monitored closely

Patient Education– Diet– Exercise– Medications– Hygiene

– Consider• Intellect

• Motivation

• Physical ability (vision, etc)

• Social and personal resources

– Success depends on ability and willingness

Documents

Nursing of Adults with Medical & Surgical Conditions Endocrine Disorders