Review Endocrine Disorders

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  • 1.  
  • 2.
    • Hypothyroidism
    • underactive state of the thyroid gland  hyposecretion of
    • thyroid hormone
    • most common in women, middle-age
    • Causes :
      • thyroidectomy
      • pituitary / hypothalamic dysfunction
      • iodine deficiency
      • autoimmune thyroiditis (Hashimoto’s disease) – immune
      • system attacks the thyroid gland
      • idiopathic (unknown)
    • DX: decreased T3, T4
    • Elevated TSH, cholesterol
  • 3.  
  • 4.  
  • 5.  
  • 6.
    • Med. Mgt . – thyroid replacement therapy
    • Levothyroxine (Synthyroid) , liothyronine
    • Expected effects: diuresis,  puffiness, improved reflexes
    • and muscle tone,  PR
    • Nsg. Interventions
      • provide a warm environment, conducive to rest
      • avoid use of all sedatives
      • assist client in choosing  calorie,  cholesterol diet
      •  fluid and fiber to relieve constipation
      •  physical activity and sensory stimulation gradually as
      • condition improves
      • monitor cardiovascular response to increased hormone
      • levels carefully
      • provide info. about prescribed medications (name, dosage, side effects) and importance of lifelong medical supervision
  • 7.  
  • 8.
    • Hyperthyroidism
    • over-secretion of the thyroid gland
    • also called thyrotoxicosis, tissues are stimulated by
    • excessive thyroid hormone
    • a recurrent syndrome, may appear after emotional
    • stress or infection
    • occurs mostly in women 20-50 yrs old
    • Causes : adenoma, goiter, viral inflammation, auto-immune glandular stimulation, grave’s disease - most common cause
  • 9.
    • Hyperthyroidism (cont.)
    • DX: > elevated T3, T4 values
    • abnormal findings in the thyroid scan
    • Goiter – enlargement of the thyroid gland
    • due to  stimulation of the thyroid gland by TSH
    • Simple goiter – enlarged thyroid gland
    • due to iodine deficiency, intake of goitrogenic foods  cabbage, turnips, soybeans
    • may be hereditary
  • 10.
    • Grave’s Disease
    • disorder char. by one or more of the ff:
      • diffuse goiter
      • hyperthyroidism
      • infiltrative opthalmopathy  exophthalmos
    • seen in females under age 40
    • result from stimulation of the thyroid gland by
    • thyroid-stimulating immunoglobulins (TSI)
    • cause is unknown, may be hereditary, gender-related,
    • often occurs after severe emotional stress or
    • infection
  • 11.
    • Thyroid Storm or Crisis
    • a medical emergency  pts. develop severe
    • manifestation of hyperthyroidism
    •  temp., tachycardia, dysrhythmias
    • worsening tremors, restlessness
    • delirious or psychotic state or coma
    • abdominal pain
    •  BP and  RR
    • Precipitated by a major stressor :
      • infection
      • trauma or surgery (thyroidectomy)
      • inadequate treatment
  • 12.
    • Complications :
      • cardiovascular disease (HPN, Angina, CHF)
      • Exophthalmos – abnormal protrusion of the eyeballs
        • caused by abnormal deposits of fat and fluid in
        • the retroocular tissue
      • Corneal abrasion
      • Thyroid storm or crisis  life-threatening
      • hypermetabolism and excessive adrenergic
      • response (  HR,  RR,  BP)
  • 13.
    • Pathophysiology:
    • hypertrophy and hyperplasia of the thyroid gland
    • excessive secretion of thyroid hormone 
    • hypermetabolic condition
    • exaggeration of all metabolic processes
    •  metabolic rate, excessive heat production
    •  appetite
    •  neuromuscular and CVS activity
    • hyperactivity of sympathetic NS
    • personality changes
  • 14.
    • Anxiety
    • Flushed, smooth skin
    • Heat intolerance
    • Mood swings
    • Diaphoresis
    • Tachycardia
    • Palpitations
    • Dyspnea
    • Weakness
    • Wt. loss
    Assessment Findings
  • 15.  
  • 16.  
  • 17.  
  • 18.  
  • 19.  
  • 20.
    • Nsg. Interventions:
    • Provide calm, restful envt.
      • physical comfort, cool envt. temp., bathe frequently w/ cool water
      • provide adequate rest, avoid muscle fatigue
      •  stressors in the envt.—  noise and lights
      • relaxation techniques
    • Provide adequate nutrients
      •  calorie,  protein, balanced diet (4,000-5,000 cal/day)
      •  fluid intake
      • Restrict stimulants (tea, coffee, alcohol)
      • small, frequent feedings if hypermotility is present
      • Daily wt.
  • 21.
    • Nsg. Interventions:
    • Provide emotional support
    • Provide eye care
      • eye drops, dark glasses, patch eyes if necessary
      • elevate head of bed for sleep
      • restrict dietary sodium
      • assess adequacy of lid closure
    • Be alert for complications
  • 22.
    • Post-op care after Thyroidectomy
    • O2 therapy, suction secretions
    • Monitor for signs of bleeding and excessive edema
    • elevate head of bed 30 o , support head and neck – to
    • avoid tension on sutures
    • check dressing frequently, check behind the neck for
    • bleeding
    • assess for signs of resp. distress, hoarseness
    • (laryngeal edema or damage)
    • keep tracheostomy set in patient’s room for emergency
    • use
  • 23.
    • Post-op Complications: be alert for the possibility of:
    • 1. Tetany (due to hypocalcemia caused by accidental removal of parathyroid glands)
      • assess for numbness, tingling or muscle twitching
      • Chvostek’s sign and Trousseau’s sign
      • Ca+ gluconate IV
    • 2. Hemorrhage
      • WOF: hypotension, tachycardia, other signs of hypovolemia
      • WOF: irregular breathing, swelling, choking---possible hemorrhage and tracheal compression
      • WOF: early signs of hemorrhage: repeated clearing of the throat, difficulty swallowing
  • 24.
    • Post-op Complications: be alert for the possibility of:
    • 3. Thyroid storm
    • - life-threatening
    • - sudden  release of thyroid hormone
    • - fever, tachycardia, increasing restlessness and
    • agitation, delirium
      • administer food and fluid with care (dysphagia is common) encourage client to gradually  ROM of neck
      • teach about medications, frequent follow-up
        • total thyroidectomy – life long replacement medication (T3, T4)
        • subtotal thyroidectomy – careful monitoring of return of thyroid function
  • 25.  
  • 26.
    • Diabetes Mellitus
      • is a chronic disorder of carbohydrate, protein, and
      • fat metabolism resulting from insulin deficiency or
      • abnormality in the use of insulin
    • Predisposing factors:
    • exact cause of diabetes mellitus remain unknown
    • genetic / hereditary predisposition
    • viruses
    • pancreatitis
    • pancreatic tumor
    • autoimmune disorder
    • obesity (overweight people require more insulin
    • to metabolize the food they eat or the number of insulin receptor sites in cells is decreased)
  • 27.
    • Types
    • Insulin – Dependent Diabetes Mellitus (IDDM) or Type I
      • destruction of beta cells of the pancreas  little or no
      • insulin production
      • requires daily insulin admin.
      • may occur at any age, usually appears below age 15
    • Non Insulin–Dependent Diabetes Mellitus (NIDDM) or Type II
      • probably caused by:
        • disturbance in insulin reception in the cells
        •  number of insulin receptors
        • loss of beta cell responsiveness to glucose leading to
        • slow or  insulin release by the pancreas
      • occurs over age 40 but can occur in children
      • common in overweight or obese
      • w/ some circulating insulin present, often do not require
      • insulin
  • 28.  
  • 29.
    • Clinical Manifestations ( Signs and Symptoms)
    • - Polyuria - weakness
    • - Polydipsia - fatigue
    • - Polyphagia -  blood sugar / glucose level
    • - weight loss - (+) glucose in urine (glycosuria)
    • nausea / vomiting
    • - changes in LOC (severe hyperglycemia)
    • (sleepiness, drowsiness  coma)
    • - recurrent infection, prolonged wound healing
    • altered immune and inflammatory response, prone to
    • infection (glucose inhibits the phagocytic action of WBC 
    •  resistance)
    • genital pruritus – (hyperglycemia and glycosuria favor fungal growth : candidal infection – resulting in pruritus, common
    • presenting symptom in women)
  • 30.
    • Fasting Blood Sugar (FBS)
      • NPO for 12 hours
      • Normal value= 80-120 mg/dl
      • 140 mg/dl or more – diagnostic of DM
    • Postprandial blood sugar
      • Blood is withdrawn 2 hrs. after a meal
      • N value = < 120mg/dl
      • 200 mg/dl or more is diagnostic of DM
    • Oral Glucose Tolerance Test (OGTT)
      • NPO 12 hrs, no smoking, coffee or tea, minimize activity, minimize stress
      • obtain FBS, administer 100 gm. Glucose by mouth diluted in juice; obtain blood and urine specimen after 1, 2 and 3 hrs.
      • N value = blood glucose rise to 140 mg/dl in the 1 st hour and returns to normal by 2 nd and 3 rd hrs.
      • Abnormal = blood glucose does not return to normal by 2 nd and 3 rd hrs.; all urine specimen positive for glucose
  • 31.
    • 4 . Glycosylated hemoglobin
      • Provides information about blood glucose level during the previous 3 months
      • bec. glucose in the bloodstream attaches to some of the hemoglobin and stay attached during the 120-day lifespan of the RBC
  • 32.
    • Interventions for Diabetes Mellitus
    • A.Dietary Management
      • Follow individualized meal plan and snacks as scheduled
        • Balanced diabetic diet – 50% CHO, 30% fats, 20% CHON, vitamins and minerals
        • diet based on pts. size, wt., age, occupation and activity
      • 2. Pt. must have adequate CHO intake to correspond to the time when insulin is most effective
      • Routine blood glucose testing before each meal and at bedtime is necessary during initial control, during illness and in unstable pts.
      • Do not skip meals
      • Measure foods accurately, do not estimate
      • Less added fat, fewer fatty foods and low-cholesterol
  • 33.
    • Interventions for Diabetes Mellitus
    • A.Dietary Management
      • Advise use of complex carbohydrates to help stabilize blood sugar. Meal should include more fiber and starch and fewer simple or refined sugars.
      • Avoid concentrated sweets, high in sugar (jellies, jams, cakes, ice cream)
      • If taking insulin, eat extra food before periods of vigorous exercise
      • Avoid periods of fasting and feasting
      • Keep weight at normal level, obese diabetics should be on a strict weight control program and should lose weight.
  • 34.
    • B. Teach pt. on correct administration of insulin and other hypoglycemic agents.
      • insulin in current use may be stored at room temp., all others in ref. or cool area
      • avoid injecting cold insulin  lead to tissue reaction
      • roll insulin vial to mix, do not shake, remove air bubbles from syringe
      • press (do not rub) the site after injection (rubbing may alter the rate of absorption of insulin)
      • avoid smoking for 30 mins. after injection (cigarette smoking  absorption)
      • Rotate sites
      • Failure to rotate sites may lead to Lipodystrophy
      • Lipodystrophy – localized disturbance of fat metabolism
      • Ex. Lipohypertrophy – thickening of subcutaneous tissue at injection site, feel lumpy or hard, spongy
        •  result to  absorption of insulin  making it difficult to control the pt.’s blood glucose
  • 35.
    • Factors that influence the body’s need for insulin
    •  need : trauma, infection, fever, severe psychological or physical stress, other illnesses
    •  need : active exercise
    • Hypoglycemia
      • low blood glucose (usually below 60mg/dl)
      • results from too much insulin, not enough food, and/or excessive physical activity
      • may occur 1-3 hrs after regular insulin injection
    • S/Sx:
    • Sweating, tremor, pallor, tachycardia, palpitations and nervousness
      • caused by release of epinephrine from the CNS when blood glucose falls rapidly
    • Headache, light-headedness, confusion, numbness of lips and tongue, slurred speech, drowsiness, convulsions and coma
      • caused by depression of the CNS because of  glucose supply of brain cells
  • 36.  
  • 37.
    • Management of Hypoglycemia
    • Give simple sugar orally if pt. is conscious and can swallow – orange juice, candy, glucose tablets, lump of sugar
    • Give Glucagon (SQ or IM) if pt. is unconscious or cannot take sugar by mouth
    • As soon as pt. regains consciousness, he should be given carbohydrate by mouth
    • If pt. does not respond to the above measures, he is given 50 ml of 50% glucose I.V. or 1000 ml of 5%-10% glucose in water I.V.
  • 38.
    • Preventing Hypoglycemic Reactions Due to Insulin
    • Instruct the pt. as follows:
    • Hypoglycemia may be prevented by maintaining regular exercise, diet and insulin
    • Early symptoms of hypoglycemia should by recognized and treated
    • Carry at all times some form of simple carbohydrate (orange juice, sugar, candy)
    • Extra food should be taken before unusual physical activity or prolonged periods of exercise
    • Between-meal and bedtime snacks may be necessary to maintain a normal glucose level.
  • 39.  
  • 40. Oral Antidiabetic Agents
  • 41.
    • Teach pt. to estabilish and maintain a pattern of regular exercise
    • Benefits of exercise :
      • promotes use of CHO & enhances action of insulin
      •  blood glucose levels
      •  need for insulin
      •  the no. of functioning receptor sites for insulin
    • perform exercise after meals to ensure an adequate level of blood glucose
    • carry a rapid-acting source of glucose during exercise
    • excessive or unplanned exercise may trigger hypoglycemia
    • take insulin and food before active exercise
  • 42.
    • Teach pt. to practice good personal hygiene and positive health promotion to avoid diabetic complications
    • teach pt. about diabetic foot care
    • teach pt. the adjustments that must be made in the event of minor illness (e.g. colds, flu)
      • continue taking insulin or oral hypoglycemic agents
      • maintain fluid intake
      •  frequency of blood testing or urine testing
    • help pt. identify stressful situations in lifestyle that might interfere with good diabetic control
    • encourage good daily hygiene
    • advise regular eye exams
    • teach aggressive care for minor skin cuts and abrasions
  • 43.  
  • 44.
    • Diabetic Ketoacidosis (DKA) Coma
    • S/Sx:
    • polyuria, thirst
    • nausea, vomiting, abdominal pain –-- due to acidosis
    • weakness, headache, fatigue --- due to acidosis and F/E imbalance
    • dim vision, flushed face
    • dehydration, hypovolemic shock (  PR,  BP, dry skin, wt. loss)
    • hyperpnea (Kussmaul’s breathing)
    • acetone breath (fruity odor)
    • lethargy  COMA
    • Blood glucose level > 250-350 mg/100 ml.
  • 45.  
  • 46.
    • Hyperglycemic, Hyperosmolar, Non-Ketotic Coma (HHNC)
      • can occur when the action of insulin is severely inhibited
      • seen in pts. w/ NIDDM, elderly persons w/ NIDDM
    • Precipitating factors:
    • infection, renal failure, MI, CVA, GI hemorrhage, pancreatitis, CHF, TPN, surgery, dialysis, steroids
    • S/Sx:
    • polyuria  oliguria (renal insufficiency)
    • lethargy
    •  temp,  PR,  BP, signs of severe fluid deficit
    • Confusion, seizure, coma
    • Blood glucose level > 600 mg/100 ml.
  • 47.
    • Interventions for DKA and Hyperosmolar Coma
    • Regular insulin IV push or IV drip
    • 0.9% NaCl IV – 1 L during the 1 st hr, 2-8 L over 24 hrs.
    • administer sodium bicarbonate IV to correct acidosis
    • Monitor electrolyte levels, esp. serum K+ levels
    • administer K+, monitor UO hourly (30ml/hr)
  • 48.
    • Long-term Complications of DM
    • Vascular Changes
    • ) Macroangiopathy – hardening and damage of the walls of large arteries
      • Coronary Artery Disease
      • CVA (Stroke)
      • Peripheral vascular disease – foot ulcers and gangrene
    • b. ) Microangiopathy – destruction of small blood vessels
      • Retinopathy – damage to retinal capillaries; hemorrhage, blindness
      • Nephropathy – damage microcirculation of kidneys; CRF
    • 2. Neuropathy
      • Damage to the neurons caused by vascular insufficiency and  blood glucose
      • Sensory and motor impairment
      • Numbness, tingling, pain in extremities
      • Painless neuropathy
      • Impotence
  • 49. INSULIN ONSET PEAK DURATION Ultra rapid acting Insulin analog ( Humalog) 15 mins. 2-4 hrs. 6-8 hrs. Rapid acting: Regular ( Semilente ) ½-1 hr 2-4 hrs. 6-8 hrs. Intermediate: NPH ( Lente ) 1-2 hrs. 7-12 hrs. 24-30 hrs. Long acting: Protamine Zinc ( Ultralente ) 4-6 hrs. 18 + hrs 30-36 hrs.
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