การพยาบาลโรคต่อมไร้ท่อที่ซับซ้อน

03/12/58
1
Endocrine Crisis Nursing Care
CHUTCHAVARN WONGSAREE
Lecturer, RN, MN.S. Adult, Ph.D. Nursing management (Learning)
Faculty Of Nursing
WESTERN UNIVERSITY KANCHANABURI CAMPUS
1. ก ก ! "#$ %
2. & " ' ' ( & ( ก ก ) %*)+ ก #ก, %
3. & ก *ก ( + %
4. - # *ก ( + %
5. & '+#กก ( + %
Lecturer, RN, MN.S. Adult
Faculty Of Nursing
WESTERN UNIVERSITY CHANCHANABURI CAMPUS
# . *"/
Faculty Of Nursing
(Endocrine system)
“hormone”
Faculty Of Nursing
ก )+ ก ! "#$
11
thyroid crisis/thyroid
strom/hyperthyroid crisis
22
addisonian crisis/adrenal
crisis/adrenal insufficiency
33
pheochromocytoma
Thyroid Dysfunction Nursing Care
Faculty Of Nursing
uncontrolled hyperthyroid /Severe thyrotoxicosis /decompression
Faculty Of Nursing
1.Thyroid Problem Nursing Care
“thyroid crisis or thyroid strom”
1 2 3
Grave’s disease Toxic multinodular
goiter
Toxic adenoma

03/12/58
2
Faculty Of Nursing
ANATOMY
ก+ ก" " ก '+#*&# %/0 /1ANATOMY
Faculty Of Nursing
ก+ ก" " ก '+#*&# %/0 /1
•T4 & T3 # ก# thyroxine-binding
globulin (TBG) ก # (2 %3%45 - 3
4++/
•T3 & ( 3*ก T4 ) 6 *
half-life #7 ก )+ ( ก ) +2 %
ก T4
•T4 reverse to T3 %
Faculty Of Nursing
1. follicular cells ; thyroxin (T4)
triiodothyronine (T3)
2. parafollicular cells (clear cells) ;
calcitonin
-" " # ก : :+ $ ' *ก
-ก $ 1 - *ก %3ก * )+
-" " %# )"+ 4 *ก
Thyroid cell
Faculty Of Nursing
Thyroid dysfunction
thyroid
hyperthyroidism
•" ( ก6 % ; (,
•: 7! ' #ก+%
•ก )
• * * ก)+
-57
hypothyroidism
• ก )" )ก 1 6
ก+ 27 ) * +7 '$ <$$
2
• : ' #* ก+ 27
) * : ' #*)'* 4% <$$
62 *6 ก%1 "" ( ก6 %& %
T3,T4 ก ' 2 !
) " TSH 3*
T3 )*+, T4 -./
012345 TSH 6785
Faculty Of Nursing
Hyperthyroidism or
thyrotoxicosis
•heat intolerance,
•increased energy,
•difficulty sleeping,
•diarrhea and anxiety.
•exophthalmos
Hyporthyroidism or
Myxedema
•dry skin,
•swellings around the lips & nose,
•mental deterioration,
•a subnormal basal metabolic rate
Faculty Of Nursing
pathophysiology
OF thyroid crisis or thyroid strom
1
ก ( -57 - *
FT3 & FT4
•)19/:4569;64,<=9>
*,>;?
•@;A*9B radioactive
iodine
2
*2;9B thyroid
binding protein
(TBG) 1;1/
•C5D2nonthyroidal
illness (<Eก5*-*A5/
TBG 1;1/)
3
C5D2G3*E>;645/ H
(stress)
•ก "+ %
•ก % 627
•ก : #%
• # ' ' 2
* * ) *
4
< # 2 =
• % # 1 % ก
'
• % # &# %/
0 /1
•' % #ก, &# %/
; (,ก ก! ' %
•ก "+! &# %/

03/12/58
3
Faculty Of Nursing
signs & symtomps
• 1. - 3* > 38.5° C' 2 102 ° F
• 2. %# " 3 5ก # + ) +*; ก ก ก # ก #
.5* coma * psychosis
• 3. ก% CHF or tachyarrhymia (>140)
• 4. "+2 * % * % * ( jaundice
• 5. 2 =; acute abdomen, status epilepticus,
coma, stroke )+ ARF from rhabdomyolysis
(Myoglobin breaks down)
Faculty Of Nursing
Principle Of Diagnosis
Burch and Wartofsky
Faculty Of Nursing
Case Discussion Thyroid storm
• CC and PI : :3 6 28 C 1 *( +% 2 * #
ก-57 2 # 1% ก # ; (#ก= ก 2 = ( %)ก
% ' 2 * ' ' 2 ก+ *"2 - )+ *
ก " 1 ก-57 # '+2 * '+2 * '*2 ก ก 2 # - 3*
' # )'*= "+2 . '+ ; 7! 5-6 " #7*
# (+ ก # ก :3 427 +% - - +* ก
' 7 ก # ; =' = * . '+ '+ %2 )
6 * 2 # 7 ก ; ก-57 5* 1 *( +
Faculty Of Nursing
• Hx. "2 1 " %/ ; (, #ก, % ) %
# 2 C %2 " 2 *%2 ) +ก 0 +/1 ) # % '/
3 ' 2 # 10 C:3 E & # ก 6 /
( % ก6 %' 2 ก : #% *= E &ก % # # '
E & # )( ' 2 )( ' E &1 " # 2 =
6 1 "'# 1 "" %# 1+' 3* 1 " ;
Faculty Of Nursing
ก *ก :3 3 5ก # % ก # ก (+ # '+2 *
'+2 * #$$ G6( G' 3 *ก 39 *I 4+ 4 6( 140 " #7*
; #*' # ' 28 " #7* " %# 1+' 167/87
++
ก *ก # '+2 * +ก %/1 - % G
10 4 ก * 5 4 ก - # - * * กก# *
%"+ *ก# (paradoxical movement) M<* % % * crepitation
* 7! 2 # )- )+ - ก% N - #7* *- * ก % 2
Faculty Of Nursing
• :3 1 " ! # % ; 1 " %/ ; (, % # 2 C
• ก )+ ก ) %* 4 %)ก
1. G' 3 *ก - 3*
2. '# )+ '+ 1+' 6( ) ; #*' # '
' ' 2 M<* % % * crepitation * )+ )- -
3. * % ' '+2 * ก " 1 * . '+ "+2
4. 2 # ก # ก
Topic Discussion Thyroid storm

03/12/58
4
Faculty Of Nursing
"% กGO/ # - * Burch )+ Wartofsky
• %" ) %#* 7
– - 38 *I 4+ 4 (100.4 F) = 10 " )
–agitation = 10 " )
–unexplained jaundice = 20 " )
–heart rate 140 bpm = 25 " )
–crepitation = 15 " )
–atrial fibrillation = 10 " )
" ) #7*' % % 90 " )
Faculty Of Nursing
ก #ก, 3 -#7
• 1. ก )ก - &# %/ ; (,
1.1 ' # #7*ก *0 /1 ; PTU 1,200-1,500 mg/day
1.2 ' -#%- *ก '+#*0 /1 ; Lugol iodine / SSKI 200-500 mg/day
''+#* ก ' PTU 1-2 6# 1 *
1.3 ' # #7*ก + T4 ; T3 27 2 + ; radiographic
contrast dyes %)ก ipodate & ipanoate )+ β-blocker, glucocorticoids 6
dexamethazone & PTU - % 3*
1.4 # #7*ก ก &P- *0 /1 27 2 1% *; β-blocker 6
Propanolol
1.5 6 '+2 ก G ก ) *; PD/ plasmapheresis
Faculty Of Nursing
• 2. ก #ก, )+ Q *ก# ) ก4
2.1 IV fluid 6 10% dextrose, ( ก : :+ $ 3*)
2.2 +% -; acetaminophen, ice packs & cooling blankets
6salicylates (aspirin/ASA) ) * # TBG ! ' FT4, FT3 ( -57
2.3 )ก - cardiac arrhythmia; digoxin, oxygen, diuretic
2.4 ' β-adrenergic blocker; propranolol (+% ก *
sympathetic)
2.5 ' glucocorticoids # #7*ก + T4 ; T3 27 2
+ )+ Q *ก# adrenal insufficiency ก hyperthyroidism
Faculty Of Nursing
• 3. ก " ' )+ )ก - < # * *=
– ก ' ABO :3 % 627
– " ' )'+* 2 * # ; ' ; ก % '
" % )+ 45 I
• ' ก:3 * ก #ก, %-57 24-48 6# 1 * )+
% # ก #ก, % antithyroid drug, ก : #% ' 2 ก 6
#* 1 %
1. ก 4#ก #
2. ก *ก
Faculty Of Nursing
ก5*`*2G<abc5/ก5*d>5B51
3. ก *' * E # ก :
– Thyroid function tests (TFT): T3, T4 & FT4 3*, FT3
ก / ! , TSH !
- CBC: Hb &Hct 3*, WBC: “shift to the left”
- Hyperglycemia, Na & Ca 3* ก- % 7! )+ ก + ก %3ก
- Liver function tests (LFTs): ALT, AST, LDH,
creatinine kinase, alkaline phosphatase & serum bilirubin
3*-57
Faculty Of Nursing
4.ก * #* :
- Chest radiography; CHF, pulmonary
edema from heart failure and/or evidence
of pulmonary infection
- Head CT scanning; neuro
5. ก 2 =:
- ECG; cardiac arrhythmias & ventricular
tachycardia

03/12/58
5
Form Case Discussion
About Part
Faculty Of Nursing
Nursing Care
Adrenal Dysfunction Nursing Care
Faculty Of Nursing
Faculty Of Nursing
Adrenal Gland
Faculty Of Nursing
Adrenal cortex; ACTH control
•mineralocorticoids; aldosterone
" " %+- * 7! )+ electrolyte
•glucocorticoids; cortisol
" " ก : :+ $ '
•gonadocorticoids ก ก# 0 /1 (I
Adrenal medulla; nerve signal control
•:1a6012)197/ catecholamine; epinephrine &
norepinephrine
•-9<d9b=?ก9Bก5*c85/5be,/*2BB sympathetic
Adrenal Gland
Faculty Of Nursing
Faculty Of Nursing
Pathology
• adrenal cortex
• cortical hyperfunction
– Hyperaldosteronism
(mineralocorticoids)
– Cushing syndrome
(glucocorticoids)
– adrenogenital or virilizing syndrome
(gonadocorticoids)
• cortical hypofunction
– primary hypoadrenalism
(Addison’s disease)
– secondary hypoadrenalism
– tertiary hypoadrenalism
• adrenal medulla
-pheochromocytoma

03/12/58
6
Faculty Of Nursing
hypothalamic-pituitary axis (HPA)
Faculty Of Nursing
“addisonian crisis / adrenal crisis /
adrenal insufficiency”
64,<)<Dก@6f9gbb,ก:1a6h,*?i<b glucocorticoids @;AbA,>กD45`ก6a
1. Primary adrenal insufficiency (Addisonjs disease); :a;`ก6acE764,<)<Dก@6
- TB or fungal infection
- ก5*c8515>e,/ adrenal cortex, adrenal hemorrhage, autoimmune disease
2. Secondary adrenal insufficiency; :a;`ก6acE764,<k6A-<,/ l5กGb+g,/,ก,)19/
:4569;64,<k6A-<,/, ก5*e5;G1+,;@`G1Eg>/l5ก6กG1+,;)19/31,; (Sheehanjs
syndrome), ก5*6a;Gf+g,
3. Tertiary adrenal insufficiency; :a;`ก6acE7@hi`=515<9-
- ก5*ก;ก5*c85/5be,/ hypothalamic-pituitary axis (HPA) l5กก5*kfA>5
glucocorticoids, endogenous steroids (l5ก tumor),,mB96aG)6mc5/-<,/, n5>0-/
- c85k)Aก5*)197/e,/ CRH & ACTH 1;1/, ก5*c85/5be,/ adrenal cortex 1;1/
Faculty Of Nursing
adrenal insufficiency
Chronic adrenal insufficiency Acute adrenal insufficiency
•ก5*)>m;>5 glucocorticoid c9bcE
•sepsis
•surgical stress
•C5D20c*กpA,bl5ก>5 anticoagulation
•adrenal hemorrhage l5กก5*6a;Gf+g,
meningococcemia, pseudomonas
a. (Waterhouse-Friderichsen
syndrome)
Faculty Of Nursing
Sign and Symptom
- ' 2 ) * 45 I 2 ' 7! ' #ก+%
- 5 I , orthostatic hypotension
- "+2 *
- Hyponatremia, hypoglycemia, mild normocytic anemia,lympocytosis
- hyperkalemia
- hyper pigmentation ( กACTH 3*-57 )
- 1 "% *- (vitiligo)
- autoimmune thyroid disease
- ก * ก+ * drenomyeloneuropathy
2˚ AI
- pale skin
- ,5ก5*0-;/e,/ก5*e5;
pituitary hormone ,+7bH
Faculty Of Nursing
Primary adrenal insufficiency
Faculty Of Nursing
Primary adrenal insufficiency
hyperpigmentation
vitiligo

03/12/58
7
Faculty Of Nursing
Secondary adrenal insufficiency
pale skin
Faculty Of Nursing
Therapeutic
1. %3)+ 2 *- *ก ' )+ ก '+ 1+'
2. IV fluid D5NS & 50% dextrose :3 hypoglycemia
3. ก +"1 + / ก ) +2 %
4. ' hydrocortisone 100 mg IV ) ' * % ACTH stimulation
testing 'dexamethasone )
5. ' fludrocortisone acetate (mineralocorticoid) #ก, ก 3$ 7! )+
ก+2 )
6. ก )ก - ' ' 2 < # 6#ก ! *= 6 ' glucose, thiamine, naloxone,
NaHCO3 ;
7. ก : #% adrenalectomy, hyphysectomy
Faculty Of Nursing
1 . ก 4#ก #
2. ก *ก
Nursing Assessment
3. ก *' * E # ก : hyponatremia, hyperkalemia
hypoglycemia & acidosis ก CBC, BUN, creatinine,
cortisol level, serum calcium )+ TFT
4.ก * #* : CT scan ' 2 MRI
CT abdomen ( " :% ก adrenal gland
CT brain ( " :% ก pituitary gland
Faculty Of Nursing
5. ก5*6*DldaGrs,+7bH
-ACTH stimulation test; Gl52G1+,;`*2G<ab345 serum cortisol cE7
baseline )19/l5กb9gbnE; cosyntropin (ACTH) 01ADGl52G1+,;
`*2G<ab345 serum cortisol pg85cmก 30, 60 b5cE 012 6 f97Di</
-serum cortisol -./etgb @<4<EC5D2 adrenal insufficiency
-serum cortisol 67851//@<4``. <EC5D2 adrenal insufficiency
-ECG; dB elevated peaked T waves (hyperkalemia)
-24-hour urinary cortisol
Nursing Assessment
Faculty Of Nursing
• 1. CO +%+* 2 * กก 3$ 7! )+ 14 % / 7! + +2 % !
• 2. %+- * 7! )+ +"1 + / 2 * ก ก 3$ '+ )+ 14 %
*ก กก )+ . '+
• 3. * ก - *'# :% ก ก K 3*
• 4. G' 3 *ก 3* กก ก : :+ $ ( -57
• 5. " . ก E # ก ก +%+* 2 * ก (+
• 6. %+- * ' : % # ก " *ก - * *ก 2 * ก
ก ก : :+ $ ' ( -57 # ' % "+2
• 7. - %" 3 ก E # # ก ก# 1 "
Nursing Diagnosis
Faculty Of Nursing
N/C cE7-8539v
1. ก %2 7! >3,000 ml/day )+ # ' ( 14 % (hyponatremia)
2. orthostatic hypotension and hypotension
3. 0 /1 %)
4. :3 ! adrenalectomy ก : #% ' # ' (
Na, +% K, ( ก %2 7! > 3000 cc/day, ( '
)+ 1 3*

03/12/58
8
Faculty Of Nursing
Cushing syndrome ก ก
ก & glucocorticoid " #
Cushing disease (Pituitary Cushing)
$ %& glucocorticoid (cortisol) ก ' ก
() *(+ $ , ACTH ก ก- .ก(
Cushing syndrome
Faculty Of Nursing
Cushing syndrome
Faculty Of Nursing
ก 2 = ( % %)ก hypertension )+
hyperglycemia/abnormal glucose
tolerance ก :% ก - * 6
depression, mood lability $
psychosis
Cushing syndrome
Faculty Of Nursing
Therapeutic
Cushing disease
1. transphenoidal tumor resection (selective microadenomectomy)
2. Pituitary radiotherapy )*+, gamma knife radiotherapy
***panhypopituitarism G`xb Complicated ก%-57 ***
adrenal tumors 012 Ectopic ACTH secreting tumor
1. Hypophedectomy
2. * ก " malignancy --- Chemo therapy
3. *$+ glucocorticoid # # $ , ก -) (, ./ ก, ก ก
adrenal crisis
Nursing Care ???
Faculty Of Nursing
Faculty Of Nursing
Adrenal medulla dysfunction
“pheochromocytoma”

03/12/58
9
Faculty Of Nursing
2 31
pheochromocytoma
•" %# 1+' 3*
•ก : :+ $ ' 3*
• %# 7! + +2 % 3*
•ก+ 27 '# ) *
•'+ % +2 % *) ก
(stroke)
• 6
•'+#* epinephrine
& norepinephrine
ก:% ก
•( (I6 )+ (I'$* #%
ก#
• # .5* # ก+ *"
•( " " # 6ก
# ; ก
• '$ ; *6 %
) * & ; ' ก - *
%
Faculty Of Nursing
Sign and Symptom
T5 Hs”
•Headache
•Hyperrhidrosis
•Hypertension
•Hypermetabolism; palpitation, tremor,
weight loss
•Hyperglycemia
Faculty Of Nursing
Sign and Symptom
1. 1 " ' ก epinephrine ! ' ก + ก+#
1" ก # ' ; ก+31"
2. Islet of Langerhans - * # ! *
ก ก * 43+ +%+*
Faculty Of Nursing
) ก4
Faculty Of Nursing
• 1. Rest I , 3* (2 Q *ก# orthostatic hypotension
• 2. monitor EKG
• 3. ' ก+ alpha adrenergic blocking agents 6
Phentolamine )+ "+ ก+ 27 6 Sodium Nitroprusside
(2 ' BP +%+*
• 4. adrenalectomy ก G 27 * ก กก 8-10 4 . 1% " "
BP ก 7-10 # 1% ' Phentolamine ' 2 Prazosin ' *
ก : #% % Sodium Nitroprusside
Therapeutic
Faculty Of Nursing
• 5. '+#*ก : #% * * % # 0 /1 %) ก+
corticosteroid (2 Q *ก# ' ก ! * ( *(
(adrenal insufficiency) 6 Solu-Medrol ' 2 Prednisolone
• 6. '+#*: #% BP ! )+ Hypoglycemia 2 * ก- %
cathecolamine ! ก * ก * ก+6%
• 7. ก G 27 * ก .: #% %' % 6 I131
metaiodobenzylguanidine - % 3*
Therapeutic

03/12/58
10
Faculty Of Nursing
adrenalectomy
laparotomy adrenalectomy open abdominal incision
Faculty Of Nursing
Nursing Assessment
• 4#ก # ; 1 " ! # ก # ก # '
• S/S ; ' 6#% severe headache, palpitation, hyperhidrosis
• ก *' * E # ก
– vanillylmandelic acid-VMA ( %# free catecholamines) < 24
6# 1 *)+ catecholamines metabolites +2 % 3*-57
– clonidine suppression test; clonidine ก%ก '+#* catecholamine
• " ก ; %# catecholamine +2 % +%+*
• Pheochromocytoma; ( ก + ) +*
• Lab; BS (hyperglycemia), Hct 3*
• ก * #* 6 CT, MRI (2 ' ! )' *- * 27 * ก
Faculty Of Nursing
NDx. Pre-adrenalectomy
• 1. %+- * 7! +"1 + / )+ ' 2 * ก
% # ก " *ก - * *ก # ' %
"+2
• 2. " - 2 * ก %I , # ก ก '*2
ก U+U ก( & (- *1 "
• 3. * ก ก% # ' +2 + ก * ก " :% ก ก
* ' / orthostatic hypotension 2 * ก % # " "
%# " %# 1+'
Faculty Of Nursing
NDx. Post-adrenalectomy
• 1. * ก ก% ) ก4 ก ' ก ! *
( *( (adrenal insufficiency)
• 2. - 2 * ก %):+: #%
• 3. - %" 3 ก E # # ก ก# 1 "ก ก+# 3
Faculty Of Nursing
• 1% # ' 2 ก : #% ( ! "#$%#* 7
• 1. S/S ก adrenal insufficiency :3 * % # 0 /1
%) ก+ corticosteroid
• 2. 6 '+2 ก % )+ %3)+ ' % # )ก % ): ก #ก,
• 3. %3)+ก % # +%" %# * 72 6# 1 *'+#*: #% 27 * ก
' ก
• 4. '"! ) ! ก %3)+ * (#กMgh /ก+# 3
- : #% ก #7* 2 - * * # corticosteroid + %6 ' ก: #%- *
% % # 6# " ก '+2 ! * ก
N/C. Post-adrenalectomy
Faculty Of Nursing
- ':3 (#ก: ก= ก G ) ก4 *'#
- ก G '+2 - * % ''+ก + *ก ก " / #*
ก % 627 '+ก + * * ! ' ก% G/ 5* " % 45* ! ' ก%
adrenal insufficiency ' 2 crisis
- ' # ' "G" 3* )"+ ( *( ก# " *ก
- * *ก ' ! ก#% ) Q*)+ 7! + )+ #
1 3*' ก #* ) ก4 - *1 "'# )+
- #% ' 2 2 ( ก :% ก ' ( )( /
N/C. Post-adrenalectomy

03/12/58
11
Faculty Of Nursing
Any questions??

การพยาบาลโรคต่อมไร้ท่อที่ซับซ้อน

Recommended

Recommended

More Related Content

Similar to การพยาบาลโรคต่อมไร้ท่อที่ซับซ้อน

Similar to การพยาบาลโรคต่อมไร้ท่อที่ซับซ้อน (10)

More from Chutchavarn Wongsaree

More from Chutchavarn Wongsaree (20)

Recently uploaded

Recently uploaded (20)

การพยาบาลโรคต่อมไร้ท่อที่ซับซ้อน