NGRTCI Endocrine System Disorders Lecture

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NGRTCI Endocrine System Disorders Lecture

  1. 1. JOFRED M. MARTINEZ, MAN, RN
  2. 2. Insufficient hormone activity Excess hormone activity • Gland hypofunction • Gland hyperfunction • Lack of tropic or stimulating hormone • Excess tropic or stimulating hormone • Target tissue insensitivity to hormone • Ectopic hormone production • Self-administration of too much replacement hormone
  3. 3. NTIDIURETIC HORMONE XYTOCIN
  4. 4. RESULTS TO… Neurogenic DI Nephrogenic DI Psychogenic DI
  5. 5. RESULTS TO…
  6. 6. CAUSES: Pituitary surgery Trauma Presence of tumor Drugs (glucocorticoids or alcohol) CAUSES: Head trauma, surgery Oat cell carcinoma of the lungs Hodgkin’s disease Medications (diuretics, anesthetics, TCAs) Hyperplasia of pituitary gland SIGNS AND SYMPTOMS: 1. Polyuria 2. Signs of dehydration 3. Weakness and fatigue 4. Hypotension 5. Weight loss 6. Untreated results to… HYPOVOLEMIC SHOCK SIGNS AND SYMPTOMS: 1.Fluid retention 2.Untreated results to CEREBRAL EDEMA results to… INCREASE ICP results to… SEIZURE ACTIVITY DIAGNOSTIC PROCEDURE: 1. Urine specific gravity DECREASED 2. Serum sodium INCREASED DIAGNOSTIC PROCEDURE: 1. Urine specific gravity INCREASED 2. Serum sodium DECREASED
  7. 7. NURSING MANAGEMENT: 1. Force fluids 2. Monitor strictly vital signs and intake and output 3. Administer medications… DESMOPRESSIN (DDAVP) Administered INTRANASAL PITRESSIN (VASOPRESIN TANNATE) administered IM Z-TRACT CHLORPROPAMIDE (DIABINESE) 4. Prevent complications… HYPOVOLEMIC SHOCK NURSING MANAGEMENT: 1. Restrict fluid (500 to 600 mL per 24 hours) 2. Administer medications… LOOP DIURETICS (LASIX) OSMOTIC DIURETICS (MANNITOL) LITHIUM CARBONATE ( ESKALITH) PHENYTOIN HCL ( DILANTIN) 3. Monitor strictly vital signs, intake and output and neuro check 4. Weigh patient daily and assess for pitting edema 5. Provide meticulous skin care 6. Prevent complications
  8. 8. MEDICATIONS SIDE-EFFECTS NURSING IMPLICATIONS • Vasopressin (Pitressin): replaces ADH • Water retention • Check daily weights and urine specific gravity. • Desmopressin (DDAVP): replaces ADH • Water loss, dehydration • Demeclocycline (Declomycin): reduces ADH release • Photosensitivity, allergy, water loss • Do not give demeclocycline with dairy products or antacids.
  9. 9. • Assess for early signs of dehydration and maintain adequate hydration • Assess neurologic status • Measure fluid I&O • Check urine specific gravity • Record daily client weight • Monitor client for education need and ability to participate in health care • Weigh daily using the same scale at the same time of day
  10. 10. • Institute seizure precautions for children • Obtain daily serum and urinary sodium and osmolality levels • Measure I&O • Record daily client weight • Monitor client for education need and ability to participate • in health care
  11. 11. • Observe changes in client neurologic status  Assess for muscle twitching  Check orientation to time, place, and person  Reduce environmental noise to prevent overstimulation • Give ice chips to combat thirst when fluids are restricted • Provide mouth care often
  12. 12. IN CHILDREN…
  13. 13. IN CHILDREN…
  14. 14. IN CHILDREN…
  15. 15. IN ADULTS…
  16. 16. IN ADULTS…
  17. 17. DWARFISM acromegaly Etiology • pituitary tumor or failure of the pituitary to develop • infection trauma • neglect or severe emotional stress • malnutrition • pituitary hyperplasia • benign pituitary tumor • hypothalamic dysfunction Signs and symptoms • grow to only 3 to 4 feet • slowed sexual maturation • children: mental retardation • adults: weakness, hypoglycemia, sexual dysfunction, skin changes, and increased risk for cardiovascular and cerebrovascular disease • nose, jaw, brow, hands, and feet enlarge • tongue becomes thick • kyphosis • visual disturbances • headaches • erectile dysfunction and amenorrhea
  18. 18. DWARFISM acromegaly Diagnostic test • growth hormone stimulation test • MRI • radiographic studies • Serum growth hormone levels are measured Treatment • children: administration of growth hormone • surgery • Bromocriptine (Parlodel) • Octreotide (Sandostatin) • Hypophysectomy or radiation • lifelong replacement of thyroid hormone, corticosteroids, and sex hormones Nursing management • assessment of mental status, ability to cope with the effects of the disorder, and understanding of the treatment plan. • assess safety in relation to impaired eyesight, chewing, swallowing, and sleep apnea • monitor serum glucose levels
  19. 19. MEDICATIONS SIDE-EFFECTS NURSING IMPLICATIONS Bromocriptine (Parlodel): reduces growth hormone release • Dizziness, hypotension, nausea • Monitor blood pressure, serum growth hormone. Octreotide (Sandostatin): supresses growth hormone • Uncommon: dizziness, nausea, constipation • Teach patient self administration. Somatropin (Humatrope): replaces growth hormone • Insulin resistance, hypothyroidism • Monitor growth; teach patient self-administration.
  20. 20. • Promote self-esteem • Support confidence by capitalizing on idol worship in adolescents • Encourage participation in a support group • Promote coping
  21. 21. RESULTS TO…
  22. 22. RESULTS TO…
  23. 23. • Most tumors of the pituitary gland are benign adenomas. • Benign tumors in the brain can cause visual disturbances, symptoms of increased pressure in the brain, and symptoms related to hormone imbalances. • Treatment for is usually hypophysectomy. • Radiation is used, either alone or as an adjunct to surgery.
  24. 24. PREOPERATIVE CARE • Ensure that the patient understands the physician’s explanation of surgery. • Perform and document a baseline neurological assessment. • Prepare the patient for what to expect following surgery. Instruct the patient to avoid any actions that increase pressure on the surgical site, such as coughing, sneezing, nose blowing, straining to move bowels, or bending from the waist. • Instruct the patient in deep breathing exercises or use of an incentive spirometer.
  25. 25. POSTOPERATIVE CARE • Perform routine neurological assessments • check urine for specific gravity • If a patient has had transsphenoidal surgery, nasal packing are left in place and not removed unless ordered by the physician. • Monitor the dressing for signs of cerebrospinal fluid (CSF) leakage. • Avoid any actions that increase pressure on the surgical site. • Obtain orders for stool softeners and antitussives as needed. • Tooth brushing is avoided until the incision line is healed. • The patient may use floss and mouth rinses. • The patient is placed on hormone replacement therapy following hypophysectomy. .
  26. 26. POSTOPERATIVE CARE • Pituitary hormones are generally given. These may include thyroid hormone, glucocorticoids, intranasal desmopressin, and sex hormones. • Instruct the patient about how to administer the hormones, as well as side effects to report.
  27. 27. A. PREDISPOSING FACTORS 1. Goiter belt area 2. Increase intake of goitrogenic foods • cabbage, turnips, radish, strawberry, carrots, sweet potato, broccoli, all nuts 3. Goitrogenic drugs a. Anti Thyroid Agent – Prophylthiuracil (PTU) b. Lithium Carbonate c. ASA (Aspirin) d. Cobalt e. Phenylbutazones (NSAIDs)
  28. 28. B. SIGNS AND SYMPTOMS 1. Enlarged thyroid gland 2. Mild dysphagia 3. Mild restlessness C. DIAGNOSTIC PROCEDURES 1. Decreased serum T3 and T4 2. Thyroid Scan –enlarged thyroid gland 3. Thyroid Stimulating Hormone (TSH) – increased CONFIRMATORY DIAGNOSTIC TEST
  29. 29. D. NURSING MANAGEMENT 1. Enforce complete bed rest 2. Administer medications as ordered a. LUGOL’S SOLUTION / SSKI ADMINISTER VIA STRAW TO PREVENT STAINING OF TEETH Medications to be taken via straw: LUGOL’S, IRON, TETRACYCLINE, NITROFURANTOIN
  30. 30. b. THYROID HORMONES • LEVOTHYROXINE (SYNTHROID) • LIOTHYRONINE (CYTOMEL) • THYROID EXTRACTS Nursing management when giving thyroid hormones: 1. Instruct client to take in the morning to prevent insomnia 2. Monitor vital signs especially heart rate because drug causes tachycardia and palpitations 3. Monitor side effects insomnia, tachycardia, palpitations, hypertension, heat intolerance
  31. 31. 4. Increase dietary intake of foods rich in iodine • seaweeds • seafood’s like oyster, crabs, clams and lobster but not shrimps because it contains lesser amount of iodine. • iodized salt, best taken raw because it is easily destroyed by heat 5. Assist in SUBTOTAL THYROIDECTOMY
  32. 32. • All body systems are DECREASED except WEIGHT & MENTRUATION • All body systems are INCREASED except WEIGHT & MENTRUATION • DECREASED CNS: drowsiness, memory losses (FORGETFULNESS) • DECREASED VS: hypotension, bradypnea, bradycardia, hypothermia • DECREASED GI motility: CONSTIPATION • DECREASED appetite but with WEIGHT GAIN results to INCREASED SERUM CHOLESTEROL LEVELS results to HYPERTENSION, MI, CHF, STROKE • DECREASED metabolism causes decreased perspiration w/c results to DRY SKIN & COLD INTOLERANCE • INCREASED menorrhagia • INCREASED CNS: tremors, insomnia • INCREASED VS: hypertension, tachypnea, tachycardia, hyperthermia • INCREASED GI motility: DIARRHEA • INCREASED appetite but with WEIGHT LOSS • INCREASED metabolism causes increased perspiration w/c results to MOIST SKIN & HEAT INTOLERANCE • DECREASED amenorrhea EXPOTHALMOS Pathognomonic Sign
  33. 33. DIAGNOSTIC TESTS: 1. Serum T3 and T4 is DECREASED 2. Serum Cholesterol is INCREASED 3. RAIU is DECREASED DIAGNOSTIC TESTS: 1. Serum T3 and T4 is INCREASED 2. RAIU is INCREASED 3. Thyroid Scan - reveals an ENLARGED THYROID GLAND NURSING MANAGEMENT: 1. Monitor strictly vital signs and intake and output to determine presence of: •MYXEDEMA COMA is a severe form of hypothyroidism is characterized by severe hypotension, bradycardia, bradypnea, hypoventilation, hyponatremia, hypoglycemia leading to progressive stupor and coma. NURSING MANAGEMENT: 1. Monitor strictly vital signs and intake and output to determine presence of: •THYROID STORM is a severe form of hyperthyroidism is characterized by severe hypertension, tachycardia, tachypnea, hyperventilation, hyperpyrexia, altered neurologic or mental state, which frequently appears as delirium psychosis, somnolence, or coma
  34. 34. NURSING MANAGEMENT FOR MYXEDEMA COMA Assist in mechanical ventilation Administer thyroid hormones as ordered Force fluids NURSING MANAGEMENT FOR THYROTOXICOSIS  Cool quiet environment  O2 inhalation  IV fluids (hypertonic)  Antithyroid agents 2. Force fluids 3. Administer isotonic fluid solution as ordered 4. Administer medications: Thyroid Hormones LEVOTHYROXINE LEOTHYRONINE THYROID EXTRACTS 5. Provide dietary intake that is LOW IN CALORIES 6. Provide comfortable and warm environment 7. Provide meticulous skin care 2. Administer medications as ordered Antithyroid Agents PROPHYTHIORACIL (PTU) METHYMAZOLE (TAPAZOLE) Side effects: AGRANULOCYTOSIS • increase lymphocytes and monocytes, fever and chills, sore throat, leukocytosis (CBC) BETA-BLOCKERS PROPANOLOL (INDERAL) ATENOLOL (TENORMIN) 3. Provide dietary intake that is INCREASED IN CALORIES.
  35. 35. NURSING MANAGEMENT: 8. Provide client health teaching and discharge planning concerning: a. Avoid precipitating factors leading to myxedema coma • stress • infection • cold intolerance • use of anesthetics, narcotics, and sedatives • prevent complications (myxedema coma, hypovolemic shock • hormonal replacement therapy for lifetime • importance of follow up care NURSING MANAGEMENT: 4. Provide meticulous skin care 5. Comfortable and cold environment 6. Maintain side rails 7. Provide bilateral eye patch to prevent drying of the eyes. 8. Assist in surgical procedures: SUBTOTAL THYROIDECTOMY • Before thyroidectomy administer LUGOL’S SOLUTION, SSKI, POTASSIUM IODIDE to decrease bleeding and hemorrhage.
  36. 36. MEDICATIONS SIDE-EFFECTS NURSING IMPLICATIONS Levothyroxine (Synthroid): replaces T3 and T4 • Tachycardia, insomnia, nervousness, weight loss • Monitor vital signs and thyroid laboratory results. Propylthiouracil (PTU): inhibits synthesis of thyroid hormones • Nausea, vomiting, agranulocytosis • Monitor WBC and differential, thyroid function. Methimazole (Tapazole): inhibits synthesis of thyroid hormones • Rash, agranulocytosis
  37. 37. • Alert physician to medications taken that can alter results of diagnostic tests, especially estrogen, salicylates, amphetamines, antibiotics, corticosteroids, and mercurial diuretics • Modify client activity to accommodate fatigue • Promote independence in self-care activities • Provide extra layers of clothing or extra blanket • Monitor body temperature and report decreases from baseline • Provide foods high in fiber
  38. 38. • Monitor respiratory rate, depth, pattern, pulse oximetry, and arterial blood gas • Orient client to time, place, and events • Monitor for increasing severity of decreased LOC, VS changes, and increasing difficulty in arousal • Position a newborn with a goiter with the neck hyperextended to aid breathing; provide supplemental oxygen; and have a tracheostomy set immediately available in case tracheal compression by the goiter requires emergency ventilation.
  39. 39. • Monitor VS especially heart rate and rhythm • Monitor serum albumin, hemoglobin, and lymphocyte • levels • Encourage a diet high in calories, proteins, and carbohydrates • Encourage six meals per day • Weigh at least weekly • Assess for visual changes: photophobia, decreased acuity, or ability to close eyes
  40. 40. • If exophthalmos is present, protect eyes with glasses, wet with artificial tears, elevate head of bed at night; avoid sleeping in a prone position and wear a patch at night if eyelids do not fully close • Assess level of mentation for impending storm
  41. 41. • May cause nausea so limit oral intake 2 hours before and after treatment • Take acetaminophen for sore throat, which may occur a few days after the treatment • I 131 is eliminated in urine over 4–5 days so drink a lot of fluid, void frequently and flush twice, and thoroughly clean up any spilled urine • Wash laundry separately if the treated person has sweated heavily, such as after exercise
  42. 42. • Keep an arm’s length from anyone who will be in contact with you for more than 2 hours in every 4-hour period; especially if in contact with children and pregnant women. • Small amount found in saliva so avoid kissing and any sharing of food, fluids, or utensils • After I 131 treatment, women should not get pregnant or breast-feed for 6 months • Report palpitations, chest pain, or dizziness
  43. 43. 1. Watch out for signs of thyroid storm/ thyrotoxicosis HYPERTHERMIA, TACHYCARDIA, AGITATION a. Administer medications as ordered ANTI PYRETICS, BETA-BLOCKERS b. Monitor strictly vital signs, input and output and neuro check. c. Maintain side rails d. Provide TSB
  44. 44. 2. Watch out for accidental removal of parathyroid gland that may lead to HYPOCALCEMIA (TETANY) Signs and Symptoms: (+) TROUSSEAU’S SIGN (+) CHVOSTEK SIGN Watch out for arrhythmia, seizure give CALCIUM GLUCONATE IV slowly as ordered.
  45. 45. CHvostek’s sign is assessed near the CHeek.
  46. 46. 3. Watch out for accidental laryngeal damage which may lead to HOARSENESS OF VOICE Nursing Management: • encourage client to talk/speak immediately after operation and notify physician 4. Signs of bleeding Nursing Management: • check the soiled dressings at the back or nape area. 5. Hormonal replacement therapy for lifetime 6. Importance of follow up care
  47. 47. ETIOLOGY: 1. Subtotal thyroidectomy 2. Atrophy of parathyroid gland due to: a. inflammation b. tumor c. trauma ETIOLOGY: 1. Hyperplasia of parathyroid gland 2. Over compensation of parathyroid gland due to vitamin D deficiency a. Children: RICKETTS b. Adults: OSTEOMALACIA SIGNS AND SYMPTOMS: 1. ACUTE TETANY • tingling sensation, paresthesia, numbness, dysphagia, POSITIVE TROUSSEAU'S SIGN, POSITIVE CHVOSTEK’S SIGN, laryngospasm/broncospasm, seizure, arrhythmia 2. CHRONIC TETANY • photophobia and cataract formation, loss of tooth enamel, anorexia, nausea and vomiting, agitation and memory loss SIGNS AND SYMPTOMS: 1. Bone pain especially at back 2. Kidney stones a. renal colic b. cool moist skin 3. Anorexia, nausea and vomiting 4. Agitation and memory impairment
  48. 48. DIAGNOSTIC PROCEDURES 1. Serum Calcium is DECREASED 2. Serum Phosphate is DECREASED 3. X-ray of long bones reveals a decrease in bone density 4. CT Scan – reveals degeneration of basal ganglia RISK FACTORS: 1. Serum Calcium is INCREASED 2. Serum Phosphate is DECREASED 3. X-ray of long bones reveals bone demineralization NURSING MANAGEMENT: 1. Administer medications as ordered such as: A. ACUTE TETANY CALCIUM GLUCONATE IV SLOWLY B. CHRONIC TETANY • Oral Calcium supplements • Calcium Gluconate • Calcium Lactate • Calcium Carbonate C. Vitamin D for absorption of NURSING MANAGEMENT: 1. Force fluids to prevent kidney stones 2. Strain all the urine using gauze pad for stone analysis 3. Provide warm sitz bath 4. Administer medication: MORPHINE SULFATE (DEMEROL) 5. Encourage increase intake of foods rich in phosphate but low in calcium
  49. 49. NURSING MANAGEMENT: 2. Avoid precipitating stimulus such as glaring lights and noise 3. Encourage increase intake of foods rich in calcium a. anchovies b. salmon c. green turnips 4. Institute seizure and safety precaution 5. Encourage client to breathe using paper bag to produce mild respiratory acidosis result. 6. Prepare TRACHEOSTOMY SET at bedside for presence of laryngospasm 7. Prevent complications 8. Hormonal replacement therapy for lifetime 9. Importance of follow up care. NURSING MANAGEMENT: 6. Provide acid ash in the diet to acidify urine and prevent bacterial growth 7. Assist/supervise in ambulation 8. Maintain side rails 9. Prevent complications (seizure and arrhythmia) 10. Assist in surgical procedure known as PARATHYROIDECTOMY 11. Hormonal replacement therapy for lifetime 12. Importance of follow up care.
  50. 50. Milk Cheeses Yogurt Sardines Oysters Salmon Cauliflower Green leafy vegetables
  51. 51. MEDICATIONS SIDE-EFFECTS NURSING IMPLICATIONS Calcium gluconate: replaces calcium • Dysrhythmia, cardiac arrest, constipation • Monitor vital signs and ECG during IV therapy. • Do not take PO calcium with other medications. Alendronate (Fosamax): inhibits resorption of bone; keeps calcium in bones • Abdominal pain, constipation, diarrhea, nausea • Do not take with calcium supplements or caffeine.
  52. 52. • Monitor serum calcium • If client complains of paresthesias suggestive of hypocalcemia check for Chvostek and Trousseau’s signs • Report signs of impending tetany immediately • Make certain a tracheostomy set and IV calcium gluconate or calcium chloride is immediately available
  53. 53. • Hypercalcemic crisis:  Monitor VS, CVP, and output hourly while administering high-volume IV normal saline (NS)  Administer medications to lower serum calcium  Assess for early signs of hypocalcemia, which are indicative of overtreatment
  54. 54. • A pheochromocytoma is an uncommon tumor that arises from the chromaffin cells of the adrenal medulla. • The tumor autonomously secretes catecholamines (epinephrine and norepinephrine) in excessive amounts. • The cause of pheochromocytoma is unknown. • About 5% of cases are hereditary. • Patients with a pheochromocytoma have exaggerated fight or flight symptoms.
  55. 55. The patient should avoid caffeine and medications for 2 days before and during the test.
  56. 56. • During hypertensive crisis, client should be in ICU to allow for needed cardiac, BP, and neurological monitoring • Manage postoperative pain because untreated it can cause hypertension • Avoid activities that increase intra-abdominal pressure
  57. 57. RISK FACTORS: 1. Atrophy of adrenal glands 2. Fungal infections RISK FACTORS: 1. Hyperplasia of adrenal gland SIGNS AND SYMPTOMS: 1. HYPOGLYCEMIA 2. Decrease tolerance to stress 3. HYPONATREMIA • hypotension • signs of dehydration • weight loss 4. HYPERKALEMIA • agitation • diarrhea • arrhythmia 5. Decrease libido 6. Loss of pubic and axillary hair 7. BRONZE LIKE SKIN PIGMENTATION SIGNS AND SYMPTOMS: 1. Increase susceptibility to infections 2. HYPERNATREMIA • Hypertension, edema, weight gain, MOON FACE APPEARANCE AND BUFFALO HUMP, obese trunk, pendulous abdomen, thin extremities 3. HYPOKALEMIA • Weakness and fatigue, constipation, U wave upon ECG (T wave hyperkalemia) 5. Hirsutism 6. Acne and striae 7. Easy bruising 8. INCREASE MASCULINITY AMONG FEMALES
  58. 58. RISK FACTORS: 1. Atrophy of adrenal glands 2. Fungal infections RISK FACTORS: 1. Hyperplasia of adrenal gland DIAGNOSTIC PROCEDURES: 1. FBS is DECREASED 2. Plasma cortisol is DECREASED 3. Serum sodium is DECREASED 4. Serum potassium is INCREASED NURSING MANAGEMENT: 1. Monitor strictly vital signs, input and output to determine presence of ADDISONIAN CRISIS Addisonian crisis characterized by: a. severe hypotension b. hypovolemic shock c. hyponatremia leading to progressive stupor and coma DIAGNOSTIC PROCEDURES: 1. FBS is INCREASED 2. Plasma cortisol is INCREASED 3. Serum sodium is INCREASED 4. Serum potassium is DECREASED NURSING MANAGEMENT: 1. Monitor strictly vital signs and intake and output 2. Weigh patient daily and assess for pitting edema 3. Measure abdominal girth daily and notify physician 4. Restrict sodium intake 5. Provide meticulous skin care 6. Administer medications as ordered a. Spinarolactone – potassium sparing diuretic
  59. 59. NURSING MANAGEMENT FOR ADDISONIAN CRISIS: 1. Assist in mechanical ventilation, 2. Administer ISOTONIC FLUID SOLUTION as ordered 3. Force fluids 4. Administer medications as ordered: CORTICOSTEROIDS: a. DEXAMETHASONE (DECADRONE) b. PREDNISONE c. HYDROCORTISONE (CORTISON) NURSING MANAGEMENT: 7. Prevent complications (DM) 8. Assist in surgical procedure (BILATERAL ADRENALECTOMY) 9. Hormonal replacement for lifetime 10. Importance of follow up care
  60. 60. MEDICATIONS SIDE-EFFECTS NURSING IMPLICATIONS Phenoxybenzamine (Dibenzyline): blocks action of epinephrine at alpha receptors in pheochromocytoma • Orthostatic hypotension • Monitor vital signs. Hydrocortisone: replaces cortisol in adrenal insufficiency • Cushing’s effects • Teach patient to take with food and not to discontinue abruptly. Fludrocortisone (Florinef): replaces aldosterone in adrenal insufficiency • Fluid retention, heart failure, hypokalemia • Monitor daily weights, vital signs, and serum potassium.
  61. 61. • Interventions to promote fluid balance and monitor for fluid deficit — Weigh daily, record I&O • Assess VS every 1–4 hours • Kayexalate may be needed if severe hyperkalemia is present • Monitor blood glucose levels every 4 hours for hypoglycemia. • Manage activity intolerance with gradual increases in self-care activities • Alert client to strategies to minimize anxiety and stress
  62. 62. • Monitor for electrolyte imbalances, hyperglycemia, and opportunistic infections • Provide a diet low in sodium, high in potassium, limited in calories and with increased amounts of calcium and vitamin D • Provide measures to prevent skin breakdown • Assist the client in avoiding pathologic fractures • Monitor and manage potential for Addisonian crisis, which can result from withdrawal of exogenous
  63. 63. • Monitor for electrolyte imbalances, hyperglycemia, and opportunistic infections • Provide a diet low in sodium, high in potassium, limited in calories and with increased amounts of calcium and vitamin D • Provide measures to prevent skin breakdown • Assist the client in avoiding pathologic fractures
  64. 64. 1. Instruct client to take 2/3 dose in the morning and 1/3 dose in the afternoon to mimic the normal diurnal rhythm 3. Monitor side effects a. HYPERTENSION b. EDEMA c. HIRSUTISM d. INCREASED SUSCEPTIBILITY TO INFECTION e. MOON FACE APPEARANCE Always slowly taper corticosteroid therapy to avoid adrenal crisis.
  65. 65. 5. Provide dietary intake, INCREASE CALORIES, CARBOHYDRATES, PROTEIN but DECREASE IN POTASSIUM 6. Provide meticulous skin care 7. Provide client health teaching and discharge planning a. avoid precipitating factor leading to Addisonian crisis: • stress • infection • sudden withdrawal to steroids b. prevent complications • Addisonian crisis • hypovolemic shock c. hormonal replacement for lifetime d. importance of follow up care
  66. 66. PREOPERATIVE CARE • Monitor the patient for electrolyte imbalance and hyperglycemia. • To prevent adrenal crisis, glucocorticoids are administered because removal of the adrenals causes a sudden drop in adrenal hormones. POSTOPERATIVE CARE • The patient is closely monitored for changes in fluid and electrolyte balance and adrenal crisis. • Patients must take replacement glucocorticoid and • mineralocorticoid hormones for the remainder of their life.
  67. 67. Chronic illness that damages the islet cells: • pancreatitis • cystic fibrosis Prolonged use of some drugs: • steroid hormones • phenytoin (Dilantin) • thiazide diuretics • thyroid hormone
  68. 68. Symptoms of diabetes plus casual plasma glucose concentration equal to or greater than 200 mg/Dl or Fasting plasma glucose greater than or equal to 126 mg/dL or 2-hour postload glucose equal to or greater than 200 mg/dL during an oral glucose tolerance test
  69. 69. • Normal plasma glucose level is less than 100 mg/dL. • When the fasting plasma glucose (drawn after at least 8 hours without eating) is 126 mg/dL, diabetes is diagnosed. • If the fasting plasma glucose is between 100 and 125 mg/dL, the patient has impaired fasting glucose (IFG). • A normal HbA1c is 4% to 6%.
  70. 70. • Diabetes is diagnosed if the CPG is 200 mg/dL, with symptoms of diabetes. • An OGTT measures blood glucose at intervals after the patient drinks a concentrated carbohydrate drink. • Diabetes is diagnosed when the blood glucose level is 200 mg/dL after 2 hours. • A result between 140 and 199 mg/dL at 2 hours diagnoses impaired glucose tolerance (IGT).
  71. 71. INCIDENCE RATE: •10% general population INCIDENCE RATE: •90% general population RISK FACTORS: 1.Age 2.Race 3.Heredity 4.Autoimmune reaction 5. Related to viruses 6. Drugs a. Lasix b. Steroids 7. Related to CARBON TETRACHLORIDE TOXICITY RISK FACTORS: 1.Age 2.Race 3.Heredity 4. OBESITY – because obese persons lack insulin receptor binding sites 5. Sedentary lifestyle (lack of exercise, increased intake of carbohydrates) 6. Hypertension 7. Triglyceride level of ≥250 mg/dL
  72. 72. SIGNS AND SYMPTOMS: 1. Polyuria 2. Polydypsia 3. Polyphagia 4. Glucosuria 5. WEIGHT LOSS 6. Anorexia, nausea and vomiting 7. Blurring of vision 8. Increase susceptibility to infection 9. Delayed/poor wound healing SIGNS AND SYMPTOMS: 1. Usually asymptomatic 2. Polyuria 3. Polydypsia 4. Polyphagia 5. Glucosuria 6. WEIGHT GAIN TREATMENT: 1. Insulin therapy 2. Diet 3. Exercise COMPLICATIONS: 1. DIABETIC KETOACIDOSIS (DKA) TREATMENT: 1. Oral Hypoglycemic agents 2. Diet 3. Exercise COMPLICATIONS: 1. HYPEROSMOLAR NON-KETOTIC COMA (HHNKC)
  73. 73. RISK FACTORS: 1. Hyperglycemia 2. STRESS 3. Infection RISK FACTORS: 1.Increased osmolarity (severe dehydration) SIGNS AND SYMPTOMS: 1. Polyuria 2. Polydypsia 3. Polyphagia 4. Glucosuria 5. Weight loss 6. Anorexia, nausea and vomiting 7. Blurring of vision 8. Acetone breath odor 9. KUSSMAUL’S RESPIRATION 10. CNS depression leading to coma SIGNS AND SYMPTOMS: 1. Headache and dizziness 2. Restlessness 3. Seizure activity 4. Decrease LOC – DIABETIC COMA DIAGNOSTIC PROCEDURES: 1. FBS is INCREASED 2. BUN is INCREASED 3. Creatinine is INCREASED 4. Hct is INCREASED
  74. 74. NURSING MANAGEMENT: 1. Assist in mechanical ventilation 2. Administer hypotonic solutions to counteract dehydration and shock 3. Monitor strictly vital signs, intake and output and blood sugar levels 4. Administer medications as ordered a. Insulin therapy (regular acting insulin/rapid acting insulin peak action of 2 – 4 hours) b. Sodium Bicarbonate to counteract acidosis c. Antibiotics to prevent infection NURSING MANAGEMENT: 1. Assist in mechanical ventilation 2. Administer hypotonic solutions to counteract dehydration and shock 3. Monitor strictly vital signs, intake and output and blood sugar levels 4. Administer medications as ordered a. Insulin therapy (regular acting insulin peak action of 2–4 hrs.) b. Antibiotics to prevent infection
  75. 75. A. SOURCES OF INSULIN 1. Animal sources • Rarely used because it can cause severe allergic reaction • Derived from beef and pork 2. Human Sources • Frequently used type because it has less antigenicity property thus less allergic reaction 3. Artificial Compound Insulin
  76. 76. B. TYPES OF INSULIN 1. RAPID ACTING INSULIN (CLEAR) • Regular acting insulin (IV only) • Peak action is 2 – 4 hours 2. INTERMEDIATE ACTING INSULIN (CLOUDY) • Non Protamine Hagedorn Insulin (NPH) • Peak action is 8 – 16 hours 3. LONG ACTING INSULIN (CLOUDY) • Ultra Lente • Peak action is 16 – 24 hours
  77. 77. NURSING MANAGEMENT FOR INSULIN INJECTIONS 1. Administer at room temperature to prevent development of lipodystrophy (atrophy, hypertrophy of subcutaneous tissues) 2. Place in refrigerator once opened 3. Avoid shaking insulin vial vigorously instead gently roll vial between palm to prevent formation of bubbles 4. Use gauge 25 – 26 needle 5. Administer insulin either 45◦ – 90◦ depending on amount of clients tissue deposit 6. No need to aspirate upon injection
  78. 78. NURSING MANAGEMENT FOR INSULIN INJECTIONS 7. Rotate insulin injection sites to prevent development of lipodystrophy 8. Most accessible route is the abdomen 9. When mixing 2 types of insulin aspirate first the clear insulin before cloudy to prevent contaminating the clear insulin and promote proper calibration. 10. Monitor for signs of local complications such as allergic reactions, LIPODYSTROPHY, INSULIN WANING, SOMOGYI PHENOMENON, DAWN PHENOMENON
  79. 79. C. NURSING MANAGEMENT 1. Administer insulin and OHA therapy as ordered 2. Monitor for peak action of insulin and OHA and notify physician 3. Monitor strictly vital signs, intake and output and blood sugar levels 4. Monitor for signs of hypoglycemia and hyperglycemia • administer simple sugars • for hypoglycemia (cold and clammy skin) give simple sugars • for hyperglycemia (dry and warm skin)
  80. 80. C. NURSING MANAGEMENT 5. Provide nutritional intake of diabetic diet that includes: carbohydrates 50%, protein 30% and fats 20% or offer alternative food substitutes 6. Instruct client to exercise best after meals when blood glucose is rising 7. Monitor signs for complications 8. Institute foot care management a. instruct client to avoid walking barefooted b. instruct client to cut toenails straight
  81. 81. C. NURSING MANAGEMENT c. instruct client to avoid wearing constrictive garments d. encourage client to apply lanolin lotion to prevent skin breakdown e. assist in surgical wound debridement (give analgesics 15 – 30 mins prior to surgery) 9. Instruct client to have an annual eye and kidney exam 10. Monitor for signs of DKA and HONKC
  82. 82. D. COMPLICATIONS 1. MACROVASCULAR COMPLICATIONS • Coronary artery disease • Cerebrovascular disease • Peripheral vascular disease 2. MACROVASCULAR COMPLICATIONS • Diabetic retinopathy • Diabetic nephropathy • Diabetic neuropathy
  83. 83. Hormone Hypofunction Hyperfunction Antidiuretic hormone Diabetes insipidus SIADH Growth hormone Dwarfism Acromegaly, gigantism—bone and tissue overgrowth Thyroid hormone Hypothyroidism Hyperthyroidism—increased metabolism Epinephrine Rare Pheochromocytoma— hypertension Parathyroid hormone Hypoparathyroidism—low serum calcium, osteoporosis, tetany Hyperparathyroidism—high calcium, weakness Cortisol Addison’s disease—sodium and water loss Cushing’s syndrome—sodium and water retention, hyperglycemia

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