Endocrine disorders & their nursing consideration.

1. Endocrine disorder
Prepared By:
Barsha Silwal

2. Diabetes mellitus
Diabetes mellitus is a group of metabolic diseases characterized by
increased level of glucose in the blood (hyperglycemia)resulting from
defects in insulin secretion, insulin action or both.”

4. RISK FACTORS FOR DIABETES MELLITUS
Non- Modifiable risk factors
 Family history (First degree family member with diabetes)
 Race/ethnicity( Eg. African Americans, native Americans)
 Age>45 years

5. Modifiable Risk Factors
 Hypertension (HTN)>=140/90 mmHg
 Hyperlipidemia (HDL<=35 mg/dl and/or triglycerides level>=250 mg/dl)
• History of gestational diabetes or delivery of babies Over >4 kg (9 Lb)
• Sedentary lifestyle
• Drugs (eg. Glucocorticoids)
• Stress (requires increased amount of insulin)
• Peripheral insulin resistance(Eg. ,cushing syndrome,
pheochromocytoma)

6. CLASSIFICATION
1. TYPE 1 DM (Insulin dependent diabetes mellitus(IDDM))
2. TYPE 2 (Non-insulin dependent diabetes (NIDDM))
3. GESTATIONAL DIABETES
• Detected during 24-28 WOG, 7 months of pregnancy
4. DIABETES MELLITUS ASSOCIATED WITH OTHER CONDITIONS OR
SYNDROMES:
• Secondary diabetes associated with glucocorticoid medication and conditions
such as Cushing syndrome and pancreatic disease

7. Differences Type 1 DM Type 2 DM
Incidence 5-10% of all DM 90-95% of all DM
Age of onset usually <30 Yr Usually >30 Yr
Risk factor Genetics
Immunological,
autoimmune
Obesity 80%
Hereditary
Environmental factors
Cause Little or no endogenous
insulin
Decreased endogenous insulin
or increased insulin resistance
Mgmt Need for insulin to
preserve life
Dietary modification
Exercise with or without oral
hypoglycemic agent is helpful
Acute complication Diabetic ketoacidosis HHNS(Hyperglycemic
Hyperosmolar Non- ketonic

8. CLINICAL MANIFESTATIONS
Three ‘P’s: Polyuria, polydipsia, polyphagia (classic/cardinal signs)
 Polyuria
 Polydipsia
 Polyphagia
 Other symptoms
• Type 1: sudden weight loss ,lethargy ,stupor, acetone breath,
Kussmaul breathing, nausea, vomiting ,abdominal pain

9. Cont’d
Type 2:obese at diagnosis
• Sudden vision changes
• Tingling or numbness in limbs
• Dry skin
• Slow wound healing
• Glycosuria
• Itchiness
• Recurrent vaginal infections

11. MEDICAL MANAGEMENT
There are 5 components of management of diabetes:
 Nutrition
 Exercise
 Monitoring
 Pharmacological therapy
 Education

12. Cont’d
Primary treatment of type 1 DM is insulin.
Primary treatment of type 2 DM is weight reduction.
Exercise is important in enhancing the effectiveness of
insulin.
Oral hypoglycemic agent if diet and exercise are not
successful in controlling blood glucose level

13. Cont’d
DIET : Caloric requirement
 Determine basic caloric requirement ,taking into consideration age, gender
,body weight, height and degree of activity
 For long term weight reduction & patient with sedentary lifestyle should
reduce basic caloric intake by 500 to 1000 Cal from total caloric
requirement
• ADA recommended that for all levels of caloric intake
• 50-60% of Cal can be derived from carbohydrate
• 20-30% from fat(saturated fat < 10%) and
• 10-20% from protein

14. Cont’d
EXERCISE
• 150 minutes of moderate physical activity helps to maintain normal
blood sugar level.
MONITORING
 Self- monitoring of blood glucose by using glucometer.
o Glycosylated or glycated hemoglobin (HbA1c)
• GRBS (Random blood sugar)
• Fasting & postprandial (PP)

15. Cont’d
PHARMACOLOGIC THERAPY
• Insulin therapy :
o Used in type 1 and some patient with type 2 DM with Oral
hypoglycemic agents
• Insulin can be delivered
• The absorption and duration of insulin varies by anatomy site. Insulin
injected into the abdomen absorbed fastest and the duration is shortest.
Moving the injection site to the arm, leg or buttocks progressively
slows absorption and lengthens duration

16. Cont’d
Types of insulin
 Rapid acting insulin: Aspart, Lispro
 Short acting insulin: Humulin R or Regular Insulin
 Intermediate acting insulin: Humulin N, Insulin isophane
 Long acting insulin: Glargine (Lantus)
 Mix insulin: Isophane & regular insulin (70/30)

17. Cont’d
Oral hypoglycemic agents
oThey lower blood sugar by stimulation of the pancreatic
cells to release insulin.
oThey make target tissues more sensitive to effect of insulin
by
oSome of them decrease glucose production in the liver.

18. Classifications
o Biguanides : Metformin: the drug of choice, contraindicated for
severe kidney or liver problems
o First generation sulfonylureas: Acetohexamide, tolazamide
o Second generation sulfonylureas: Glipizide

19. Cont’d
1.COMPLICATIONS OF DIABETES
Acute Metabolic Complications
• Hypoglycemia
• Diabetic ketoacidosis (DKA)
• Hyperosmolar hyperglycemic non-ketonic
syndrome(HHNS)

20. Hypoglycemia
 S/S of hypoglycemia: Early symptom; sweating, tremor, pallor,
tachycardia, palpitation, nervousness,
• Late symptoms: light – headedness, headache, confusion, irritability,
slurred speech due to central nervous system depression.

21. Cont’d

22. Pituitary Disorders

25. Diabetes insipidus
Hypo secretion of antidiuretic hormone (ADH)from posterior pituitary
gland, resulting in failure of tubular reabsorption of water in kidney and
diuresis.

26. Causes
• Idiopathic
• Tumor
• Family history
• Surgery
• Infection

27. C/F
• Excretion of large amount of diluted urine.
• Polydipsia ( 2 -20 L/Day)
• Polyuria ( 5 – 25 L /Day)
• Dehydration
• Inability to concentrate urine , Low urinary specific gravity < 1.006
• Increase serum sodium

28. Mgmt
• Pharmacological therapy: Desmopressin
• Observe for sign of dehydration
• Maintain fluid and electrolyte balance.
• Advice to avoid alcohol.

29. Hypothyroidism
•Decrease thyroid hormone secretion )
•Low level of T3(tri-iodothyronine) and T4 (thyroxine) and
compensatory increase in TSH.
•More common in female than in male

30. Etiology
• Congenital thyroid defect
• Prenatal and postnatal iodine deficiency
• Autoimmune disease :
- Hasimoto ‘s thyroiditis( Also K/A thyroid dwarfism ,congenital)
• A. Cretinism : at birth (in child) , causes retardation of physical
growth and mental retardation.
• B. Myxedema : In adult

31. C/F
• Decrease BMR
• Dull mental process
• Apathy , lethargy , loss of libido
• Intolerance to cold , anorexia
• Constipation , weight gain
• Brittle hair and nails
• Dry skin (Coarse and scaly)
• Enlarge tongue , slow speech

32. C/F
• Peri-orbital oedema
• Elevated cholesterol , ↑ risk for CAD
• Muscle aches and weakness
• Subnormal temperature , bradycardia
• Infertility , heavy menstrual period
• Mood swing , depression

33. MGMT
• Medical management : levothyroxine
• Low calorie & low saturated fat diet

34. Hyperthyroidism
↑ thyroid hormone leading to hypermetabolic state(Low
TSH and ↑ T3 or T4)

35. Causes
• Autoimmune disorder: Graves disease
• Tumor of pituitary or thyroid gland

36. C/F
• Increase BMR
• Intolerance to heat
• Fine, straight hair
• Bulging Eyes (exopthalmus)
• Facial flushing
• Tachycardia
• ↑ Systolic BP

37. Cont’d
•Diarrhea, Weight loss
•Tremors, Clubbing of finger
•Menstrual changes (Amenorrhea)
•Gynecomastia ( enlarged breast)
•Depression , mood swing
• Diaphoresis (↑ sweating)

38. MGMT
Medical management :
• Propylthiouracil (PTU) , Carbimazole to inhibit thyroid hormone
• Antihypertensive :Propanolol to ↓ BP
• Corticosteroid like hydrocortisone in autoimmune disease
Surgery
• Subtotal or total thyroidectomy

39. • High calorie ,high protein diet (3000-5000 calorie per day)
• Keep room cool ,protect eye
• Elevate head.

41. Adrenal Gland Disorders
• (Note: Cortisol is also known as stress hormone)

42. Glucocorticoid (Cortisol )

44. Mineralocorticoid (Aldosterone)
Sodium & water retention in kidney tubule & increase
blood volume.

45. Cushing’s syndrome
Excessive secretion of adreno-cortical hormone called cortisol.
Etiology
• Pituitary tumor (↑ ACTH)
• Tumor of adrenal gland
• Prolong use of cortisone drug such as prednisone (Used in asthma or
arthritis): Most common cause, also known as

46. C/F
Clinical manifestations caused by excess glucocorticoids (Cortisol)
 Weight gain or obesity
 Moon face, Buffalo hump (Fat deposit on neck, back of shoulder )
 Trunk obesity (upper body obesity) & thin extremities
 Fragile & thin skin, acne
 Osteoporosis(↑Cortisol,↓ Bone density)
 Hyperglycemia
 Increased susceptibility to infection , poor wound healing
 Emotional instability ,depression , psychosis

47. Clinical manifestations caused by excess Mineralocorticoid
(Aldosterone)
 High blood pressure
 Hypernatremia, hypokalemia
 Weight gain
 Edema

48. Clinical manifestations caused by excess Sex hormone
(Androgen)
 Gynecomastia in male
 Menstrual irregularities (Amenorrhea)
 Hirsutism: excessive hair growth
 Loss of libido in male

50. Diagnosis
• Excessive plasma cortisol level

51. Mgmt
 Decrease dose of exogenous steroid
 Radiation therapy for tumor
 Potassium supplementation
 Monitor V/S , weight daily , I/O charting to measure fluid retention
 Monitor blood glucose level
 Ketoconazole to inhibit steroidogenesis
 Surgical excision of adrenal tumor (Adrenelectomy)

52. Adrenal Insufficiency
Decrease secretion of adrenal hormone (low level of cortisol and
aldosterone)
Causes
• 80 % is due to autoimmune disease called Addison’s disease

53. C/F
 Weakness, fatigue, anorexia
 Vomiting, Diarrhea
 Hypotension
 Decrease serum cortisol
 Hyponatremia
 Hypoglycemia
 Hyperkalemia
 Depression

54. Mgmt
 Replace glucocorticoid: Hydrocortisone
 Fluid and electrolyte balance
 Monitor blood glucose level
 High carbohydrate, high protein diet
 Monitor V/S , pulse rate
 Reduce stress
 Control visitors and isolation to prevent infection