ENDOCRINE DISORDERS Prepared by : LORI R.LARA, R.N.

ABNORMAL PITUARY FUNCTIONS Hyper and Hyposecretion of Growth Hormone

Growth hormone (Somatotropin) a protein hormone that increases protein synthesis the breakdown of fatty acids in adipose tissue and increases the glucose level in the blood. Insufficient secretion during childhood results in generalized limited growth and dwarfism. Hypersecretion would result in Cushings syndrome or acromegaly.

Panhypopituarism (Simmonds Disease)

Extreme weight loss Emaciation Hair loss Impotence Atrophy of all endocrine glands and organs Amenorrhea Hypometabolism Hypoglycemia

Pituitary Tumor Usually occurs in the anterior lobe of the pituitary and characterized as benign, small and encapsulated Medical and Surgical Management

Transphenoidal Hypophysectomy Stereotactic radiation therapy, bromocriptine and octreotide

Nursing Management for Patient who has Undergone Transphenoidal Hypophysectomy: Asses for any signs of increasing ICP and CSF leaks. Elevate the head to 20 degrees and notify physician in case CSF leaks. Monitor for seizure and stress ulcer Apply cool, moist packs over the eyes for ecchymosis and periorbital edema. Administer artificial tears or ointment as prescribe Use sterile technique for all dressing changes to prevent meningitis. Do not suction through the nose if the nasal membrane is torn, CSF may leak and infection may occur. Do suction by other routs minimally, suctioning increases ICP.

Types of Hypophysectomy and the Nursing Consideration

Supratentorial Surgery: Elevate head of the bed to 30 degrees.

Infrantentorial Surgery: Keep client flat on the bed to prevent pressure on the brainstem. Turn every 2 hrs. but never onto the back Posterior Fossa Surgery: Position on either side but never on the back. A pillow may be placed under the head for support. Monitor for changes in vital signs because the surgery site is close to vital brain stem functions. Monitor for cardiac arrythmias and air embolism..

Bony Flap: Place the client only on the unoperated side or back.

Diabetes Insipidus
A condition charecterized by a deficiency of antidiuretic hormone (ADH)

Results in water imbalance characterized by polydipsia and a large amount of dilute urine Signs and Symptoms

Polyuria Polydypsia Excretion of urine with abnormally low specific gravity

Medical and/or Surgical Management Vasopressin (e.g. Desmopressin or DDAVP) and lypressin (e.d Diapid) may be given nasally. Benzothiadiazine diuretics, clofibrate and chlorpropamide may be given as antidiuretics. If it is secondary to tumor, excision of the tumor may be curative. ABNORMAL THYROID FUNCTION Diagnostic Evaluation Serum Immunoassay for Thyroid Stimulating Hormone the single best screening test of thyroid function because of its high sensitivity. Serum Immunoassay for Free Thyroxine (FT4) test to confirm an abnormal thyroid-stimulating hormone

Hypothyroidism

Deficiency of thyroid hormones thyoxine (T4) and triodothyronine (T3) resulting in slowed body metabolism and pronounced personality changes Signs and Symptoms Decreased heart rate, stroke volume and cardiac output Hyperlipidemia, hypercholesterolemia Anemia, easy bruising Dyspnea, fatigue, lethargy Fluid retention, and possible weight gain Anorexia and constipation Sensitivity to cold, decreased ability to sweat Slowed physical and mental reactions Dry, course skin and hair, brittle nails, alopecia Normal to enlarge thyroid gland Expressionless face Periorbital edema Slow deliberate speech Myxedema, myxedema coma Medical and/or surgical Management Thyroid hormone preparation (synthetic levothyroxine, desiccated thyroid) Iodine preparations and Iodine enriched diet Surgery is done if the goiter is very large and not responding to therapy. Nursing Management

Monitor for angina and dysrhythmias

Assess symptoms of thyrotoxicosis: (tachycardia, diarrhea, sweating, agitation, tremors, and shortness of breath) Instruct patient to avoid extreme cold until stable Avoid using heating pads or electric blankets because of potential vasodilation, loss of heat and vascular collapse Administer narcotics and sedatives judiciously due to decreased metabolic rate.

Educate the client about the drug-drug interactions: Thyroid hormones increase blood glucose levels Phenytoin and tricyclic antidepressants increase the effect of thyroid hormone Thyroid hormones increase the effect of digitals, anticoagulants and indomethacin

Hyperthyroidism

gland

Excessive seretion of thyroid hormones due to over functioning of the thyroid Most common form : Graves disease Thyroid enlargement due to hyperplasia exophthalmos

Signs and Symptoms Tachycardia, palpitations, and elevated blood pressure Increased respiratory rate and depth Weight loss despite ravenous appetite Diarrhea Heat intolerance, profuse diaphoresis Hand tremors at rest Flushed, warm skin Fine, soft hair Mood swings ranging from mild euphoria to delirium

Agitation, restlessness and irritability Enlarge thyroid gland Exophthalmos Fatigue and muscle weakness

Thyroid Storm (Thyrotoxic Crisis) Medical emergency characterized by high fever, severe tachycardia, delirium and dehydration, and extreme irritability Precipitated stress, infection, insulin reaction, diabetic acidosis, pregnancy, digitals toxicity, withdrawal to antithyroid drugs or vigorous palpation of thyroid Medical and/or Surgical Management Antithyroid Hormone Medications: Propylthiouracil (e.g. Propacil, PTU) Ethimazole (Tapazole) Radioiodine Therapy Thyroidectomy

Iodine and iodide compounds (e.g. potassium iodide, Lugols solution, SSKI) Beta-adrenergic blockers

Nursing Management

Provide high calorie, high protein diet. For exopthalmos, provide eye moisturizers and eye patches as needed to prevent irritation. Instruct patient to avoid taking over the counter medications with iodine, cough medications, expectorants, bronchodilators and salt substitutes if the patient is receiving iodine or iodide compounds.

Decrease strain on suture line by: Placing the patient in Semi-flowers position Supporting the head and neck with pillows and sand bags Instructing the client not to extend the neck.

ABNORMAL PARATHYROID FUNCTION Hypoparathyroidism Results when insufficient amount of PTH are secreted, or when the hormone fails
to act the tissue level Characterized by decreased serum calcium level Signs and Symptoms

Hypocalcemia, hyperphosphatemia

Latent tetany: Numbness, tingling, crams, stiffness of hands and feet

Overt tetany: bronchospasm, laryngospasm, photophobia, dysrrhythmias, seizures Anxiety, irritability, depression, delirium Positive Chvosteks and Trousseaus signs Thin, patchy hair, brittle nails, dry, scaly skin Cataract formation

Medical and/or Surgical Management Elevate the serum calcium level to 9-10 mg/dL Calcium gluconate IV in hypoparathyroidism and hypocalcemia Parental parathormone, bronchodilators and phenobarbital Tracheostomy or mechanical ventillation High calcium, low phosphorous diet

Oral calcium salts, aluminum hydroxide gel or aluminum carbonate may be given Vitamin D Hyperparathyroidism Overactivity of one or more of the parathyroid glans Regulates serum calcium level Excess in circulating PTH leads to bone damage, hypercalcemia, renal failure, and decreased phosphate levels Signs and Symptoms Back ache, joint pain Pathologic fractures of the spine, ribs, and long bones Polyuria, polydypsia Kidney stones Nausea, anorexia, contipation, abdominal pain Restlesness, depression, emotional irritability neurosis, psychosis Medical and/or Surgical Management Hydration therapy Loop diuretics, furosemide (lasix) to promote renal calcium secretion Avoid thiazide diuretics because they increase calcium levels Medications that inhibit bone resorption: Mithramycin (mitracin), Gallium nitrate (ganite), Phosphates and calcitonin Parathyroidectomy Nursing Management Encourage fluid intake up to 3000 ml/day unless contraindicated. Cranberry juice, prune juice and ginger ale make the urine more acidic and help prevent stone formation. Encourage low calcium, low vitamin D diet. ABNORMAL ADRENAL FUNCTIONS Pheochromocytoma Catecholamine-secreting tumor of the adrenal medulla Excessive secretion of epinephrine and norepinephrine Signs and Symptoms 5 Hs Hypermetabolism, Hypertension, Hyperhidrosis, Hyperglycemia and Headache

Acute attack: profuse diaphoresis, dilated pupils, and cold extremities, extreme anxiety and weak, headache, vertigo, blurring of vision, tinnitus, air hunger, dyspnea, feeling of impending doom, palpitations, tachycardia Clonidine suppression test reveals no change in cathecholamine levels

Medical and/or Surgical Management Alpha-adrenergic blockers (e.g. phentolamine) smooth muscle relaxants (e.g. Nitroprusside) are given for hypertensive crises. Phenoxybenzamine, beta-adrenergic blockers, metyrosine and corticosteriods therapy. Unilateral or bilateral adrenalectomy Primary Adrenocortical Insufficiency Addisons Disease Insufficient secretion of adrenocortical hormones by the adrenal cortex as a result of a disorder within the adrenal gland Decreased levels of mineralcorticoids, glucocorticoids and androgens Signs and Symptoms Muscle weakness, fatigue Anorexia, loss, emaciation Postural hypotension Bronzed skin discoloration (knuckles, knees, elbows, mucous membranes) Emotional disturbances ranging from mild neurotic symptoms to severs depression Decreased resistance to emotional or physical stress Depleted sodium and water, chronic dehydration Addisonians Crisis: Shock, rapid, weak pulse, tachypnea, pallor, weakness, sudden profound weakness, severe abdominal, back and leg pain, hyperpyrexia followed by hypothermia, peripheral vascular collapse, coma, renal shutdown

Hypoglycemia, hyponatremia, hyperkalemia, leukocytosis

Medical and/or Surgical Management Corticosteroid replacement therapy Restore blood circulation and prevent shock Vasopressors and antibiotics may be given

Nursing Management Instruct the patient to report increased thirst Provide sodium and high-carbohydrate and high protein diet Educate about the lifelong adrenal cortex hormone replacement Prohibit beverages or food with caffeine Instruct the patient to avoid strenuous activity in hot and humid weather Cushings Syndrome Hypersecretion of glucocorticoids and androgens due to over activity of the adrenal gland Most common cause: Pituitary tumors Signs and Symptoms Muscle wasting, osteoporosis, kyphosis, backache, fractures Hypokalemia , metabolic alkalosis Hypertension, CHF Abnormal fat distribution: Moon-shaped face, dorsocervical fat pad (buffalo hump), truncal obesity with slender limbs Skin oiliness, acne Increased susceptibility to infection, decreased resistance to stress Poor wound healing

Virility in women, menstrual irregularities Loss of libido

Medical and/or Surgical Management Radiation therapy for pituitary tumors and adenomas Cytoxic anti-hormonal agents Hydorcortisone therapy Lifetime replacement of adrenal cortex hormones Adrenal enzyme inhibitors Transphenoidal hypophysectomy Adrenalectomy Nursing Management Provide high protein, calcium and Vit. D and low sodium, carbohydrates and calories diet Promote rest and activity Post-transphenoidal hypophysectomy Assess for signs of cerebral edema and rising intracranial pressure Assess for signs of meningitis

Observe client for rhinorrhea after nasal packing removed. ABNORMAL PANCREATIC FUNCTIONS

Acute Pancreatitis Inflammation of the pancreas characterized by hemmorage, necrosis and suppuration of pancreatic parenchyma. Major causes: Alcoholism and cholelithiasis Alcohol associated pancreatitis: Pain begins 12-48 hrs. after an episode of inebriation Gallstone related pancreatitis: Pain begins after a large meal

DIABETES MELLITUS Nature of Diabetes Mellitus Group of metabolic diseases characterized by elevated levels of glucose in the blood resulting from defects in insulin secretion. Metabolic disorder characterized by glucose intolerance Systemic disease caused by an imbalance between insulin supply and insulin demand of the cell 2 types of Diabetes Mellitus Type 1 (IDDM) Insulin Dependent Diabetes Mellitus Insulin-producing pancreatic beta cells are destroyed by autoimmune process Usually occurs before 30yrs of age Insulin injection is required

Type 2 (NIDDM) Non-Insulin Dependent Diabetes Mellitus Sensitivity to insulin (insulin resistance) or decrease amt. of insulin produced Also called adult onset and mild diabetes Occurs in clients over 35yrs of age but can also occur in children Only 20-30% of clients require injection

Metabolic effects of Diabetes

Decreased utilization of glucose Increased fat metabolism Increased protein utilization

Complications of Diabetes Neuropathy, retinopathy, nephropathy Cataracts, glaucoma, pyelonephritis and infections Peripheral vascular lesions, coronary artery disease (CAD) Stroke, hypertension Signs and Symptoms Polyuria Polydypsia Polyphagia Weight loss Vision changes Tingling, numbness in hands or feet Slow healing sores Fasting plasma glucose(FPG)>126mg/dL Random plasma glucose levels>200mg/dL Medical and/or Surgical Management 5 components in diabetes management Nutrition or diet management Exercise Monitoring Pharmacologic therapy Education Insulin therapy Pancreas transplant

MUSCULOSKELETAL DISORDERS Cast Purpose of cast Immobilization of the reduced fracture Correction of deformity Support and stabilization of weakened structures

Types of Cast Arm Cast Leg Cast Walking Cast Body or Spica Cast Cast Syndrome Acute anxiety reaction characterized by behavioral changes and sympathetic autonomic responses Physiologic GI motility, intestinal gas accumulation, abdominal distention, nausea, and vomiting Treatment: Decompression and intravenous fluid therapy until GI motility is restored Nursing Management for Potential Complications from Cast Compartment Syndrome Condition of compromised circulation related to progressively increased pressure in a confined space. Caused by factors that decrease the compartment size such as external compression, bleeding or edema Nursing Management Assist in bivalving & fasciotomy Elevate extremity no higher tha heart level Record neurovascular responses and report any changes to the physician Pressure Ulcers Any lesion on the skin caused by unrelieved pressure resulting to damage underlying tissues Immobility is the major risk factor

Classification of ulcers Stage I: Non-blanching erythema of intact skin Stage II: Partial-thickness skin loss involving epiderms and/or dermis; superficial ulcer which appear as abrasion, blister, or shallow crater Stage III: Full-thickness skin loss involving damage or necrosis of subcutaneous layer; ulcer presents as deep crater

Stage IV: Full-Thickness skin loss with extensive destruction, tissue necrosis, or damage to muscle, bone or supporting tissues Nursing Management Elevate the heels using pillows or pressure reduction boots Remove devitalized tissue from ulcer Monitor for possible infection Position the client off the ulcers

Disuse Syndrome Muscle weakness due to immobilization, which occurs as early as 1wk after immobilization Decreased bone mass; increases risk for developing heterotopic ossification

Nursing Management Ask the patient to push down or make a fist (isometrics), to help reduce muscle atropy and maintain muscle strenght. Portable electrical stimulators may be attached over large muscles of afected area prior to cast application