University:
Michigan State University
Course:
MED 622 | Endocrinology and Metabolism Clerkship
Academic year:

2020
Views:

222

Pages:

61
Author:

VequeNupdubr6r

Chapter 52 Assessment and Management of Patients with Endocrine Disorders Pituitary Gland and Hormones Secreted 2 Hypo & hyper secretion of GH Excess GH in adults:  Acromegaly : enlargement of peripheral body parts without height. large hands & feet Excess GH, in children .  Gigantism can be caused by tumors.  Symptoms: large all organs low GH:  Dwarfism limited growth 3 Pituitary Tumors  95% are benign.  Early in life result in Gigantism .  large in all proportions, weak (hardly stand). (↑in height).  During adult life, result in Acromegaly ).  the excessive skeletal growth occurs only in the feet, the hands, (no height ↑)  May suffer from headaches & visual disturbances because of pressure on the optic nerves.  May give rise to Cushing syndrome (↑ACTH, hyperadrenalism) leading to Masculinization and Amenorrhea 4 Diabetes Insipidus • Deficiency of ADH • Excessive thirst (polydipsia) & large volumes of diluted urine with a low specific gravity of 1.001 to 1.005. • Causes: head trauma, brain tumor, surgical ablation or irradiation of the pituitary gland, failure of the renal tubule to respond to ADH ADH replacement (Vasopressin), Management: identify and treat the cause Monitor patient for electrolytes imbalances. • Normal specific gravity of urine: 1.015-1.030 5 Syndrome of Inappropriate Antidiuretic Hormone (SIADH) • Excessive ADH secretion • Retain fluids → dilutional hyponatremia. • SIADH may occur with bronchogenic carcinoma (malignant cells synthesize and release ADH). • Interventions: eliminating the cause, and restricting fluid 6 Thyroid hormones • T3, T4, calcitonin • T3 is more potent and rapidacting than T4 • Iodine is contained in thyroid hormone (T3, T4) • Calcitonin is secreted in response to high plasma calcium level and increases calcium deposit in bone TSH controls the release of thyroid hormone The major use of iodine in the body by the thyroid. Iodized table salt is a source of iodine. 7 Hypothalamic–Pituitary–Thyroid Axis 8 Thyroid Diagnostic Tests  TSH: stimulates thyroid to release T3 and T4  Serum-free T4  free T4: tests used to evaluate thyroid function and diagnose thyroid diseases, usually after TSH level is abnormal.  T3 and T4  Thyroid antibodies  Radioactive iodine uptake  Fine-needle biopsy  Thyroid scan  Serum thyroglobulin Ask pt about allergy to iodine 9 Thyroid Disorders • Cretinism: ‫البالهه او القماءه‬ - stunted physical and mental growth due to untreated congenital deficiency of thyroid hormones due to maternal hypothyroidism • Hypothyroidism • Hyperthyroidism • Thyroiditis • Goiter : non cancer enlargement of thyroid gland. • Thyroid cancer 10 Hypothyroidism Causes: 1. Autoimmune thyroiditis (Hashimoto’s disease) (most common cause) 2. Aging: atrophy of thyroid gland 3. Therapy of hyperthyroidism 4. Medications: lithium 5. Radiation to head and neck 6. Iodine deficiency and excess  Affects women 5X more than men  Early symptoms: )↓ HR, ↓ Temp, Menstrual disturbances, feels cold, fatigue) 11 Hypothyroidism Complications:  Myxedema: (severe deficiency), Myxedema refers to the accumulation of mucopolysaccharides in subcutaneous and other interstitial tissues )→ thick skin( .  Occurs commonly among older women in the winter  Manifestations: respiratory drive is depressed, hypoventilation, CO2 retention, coma. Hyponatremia, hypoglycemia, hypotension, bradycardia, and hypothermia.  Mortality rate is high at 30% to 40%. 12 Med. Management Synthetic levothyroxine Medication interactions: Effects of hypnotic and sedative agents; reduce dosage 13 Nursing Care of the Patient With Hypothyroidism Activity intolerance r/t insufficient energy  Promote independence of self care activities  Space activities and promote rest Risk of imbalance body temperature     Provide extra blanket Avoid and discourage the use of external heat source Monitor body temp Protect from exposure to cold Constipation r/t diminished GI peristalsis • Increase fluid intake & High fiber diet • Increase mobility • Use laxatives and enemas 14 Nursing Care of the Patient With Hypothyroidism Deficient knowledge about the therapeutic regimen  Explain rational for thyroid hormone replacement (action, doses)  Describe the effects of over and under medication  Explain the importance of Follow up Ineffective breathing pattern r/t depressed ventilation  Monitor RR, depth, pulse oximetry, ABGs  Encourage deep breathing, coughing and the use of spirometry  Be cautious during administration of hypnotics and sedatives with L.thyroxine  Monitor patent airway 15 QUESTION • A patient with a history of thyroid problem is presented to the emergency department unconscious and with a temperature of 35.1ºC. A family member informs the nurse that the patient has not taken thyroid medication in over 2 months. What does the nurse suspect that these findings indicate? a) SIADH b) Diabetes insipidus c) Myxedema coma d) Thyroid storm 16 Hyperthyroidism  Affects women 8x than men  Graves’ disease: autoimmune disorder result from excessive thyroid hormones  Thyrotoxicosis: excessive output of thyroid hormone (thyroid storm) Clinical Manifestations: • Nervousness; rapid pulse; heat intolerance; tremors; skin flushed, warm, soft, and moist; exophthalmos; increased appetite (encourage small frequent meal, high in protein); weight loss; elevated systolic BP; cardiac dysrhythmias 17 Exophthalmos 18 19 Hyperthyroidism Assessment and Diagnostic Findings  Thyroid gland is enlarged, soft and may pulsate; a thrill may be felt and a bruit heard over thyroid arteries.  Laboratory tests • a decrease in serum TSH, • increased free T4, and an increase in radioactive iodine uptake. 20 Hyperthyroidism Medical Management  Medications: • Propylthiouracil and methimazole • Sodium or potassium iodine solutions • Dexamethasone • Beta-blockers (to decrease heart rate, systolic blood pressure, muscle weak-ness, nervousness, tremor, anxiety, and heat intolerance. )  Surgery; subtotal thyroidectomy 21 Hyperthyroidism Assessment  Family history of hyperthyroidism, irritability or increased emotional reaction.  Assess patient’s ability to cope with stress.  Evaluate nutritional status, note excessive nervousness and changes in vision and appearance of eyes.  Assess (heart rate, BP, heart sounds, and pulses. 22 Hyperthyroidism Nursing Diagnoses  Imbalanced nutrition: Less than body requirements related to exaggerated metabolic rate, excessive appetite, and increased gastrointestinal activity  Ineffective coping related to irritability, hyperexcitability, apprehension, and emotional instability  Low self-esteem related to changes in appearance, excessive appetite, and weight loss • Altered body temperature 23 Hyperthyroidism Potential Complications • Thyrotoxicosis or thyroid storm • Hypothyroidism 24 Hyperthyroidism/ Nursing Interventions Improving Nutritional Status  Small, high-calorie, high-protein diet (up to 6 meals /d  Replace fluids lost, avoid stimulants such as coffee, tea, cola, and alcohol • Provide quiet atmosphere during mealtime • Record weight and dietary intake daily. 25 Hyperthyroidism Nursing Intervention Enhancing Coping Measures  Reassure the patient & family (with effective treatment symptoms will be controlled.  Keep the environment quiet , minimize stress  Provide information regarding thyroidectomy  Encourage adherence to the therapeutic regimen. • Provide written instructions 26 Hyperthyroidism Nursing Intervention Improving Self-Esteem  Develop coping strategies regarding problems with appearance, appetite, and weight,  Provide eye protection (instillation eye drops to soothe the eyes and protect the exposed cornea).  Discourage smoking.  Arrange for patient to eat alone, if desired and if embarrassed by the large meals consumed due to increased metabolic rate. Avoid commenting on intake. 27 Hyperthyroidism / Nursing Intervention Maintaining Normal Body Temperature  Provide a cool, comfortable environment and fresh bedding and gown as needed.  Give cool baths and provide cool fluids; monitor body temperature. 28 Thyroid storm (thyrotoxic crisis) • A form of severe hyperthyroidism, lifethreat condition • characterized by: • hyperpyrexia > 38.5, extreme tachycardia >130, and delirium & coma. Exaggerated symptoms of hyperthyroidism • Precipitated by • stress (injury, infection, surgery, tooth extraction, DKA, pregnancy, digitalis 29 Thyroid storm Management  Reduce temp, HR and prevent vascular collapse.  Humidified oxygen to improve tissue oxygenation  Intravenous fluids (dextrose) to replace glycogen stores.  Hydrocortisone to treat shock or adrenal insufficiency.  Propylthiouracil or methimazole to prevent formation of thyroid hormone.  Iodine to decrease output of thyroxine (t4) from thyroid gland.  Salicylates are not used in the management of thyroid storm because they displace thyroid hormone from binding proteins and worsen the hypermetabolism. 30 Question Which medication blocks synthesis of thyroid hormone? A. Dexamethasone B. Methimazole C. Potassium iodide D. Sodium iodide Methimazole blocks synthesis of thyroid hormone. Dexamethasone, potassium iodide, and sodium iodide suppress release of thyroid hormone. 31 Thyroidectomy Postoperative Care  Monitor for potential airway impairment, bleeding and hematoma formation  Assess pain and provide pain relief  Semi-Fowler’s position, with the head elevated and supported by pillows.  Assess voice, discourage talking  Potential hypocalcaemia related to injury or removal of parathyroid glands 32 Parathyroid Glands • Parathormone: regulates calcium and phosphorus • Increased parathormone : • elevates blood calcium by increasing calcium absorption from the kidney, intestine, and bone • Parathormone lowers phosphorus level 33 Hyperparathyroidism  (Overproduction of Parathormone) Primary hyperparathyroidism: • 2-4 times more frequent in women than men Secondary hyperparathyroidism • Occurs in patients with chronic kidney failure as a result of phosphorus retention, increased stimulation of the parathyroid gland Clinical manifestations: • Elevated serum calcium, bone decalcification, renal calculi, apathy, fatigue, muscle weakness, nausea, vomiting, constipation, hypertension, dysrhythmias, 34 Hyperparathyroidism Management: • Surgery: Parathyroidectomy • Hydration therapy (2L daily) to prevent renal stone • Encourage mobility (Bones subjected to the normal stress of walking give up less calcium). • Encourage fluid, restrict calcium Hypercalcemic crisis (> 13 mg/dl); results in neurologic, cardiovascular, and kidney symptoms that can be life threatening. 35 Hypoparathyroidism • Parathormone deficiency caused by thyroidectomy, parathyroidectomy, or radical neck dissection • Results in hypocalcaemia and hyperphosphatemia. • Tetany, numbness, tingling in extremities, stiffness of hands and feet, bronchospasm, laryngeal spasm, carpopedal spasm, anxiety, irritability, depression, delirium, ECG changes • Positive Chvostek’s and Trousseau’s signs 36 Parathyroidectomy Postoperative care  detecting early signs of hypoparathyroidism and subsequent hypocalcemia and anticipating signs of tetany, seizures, and respiratory difficulties Trousseau’s sign Chvostek’s signs 37 Hypoparathyroidism Assessment and Diagnostic Findings  Tetany is suggested by  a positive Trousseau’s sign or  a positive Chvostek’s sign  serum calcium 5 to 6 mg/dL or lower, increased serum phosphate 38 Medical Management of Hypoparathyroidism  Goal: to Raise Serum calcium to 9 to 10 mg/dL  If hypocalcemia and tetany occur after thyroidectomy • Administer IV calcium gluconate. • Administer parathormone if osteoporosis occur  Quite environment to reduce neuromuscular irritability  Tracheostomy or MV if respiratory distress developed. 39 Hypoparathyroidism Diet: high in calcium and low in phosphorus. avoid milk, milk products, egg yolk (contain phosphorus) avoid spinach (contain oxylate which would form insoluble calcium) . Calcium tablets and vitamin D Aluminum hydroxide or aluminum carbonate after meals to bind phosphorus and promote its excretion from the GIT. Thiazide diuretics to decrease urinary calcium excretion 40 Nursing Management of Hypoparathyroidism  Detecting early signs of hypocalcemia  Assess signs of tetany, seizures, and respiratory difficulties.  Keep calcium gluconate at the bedside; if patient has a cardiac disorder, is subject to dysrhythmias, or is receiving digitalis, the calcium gluconate is administered slowly and cautiously.  Teach patient about medications and diet therapy 41 Question Is the following statement true or false? A patient in acute hypercalcemic crisis requires close monitoring for life-threatening complications and prompt treatment to reduce serum calcium levels. (True) 42 Adrenal Glands • Adrenal medulla • Catecholamines: (epinephrine and norepinephrine) • Adrenal cortex • Glucocorticoids (cortisol) • Mineralocorticoids (aldosterone) • Androgens (male sex hormones) 43 Adrenocortical Insufficiency Addison’s disease • Hypo secretion of Aldosterone & Cortisol Causes:  Autoimmune or atrophy of the adrenal glands  surgical removal of adrenal glands or infection  Inadequate secretion of ACTH  Therapeutic use of corticosteroids is the most common cause (sudden cessation) 44 Addison’s disease Clinical Manifestations  Muscle weakness, anorexia, fatigue,  Dark pigmentation of the skin and mucous membrane  Hypotension, low blood glucose, low serum sodium, and high serum potassium.  Mental changes (depression, apathy, and confusion)  In severe cases, disturbance of sodium and potassium metabolism may be marked by depletion of sodium and water and severe, chronic dehydration. 45 Addisonian Crisis • Medical emergency • Signs and symptoms • Cyanosis and signs of shock: pallor, rapid weak pulse, rapid respirations, low BP • Nausea, abdominal pain, diarrhea, • Headache, confusion, and restlessness.  Slight overexertion, exposure to cold, acute infections, or a decrease in salt intake may lead to circulatory collapse, shock, and death.  Stress of surgery or dehydration precipitate addisonian or hypotensive crisis. 46 Addison’s disease Diagnostic Findings  Increased plasma ACTH (more than 22.0 pmol/L)  Low serum cortisol (less than 165 nmol/L) or in the low-normal range  Decreased blood glucose, hyponatremia, hyperkalemia, and leukocytosis 47 Addison’s disease Management  Administer fluids and corticosteroids  Place patient in a recumbent position with legs elevated  Vasopressor & Antibiotics if indicated  If adrenal gland does not regain function, lifelong corticosteroids and mineralocorticoids is required.  Dietary intake should be supplemented with salt during times of GI losses of fluids through vomiting and diarrhea. 48  The development of edema or weight gain may signify too high a dose of hormone;  postural hypotension and weight loss may indicate too low a dose. 49 Addison’s disease Nursing Management  Monitor BP, pulse , skin color and turgor.  Assess Hx of weight changes, muscle weakness, and fatigue.  onset of illness or increased stress that may have precipitated crisis.  Monitor for S&S indicative of addisonian crisis  (shock; hypotension; rapid, weak pulse; rapid respiratory rate; pallor; and extreme weakness). 50 Addison’s disease Nursing Management  Avoid stressors  (cold exposure, overexertion, infection, and emotional stress)  Treat addisonian crisis with  IV fluid, glucose, and electrolytes, especially sodium; steroid hormones; and vasopressors. • Consume foods and fluids to maintain fluid and electrolyte • select foods high in sodium during GI tract disturbances and in very hot weather. 51 Addison’s disease Nursing Management  Administer hormone replacement as prescribed  Provide written and verbal instructions about medications  Teaching patients self-care  How to modify drug dosage and increase salt intake in times of illness, very hot weather, and stressful situations.  A single-injection syringes of corticosteroid for use in emergencies.  Advise patient to inform health care providers (eg, dentists) of steroid use 52 Cushing Syndrome (Excessive adrenocortical activity or corticosteroid medications) • Remember the mnemonic: “STRESSED” (too much of the STRESS hormone CORTISOL) • Skin fragile, Weakness, Lassitude (lack of energy), acne • Trunk obesity & thin extremities, Osteoporosis, muscle wasting • Round face (moon-face) • Ecchymosis, elevated BP (hypertension) • Striae on extremities and abdomen, 53 Continue….the mnemonic: “STRESSED” Sugar (hyperglycemia), susceptible to infection; slow healing Excessive body hair especially in women…and Hirsutism, loss of libido, Electrolytes imbalance: hypokalemia, hypernatremia Dorsocervical fat pad (Buffalo hump), Depression, disturbance in sleep, mood changes 54 Cushing’s triad • Buffalo hump. fat pads over the upper back. • Moon face. excess fats over the face. • Truncal obesity. Fat pads throughout the trunk ‫جاموسة‬ 55 56 Cushing Syndrome/Diagnostic Findings  Low-dose dexamethasone suppression test. • Administer dexamethasone (1 mg) orally at 11pm, and cortisol level at 8am. >5mg indicate hypothalamic-pituitary –adrenal axis is functioning properly  Imaging studies. • Ultrasound, CT scan, or angiography localizes adrenal tumors and may identify pituitary tumors.  Blood studies. • increase in serum Na & blood glucose, decrease in K 57 Cushing Syndrome/ medical management Surgical Management  Removal of the adrenal or pituitary gland . • Transsphenoidal hypophysectomy. the treatment of choice if Cushing’s syndrome is caused by pituitary tumors and has an 80% success rate. • Adrenalectomy. the treatment of choice in patients with primary adrenal hypertrophy.  Pituitary irradiation • Hydrocortisone may be necessary for several months 58 Cushing Syndrome/ Nursing Diagnosis • Risk for injury related to weakness (the highest priority) • Risk for infection related to altered protein metabolism and inflammatory response. • Self-care deficit related to weakness, fatigue, muscle wasting, and altered sleep patterns. • Impaired skin integrity related to edema, impaired healing, and thin and fragile skin. • Disturbed body image related to altered physical appearance, impaired sexual functioning, and decreased activity level. • Disturbed thought processes related to mood swings, irritability, and depression. 59 • Decreasing Risk of Injury • Measures to prevent falls, Assist in ambulating, Foods high in protein, calcium, and vitamin D • Decreasing Risk of Infection • Avoid exposure to people with infections, Assess frequently for signs of infections • Improving Body Image • Discuss the major physical changes will disappear if the cause of Cushing syndrome can be treated. • Weight gain and edema may be modiﬁed by a lowcarbohydrate, low-sodium diet; a high-protein intake 60 Cushing Syndrome/nursing intervention Patient and family education  DO NOT stop corticosteroid abruptly to avoid adrenal insufficiency and reappearance of symptoms.  keep an adequate supply of the corticosteroid to prevent running out, because this could result in addisonian crisis.  Dietary modifications: adequate calcium intake without increasing risk for hypertension, hyperglycemia, and weight gain.  Monitor BP, glucose levels, and weight. 61

Assessment and Management of Patients with Endocrine Disorders

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