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Review   Endocrine Disorders
 

Review Endocrine Disorders

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    Review   Endocrine Disorders Review Endocrine Disorders Presentation Transcript

    •  
      • 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
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      • 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
    •  
      • 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
      • 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
      • 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
      • 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
      • 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)
      • 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
      • Anxiety
      • Flushed, smooth skin
      • Heat intolerance
      • Mood swings
      • Diaphoresis
      • Tachycardia
      • Palpitations
      • Dyspnea
      • Weakness
      • Wt. loss
      Assessment Findings
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      • 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.
      • 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
      • 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
      • 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
      • 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
    •  
      • 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)
      • 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
    •  
      • 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)
      • 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
      • 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
      • 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
      • 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.
      • 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
      • 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
    •  
      • 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.
      • 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.
    •  
    • Oral Antidiabetic Agents
      • 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
      • 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
    •  
      • 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.
    •  
      • 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.
      • 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)
      • 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
    • 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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