MEDICAL SURGICAL NURSING

ENDOCRINE SYSTEM

THE ENDOCRINE SYSTEM

1.chemical communication and coordination system that enables reproductive growth and devt and regulation of energy 2. composed of glands/glandular tissue - secrete, store and synthesize chemical messengers (hormones) that travel to target cells throughout the body - include hypothalamus, pituitary, thyroid, adrenals, pancreas, ovaries, testes, pineal and thymus

Major action and source of selected hormones

SOURCE
Hypothalamus

HORMONE
Releasing and inhibiting hormones Corticotropin releasing hormone (CRH) Growth hormone-releasing hormone (GHRH) Gonadotropin-releasing hormone (GnRH) Thyrotropin-releasing hormone (TRH)

MAJOR ACTION
Controls the release of pituitary hormones

Anterior pituitary

Growth hormone (GH)

Adrenocorticotropic hormone (ACTH) Thyroid-stimulating hormone (TSH) Follicle stimulating hormone (FSH) Luteinizing hormone (LH)

Stimulates growth of bone and muscle, promotes protein synthesis and fat metabolism, decreases carbohydrate metabolism Stimulates synthesis and secretion of adrenal cortical hormones Stimulates synthesis and secretion of thyroid hormones Female: stimulates growth of ovarian follicle, ovulation Male: stimulates sperm production Female: stimulates development of corpus luteum, prdxn of estrogen and progesterone Male: stimulates secretion of testosterone

Posterior pituitary

Antidiuretic hormone Oxytocin

Increases water reabsorption by kidney Stimulates contraction of pregnant uterus, milk ejection

PITUITARY GLAND

Anterior pituitary gland adenohypophysis Posterior pituitary gland neurohypophysis

ANTERIOR PITUITARY GLAND

Growth hormone (GH) (Somatotropic hormone) Fx: Elongation of long bones Decrease GH dwarfism insufficient secretion of growth hormone during childhood Increase GH gigantism Increase GH acromegaly adult Puberty 9 yo 21 yo Epiphyseal plate closes at 21 yo Square face Square jaw Drug of choice in acromegaly: Ocreotide (Sandostatin) SE dizziness, nausea, headache Drug of choice in growth failure in children: Somatropin (Humatrope) SE headache, muscle pain, weakness Melanocytes stimulating hormone - MSH Skin pigmentation Prolactin/luteotrpic hormone/ lactogenic hormone - Promotes development of mammary gland (Oxytocin-Initiates milk letdown reflex) Adrenocorticotropic hormone ACTH Luteinizing hormone produces progesterone. FSH- produces estrogen

DWARFISM
Assessment Height below normal, features delicate, sexual maturity delayed, bone and tooth development delayed

ACROMEGALY
Body size enlarged, deep voice, flat bones enlarged, sexual abnormalities, skin thick and soft

Analysis

Hyposecretion of GH, occurs before maturity Ttt: thyroid hormone replacement, Testosterone therapy Complication: diabetes

Hypersecretion of GH, occurs after maturity Ttt: hypophysectomy, external irradiation of tumor

POSTERIOR PITUITARY

Posterior pituitary: 1.) Oxytocin a.) Promotes uterine contraction preventing bleeding/ hemorrhage. - Give after placental delivery to prevent uterine atony. b.) Milk letdown reflex with help of prolactin.

2.) ADH antidiuretic hormone (vasopressin) Prevents urination conserve H2O

DIABETES INSIPIDUS

A. DIABETIS INSIPIDUS (DI- dalas ihi) hyposecretion of ADH Cause: idiopathic/ unknown Predisposing factor:

Pituitary surgery Trauma/ head injury Tumor Inflammation

S & Sx: 1. Polyuria of 4 to 24 L per day 2. Sx of dehydration (1st sx of dehydration in children-tachycardia) - Excessive thirst (adult) - Agitation - Poor skin turgor - Dry mucus membrane 3. Weakness & fatigue 4. Hypotension if left untreated 5. Hypovolemic shock Anuria late sign hypovolemic shock

DIABETES INSIPIDUS

Dx Proc: Decrease urine specific gravity 1.006 or less N= 1.015 1.035 Serum Na = increase (N=135 -145 meq/L) Hypernatremia Mgt: Force fluid 2,000 3,000ml/day Administer IV fluid replacement as ordered Monitor VS, I&O Administer meds as ordered a.) Pitressin (vasopressin) by nasal spray b.) Vasopressin tannate by SQ or IM Prevent constipationlaxatives and stool softeners 5. Prevent complications Most feared complication Hypovolemic shock

SIADH - Syndrome of Inappropriate AntiDiuretic Hormone

- Increase ADH - Idiopathic/ unknown

Predisposing factor 1. Head injury 2. Related to Bronchogenic cancer or lung cancerEarly Sign of Lung Ca - Cough 1. non productive 2. productive 3. Hyperplasia of Pit gland Increase size of organ

SIADH

S&Sx Fluid retention Increase BP HPN Edema Wt gain Danger of H2O intoxication Complications: 1. cerebral edema increase ICP 2. seizure Dx Proc: Urine specific gravity increase concentrated urine Hyponatremia Decreased Na Nsg Mgt: Restrict fluid Administer meds as ordered eg. Diuretics: Loop and Osmotic Monitorstrictly V/S, I&O, neuro check increase ICP Weigh daily Assess for presence edema Provide meticulous skin care Prevent complications increase ICP & seizures activity

DI (decreased ADH)

SIADH (increased ADH)

Assessment

Excessive UO Chronic, severe dehydration Excessive thirst, constipation Decreased ADH Dx test: low urine SG High serum Na

Decreased UO Tachycardia Change in LOC Decreased DTR ADH increased Dx test: serum Na dec Inc urine SG

Analysis

Nsg considerations

Monitor I&O Administer Pitressin Monitor urine SG, wt, VS

Restrict water intake (500600ml/24h) Administer diuretics Hypertonic saline IV (3%) Monitor VS

HYPOPHYSECTOMY

- removal of the pituitary tumor via craniotomy or via transsphenoidal (endoscopic transnasal) approach Complications for craniotomy: increased ICP, bleeding, meningitis Complications for the transsphenoidal surgery: CSF leak, infection and hypopituitarism Post op interventions: elevate the HOB Monitor for ICP, VS Monitor for any postnasal drip or nasal drainage (check the nasal drainage for glucose) Monitor for temporary diabetes insipidus resulting from ADH disturbances Instruct the client to avoid sneezing, coughing and blowing the nose

SOURCE

HORMONE

MAJOR ACTION

Adrenal cortex

Mineralocorticoids (aldosterone) Glucocorticoids (cortisol)

Increases sodium absorption, potassium loss by kidney Regulates blood glucose levels, affects growth, decreases effects of stress Serve as neurotransmitters for the sympathetic nervous system

Adrenal medulla

Epinephrine Norepinephrine

ADRENAL GLAND

At the top of each kidney 2 parts Adrenal cortex outermost layer - secretes glucocorticoids and mineralocorticoids Adrenal medulla - innermost layer - Secretes catecholamines - Epinephrine / Norephinephrine potent vasoconstrictor adrenaline=Increase BP

Adrenal Medullas only disease: PHEOCHROMOCYTOMA- presence of tumor at adrenal medulla -hypersecretion of catecholamines (nor/epinephrine) -with HPN -drug of choice: beta blockers -complication: HPN crisis = lead to stroke -no valsalva maneuver

Assessment: Persistent hyperstension Increased HR, palpitations Hyperglycemia, glucosuria, polyuria Pounding headache Tremor, nervousness
Dx test: Urinary VMA test - 24-h urine for vanillylmandelic acidbreakdown product of catecholamine metabolism N= 1-5mg; positive for tumor if significantly higher Foods affecting VMA excretion excluded 3 days before test: - coffee, tea, bananas, vanilla, chocolate All drugs discontinued during test Urine collected on ice or refrigeration and preservative needed

Complications: Hypertensive retinopathy and nephropathy Cardiac enlargement Congestive heart failure Increased platelet aggregation CVA

Nursing management: A. promote comfort: avoid physical and emotional stress, encourage rest B. provide appropriate nutrition: ample diet because of increased metabolic demand - avoid coffee, tea, cola and other stimulating foods C. provide postsurgical careadrenalectomy or medullectomy

ADRENAL CORTEX

Secretes: GLUCOCORTICOIDS: Cortisol, Cortisone Responsible for glucose metabolism, protein metablosim, suppression of inflammatroy response to injury MINERALOCORTICOIDS: Aldosterone Regulation of electrolyte balance by promoting sodium retention and potassium excretion

ADDISONS DISEASE hyposecretion of adrenal cortex hormones (glucocorticoids and mineralocorticoids) leading to: Metabolic disturbances (sugar) F&E imbalances- Na, H2O, K Deficiency of neuromuscular function (salt & sex) Steroids-lifetime Predisposing Factors: Atrophy of adrenal gland Fungal infections Tubercular infections S/Sx: Decrease sugar Hypoglycemia Decreased glucocorticoids - cortisol

T tremors, tachycardia I - irritability R - restlessness E extreme fatigue D diaphoresis, depression

Decrease plasma cortisol Decrease tolerance to stress lead to Addisonians crisis Decrease salt Hyponatremia Decreased mineralocorticoids Aldosterone Hypovolemia Hypotension Signs of dehydration extreme thirst, agitation Wt loss Hyperkalemia Irritability Diarrhea Arrhythmia Decrease sexual urge or libido- Decreased Androgen Loss of pubic and axillary hair

Pathognomonic sign bronze like skin pigmentation due to decrease cortisol will stimulate pituitary gland to release melanocyte stimulating hormone. Dx Proc: FBS decrease FBS (N 80 120 mg/dL) Serum Na decreased (N 135 145 meg/L) Serum K increased (N 3.5 5.5 meg/L)

Nsg Mgt: Monitor VS, I&O to determine presence of Addisonian crisis Complication of Addisons dse : Addisonian crisis Results the acute exacerbation of Addisons dse characterized by : Severe headache, severe hypotension, hypovolemia, hyponatremia, wt loss, arrhythmia, generalized weakness Lead to progressive stupor & coma Nsg Mgt Addisonian Crisis (Coma) Assist in mechanical ventilation Adm steroids hydrocortisone sodium (Solu-Cortef IV) prescribed initially Force fluids to restore electrolyte balance Administer meds a.) Corticosteroids - (Decadron) or Dexamethazone - Hydrocortisone (cortisone)- Prednisone

Nsg Mgt with Steroids Adm 2/3 dose in AM & 1/3 dose in PM in order to mimic the normal diurnal rhythm. Taper the dose (w/draw, gradually from drug) sudden withdrawal can lead to addisonian crisis Monitor S/E (Cushings syndrome S/Sx) HPN Hirsutism Edema Moon face & buffalo hump Increase susceptibility to infection sue to steroids- reverse isolation b.) Mineralocorticoids ex. Flourocortisone Diet increase calorie or CHO Increase Na, Increase CHON, Decrease K Force fluid Administer isotonic fluid as ordered Meticulous skin care due to bronze like HT & discharge planning a) Avoid precipitating factors leading to Addisonian crisis

Sudden withdrawal crisis Stress Infection Prevent complications

CUSHINGS SYNDROME increase secretion of adrenocortical hormone

S/Sx Increase sugar Hyperglycemia 3 Ps 1. Polyuria 2. Polydipsia increase thirst 3. Polyphagia increase appetite Classic Sx of DM 3 Ps & glycosuria + wt loss Increase susceptibility to infection due to increased corticosteroid

Hypernatremia a. HPN b. Edema c. Wt gain d. Moon face Buffalo hump Obese trunk classic signs Pendulous abdomen Thin extremities Hypokalemia Weakness & fatigue Constipation ECG (+) U wave Hirsutism Acne & striae (reddish-purple striae on abdomen and upper thighs) Increase muscularity of female

Dx: FBS increase (N: 80-120mg/dL) Na increase (135-145 meq/L) K- decrease (3.5-5.5 meq/L) Nsg Mgt: Monitor VS, I&O Administer meds a. K- sparing diuretics (Aldactone) Spironolactone - promotes excretion of Na while conserving potassium Not lasix due to S/E hypoK & Hyperglycemia! Restrict Na Provide Dietary intake low in CHO, low in Na & fats High in CHON & K Weigh pt daily & assess presence of edema- measure abdominal girth- notify doc. Reverse isolation Skin care due acne & striae Prevent complication - Most feared arrhythmia & DM (Endocrine disorder lead to MI Hypothyroidism & DM) Surgical bilateral Adrenolectomy Hormonal replacement therapy lifetime due to adrenal gland removal- no more corticosteroid!

ADDISONS DISEASE Dec BP, eternal tan, dehydration, weight loss

CUSHING SYNDROME

Assessment

Inc BP, edema, muscle wasting, purple skin striations, hirsutism, moon face, buffalo hump, masculinization in females, blood sugar imbalance

Analysis

Hyposecretion of adrenal hormones (mineralo, glucocorticoids, androgen) Dec sodium Dec bld volume Inc K Dec bld sugar Ttt: hormone replacement

Hypersecretion of adrenal hormones Inc sodium Inc BP Dec K Inc bls sugar Ttt; hypophysectomy, adrenalectomy

SOURCE
Thyroid (follicular cells)

HORMONE
Triiodothyronine (T3) Thyroxine (T4)

MAJOR ACTION
Increase metabolic rate; increase protein and bone turnover

Thyroid C cells

Calcitonin

Lowers blood calcium and phosphate levels

Parathyroid glands

Parathyroid hormone

Regulates serum calcium

THYROID GLAND

Question: Normal physical finding on TG: a. With tenderness thyroid never tender b. With nodular consistency- answer c. Marked asymmetry only 1 TG d. Palpable upon swallowing - Normal TG never palpable unless with goiter

Thyroid hormones: T3 T4 Thyrocalcitonin Triodothyronine Tetraiodothyronine/ Tyroxine FX antagonizes 3 molecules of iodine 4 molecules of iodine effects of parathormone

Metabolic hormone Hypo T3 T4 - lethargy & memory impairment all v/s down, constipation Hyper T3 T4 - agitation, restlessness, and hallucination - Increase metabolism brain inc cerebration, inc v/s, inc motility

HYPOTHYROIDISM all decreased except wt & menstruation, loss of appetite but with wt gain menorrhagia increase in menstruation HYPERTHYROIDISM - Increase appetite wt loss, amenorrhea

SIMPLE GOITER enlarged thyroid gland - iodine deficiency Predisposing factors 1. Goiter belt area - Place far from sea no iodine. Seafoods rich in iodine 2. Mountainous area increase intake of goitrogenic foods Cabbage has progoitrin an anti thyroid agent with no iodine Example: Turnips (singkamas), radish, peas, strawberries, potato, beans, kamote, cassava (root crops), all nuts. 3. Goitrogenic drugs: Anti thyroid agents :(PTU) propylthiuracil Lithium carbonate, Aspirin

S & Sx enlarged TG Mild restlessness Mild dysphagia

Dx Proc. Thyroid scan reveals enlarged TG predx: discontinue medications continuing iodine for 14 days before the test and the need to discontinue thyroid medication before the test. NPO post midnight, oral iostope is used Serum TSH increase (confirmatory) Serum T3, T4 N or below N N TSH level: 0.2 to 5.4 microunits/ml N T3: 80-230 ng/dl N T4: 5-12 mcg/dl Nsg Mgt: 1. Administer meds a.) Iodine solution Lugols solution or saturated sol of K iodide (SSKI) Nsg Mgt Lugols sol violet color Prophylaxis 2 -3 drops Treatment 5 to 6 drops Use straw to prevent staining of teeth 1. Lugols sol., 2. tetracycline 3. nitrofurantin (macrodantin)-urinary antisepticpyelonephritis. 4. Iron solution.

B. Thyroid h / Agents 1. Levothyroxine (Synthroid) 2. Liothyronine (cytomel) 3. Thyroid extract

Nsg Mgt: for TH/agents Monitor vs. HR due tachycardia & palpitation Take it early AM SE insomnia Monitor s/e Tachycardia, palpitations Signs of insomnia Hyperthyroidism restlessness agitation Heat intolerance HPN Encourage increase intake of iodine iodine is extracted from seaweeds (!) Seafood- highest iodine content oysters, clams, crabs, lobster Lowest iodine shrimps Iodized salt easily destroyed by heat take it raw not cooked Assist surgery- Sub total thyroidectomy- removal of 5/6 of the thyroid tissue Complication: 1. Tetany 2. laryngeal nerve damage 3.Hemorrhage-feeling of fullness at incision site.Check nape for wet blood. 4.Laryngeal spasm DOB, SOB trache set ready at bedside. Thyroid storm abrupt onset of HF, pulmonary edema, delirium, inc fever, PR, BP, coma; treatment: hypothermia blanket, oxygen, PTU, propanolol (Inderal), hydrocortisone

THYROIDECTOMY

THYROIDECTOMY

Post

Assess status of dressing Inspect and feel behind the neck Complx- parathyroid removal Laryngeal nerve injury Hypovolemic shock Pressure sensation at sitebleeding- prepare tracheostomy set Airway obstruction

Semi fowlers Apply ice collar Use incentive spirometer Laryngeal nerve injury

Respiratory obstruction, dysphonia, high-pitched voice, stridor, dysphagia and restlessness Assess level of hoarseness Monitor serum Calcium Monitor for positive trousseau and chvostek sign CaGluconate

PT removal

HYPOTHYROIDISM decrease secretion of T3, T4 can lead to MI / Atherosclerosis Adult myxedema Child- cretinism only endocrine dis lead to mental retardation Predisposing factor: `Iatrogenic causes caused by surgery Atrophy of TG due to: Irradiation Trauma Tumor, inflammation Iodine def Autoimmune Hashimoto disease

S&Sx everything decreased except wt gain & mens increase) Early signs weakness and fatigue Loss of appetite increased lypolysis breakdown of fats causing atherosclerosis = MI Wt gain Cold intolerance Constipation Late Sx brittle hair/ nails Non pitting edema due increase accumulation of mucopolysacharide in SQ tissue -Myxedema Decrease libido Decrease VS hypotension bradycardia, bradypnea, and hypothermia Lethargy Memory impairment leading to psychosis-forgetfulness Menorrhagia generalized puffiness and edema around the yes and face

Dx: Serum T3 T4 decrease Serum cholesterol increase can lead to MI RAIU radioactive iodine uptake decrease

Nsg Mgt: Monitor strictly V/S. I&O to determine presence of myxedema coma! Myxedema Coma - Severe form of hypothyroidism Hypotension, hypoventilation, bradycardia, bradypnea, hyponatremia, hypoglycemia, hypothermia Might lead to progressive stupor & coma Impt mgt for Myxedema coma Assist mech vent priority a/w Adm thyroid hormone levothyroxine sodium (Synthroid) Adm IVF replacement force fluid

Mgt myxedema coma Monitor VS, I&O Provide dietary intake low in calories due to wt gain Skin care due to dry skin Comfortable & warm environment due to cold intolerance Administer IVF replacements Force fluid Administer meds take AM SE insomia. Monitor HR. Thyroid hormones Levothyroxine(Synthroid), Liothyronine (cytomel) Thyroid extracts Health teaching & discharge plan Avoidance precipitating factors leading to myxedema coma: 1. Exposure to cold environment 2. Stress 3. Infection 4. Use of sedative, narcotics, anesthetics not allowed CNS depressants V/S already down

Complications: Hypovolemic shock, myxedema coma Hormonal replacement therapy - lifetime Importance of follow up care

HYPERTHYROIDISM hypersecretion of thyroid hormones Common cause: Graves disease or thyrotoxicosis toxic diffuse goiter ( everything up except wt and mens) -Increased T3 & T4 Predisposing factors: Excessive iodine intake Hyperplasia of TG S&Sx: Increase in appetite hyperphagia wt loss due to increase metabolism Skin is moist - perspiration Heat intolerance Diarrhea increase motility All VS increase = HPN, tachycardia, tachypnea, hyperthermia CNS changes Irritability & agitation, restlessness, tremors, insomnia, hallucinations Goiter Exopthalmos pathognomonic sx Amenorrhea

Dx: Serum T3 & T4 - increased Radioactive iodine uptake increase Thyroid scan reveals enlarged TG

Nsg Mgt: 1. Monitor VS & I & O determine presence of thyroid storm Administer meds Antithyroid agents

Prophylthiuracil (PTU) Methimazole (Tapazole)

Most toxic s/e agranulocytosis- fever, sore throat, leukocytosis=inc wbc: check cbc and throat swab culture Most feared complication : Thrombosis stroke CVS

Diet increase calorie to correct wt loss Skin care Comfy & cool environment Maintain siderails- due agitation/restlessness Provide bilateral eye patch to prevent drying of eyes- exopthalmos Assist in surgery subtotal thyroidectomy

Nsg Mgt: pre-op Adm Lugols solution / SSKI To decrease vascularity of TG To prevent bleeding & hemorrhage Mgt post op: Complication: 1. Watch out for signs of thyroid storm or thyrotoxicosis
Triad signs of thyroidstorm; Tachycardia /palpitation Hyperthermia Agitation Nsg Mgt Thyroid Storm: Monitor VS & neuro check Agitated might decrease LOC Antipyretic fever Tachycardia - blockers (-lol) Siderails agitated

Comp 2. Watch for inadvertent (accidental) removal of parathyroid gland If removed, hypocalcemia - classic sign tetany 1. .(+) Trousseau sign/ 2. Chvostecks sign Nsg Mgt: Adm calcium gluconate slowly to prevent arrhythmia Ca gluconate toxicity antidote MgSO4 3.Laryngeal (voice box) nerve damage (accidental) Sx: hoarseness of voice ***Encourage pt to talk or speak post operatively asap to determine laryngeal nerve damage Notify physician! 4. Signs of bleeding post subtotal thyroidectomy - Feeling of fullness at incision site Nsg mgt: Check soiled dressing at nape area 5. Signs of laryngeal spasm a. DOB b. SOB Prepare at bedside tracheostomy 6. Hormonal replacement therapy - lifetime 7. Importance of follow up care (Liver cirrhosis bedside scissor if pt complaints of DOB)

Parathyroid gland pair of small nodules located behind the TG Secrets parathyroid hormone promotes Ca reabsorption Thyrocalcitonin antagonises secretion of parathyroid hormone Hypoparthroidism decrease of parathyroid hormone Hyperparathroidsm

HYPOPARATHYROIDISM decreased parathormone HypocalcemiaHyperphosphatemia (Or tetany) [If Ca decreases, phosphate increases]

A. Predisposing, factors: 1. Following subtotal thyroidectomy 2. Atrophy of parathyroid gland due to a. Irradiation b. Trauma S&Sx: Acute tetany Tingling sensation Paresthesia Dysphagia Laryngospasm Bronchospasm Pathognomonic Sign of tetany: (+) Trousseaus or carpopeial spasm (+) Chvostecks sign Seizure Arrhythmia Chronic tetany

most feared complication

Loss of tooth enamel Photophobia & cataract formation GIT changes anorexia, n/v, general body malaise CNS changes memory impairment, irritability

Dx: Serum calcium decrease (N 8.5 11 mg/100ml) Serum phosphate increase (N 2.5 4.5 mg/100ml) X-ray of long bone decrease bone density CT Scan reveals degeneration of basal ganglia

Nsg Mgt: Administration of meds: Acute tetany Ca gluconate IV, slowly Chronic tetany Oral Ca supplements Ex. Ca gluconate Ca carbonate Ca lactate

Vit D (Cholecalciferol)

Drug

diet

sunlight

Cholecalceferol

calcidiol

calcitriol

7am 9am

Phosphate binder Alumminum DH gel (ampho gel) SE constipation Antacid AAC Aluminum containing acids Aluminum OH gel Constipation

MAD Mg containing antacids Ex. Milk or magnesia Diarrhea

Maalox magnesium & aluminum - Less s/e 2. Avoid precipitating stimulus such as bright lights & noise: photophobia leading to seizure 3. Diet increase Ca & decrease phosphorus - Dont give milk due to increase phosphorus Good = anchovies increase Ca, decrease phosphorus + inc uric acid. Tuna & green turnipsInc Ca. 4. Bedside tracheostomy set due to laryngospasm 5. Encourage to breathe with paper bag in order to produce mild respiratory acidosis to promote increase ionized Ca levels 6. Most feared complication : Seizure & arrhythmia 7. Hormonal replacement therapy - lifetime 8. Important follow up care

HYPERPARATHYROIDISM - increase parathormone. Complication: Renal failure Hypercalcemia can lead to Hypophosphatemia

Bone dse Mineralization

kidney stones

Leading to bone fracture

Ca 99% bones 1% serum blood

Predisposing Factors:

Hyperplasia parathyroid gland (PTG) Over compensation of PTG due to Vit D deficiency

Children Rickets Adults Osteomalacia

Vit D deficiency

Sippys diet Vit D diet not good for pt with ulcer 2 -4 cups of milk & butter Karrels diet Vit D diet not good for pt with ulcer 6 cups of milk & whole cream

Food rich in CHON eggnog combination of egg & milk

S/Sx: Bone fracture Bone pain (especially at back), bone fracture Kidney stone Renal colic Cool moist skin GIT changes anorexia, n/v, ulcerations CNS involvement irritability, memory impairment

Dx Proc: Serum Ca increase Serum phosphorus decreases X-ray long bones reveals bone demineralization

Nsg Mgt: Kidney Stone Force fluids 2,000 3,000/day or 2-3L/day Isotonic solution Warm sitz bath for comfort Strain all urine with gauze pad Acid ash diet cranberry, plum, grapefruit, vit C, calamansi to acidify urine Adm meds

Narcotic analgesic Morphine SO4, Demerol (Meperidine Hcl)

S/E resp depression. Monitor RR) Narcan/ Naloxone antidote Naloxone toxicity tremors Siderails Assist in ambulation Diet low in Ca, increase phosphorus lean meat Prevent complication Most feared renal failure Assist surgical procedure parathyroidectomy Impt ff up care Hormonal replacement- lifetime

PANCREAS behind the stomach, mixed gland both endocrine and exocrine gland Acinar cells (exocrine gland) Secrete pancreatic juices at pancreatic ducts. Islets of Langerhans (endocrine gland ductless) cells secrets glucagon Fxn: hyperglycemia (high glucose)

Aids in digestion (in stomach)

Cells Secrets insulin Fxn: hypoglycemia Delta Cells Secrets somatostatin

Fxn: antagonizes growth hormone

3 disorders of the Pancreas

DM Pancreatic Cancer Pancreatitis

PANCREATITIS acute inflammation of pancreas leading to pancreatic edema, hemorrhage & necrosis due to Autodigestion self-digestion Cause: unknown/idiopathic Or alcoholism Pathognomonic sign- (+) Cullens sign - Ecchymosis of umbilicus (bluish color)- pasa (+) Grey turners sign ecchymosis of flank area

Both sx means hemorrhage

CHRONIC HEMORRHAGIC PANCREATITISbangungot Predisposing factors - unknown Risk factor:

History of hepatobiliary disorder Alcohol Drugs thiazide diuretics, oral contraceptives, aspirin, penthan Obesity Hyperlipidemia Hyperthyroidism High intake of fatty food saturated fats

DIABETES MELLITUS - metabolic disorder characterized by non utilization of CHO, CHON,& fat metabolism Classification: Type I DM (IDDM) destruction of the pancreatic beta cells Juvenile onset, common in children -Insulin dependent diabetes mellitus Incidence rate 10% of population with DM have Type I Predisposing Factor: 90% hereditary total destruction of pancreatic dells Virus Toxicity to carbon tetrachloride Drugs Steroids both cause hyperglycemia Lasix - loop diuretics

S/Sx: 3 PS + G 1.) Polyuria 2.) Poydipsia 3.) Polyphagia 4.) Glycosuria 5.) Weight loss 6.) Anorexia 7.) N/V 8.) Blurring of vision 9.) Increase susceptibility to infection 10.) Delayed/ poor wound healing

Mgt: Insulin Therapy Diet Exercise Complications Diabetic Ketoacidosis (DKA) Diabetic Ketoacidosis (DKA) due to increase fat catabolism or breakdown of fats DKA (+) fruity or acetone breath odor Kussmauls respiration rapid, shallow breathing Diabetic coma (needs oxygen)

Type II DM (NIDDM) Relative lack of insulin or resistance to the action of insulin Adult/ maturity onset type age 40 & above, obese Incidence Rate 90% of pop with DM have Type II Mid 1980s marked increase in type II because of increase proliferation of fast food chains! Predisposing Factor: Obesity obese people lack insulin receptors binding site Hereditary S/Sx: Asymptomatic 3 Ps and 1G

Tx: Oral Hypoglycemic Agents (OHA) Diet Exercise

Complication: HONKC H hyper O osmolar N non K ketotic C coma

3 MAIN FOOD GROUPS 1. CHO 2. CHON 3. Fats Ketones glucose amino acids fatty acids glycogen nitrogen free fatty acids (FFA) Cholesterol &

Pancreas glucose ATP (Main fuel/energy of cell ) Reserve glucose glycogen Liver will undergo glucogenesis synthesis of glucagons & Glycogenolysis breakdown of glucagons & Gluconeogenesis formation of glucose form CHO sources CHON & fats

Hyperglycemia pancreas will not release insulin. Glucose cant go to cell, stays at circulation causing hyperglycemia. increase osmotic diuresis glycosuria Lead to cellular starvation

Lead to wt loss

stimulates the appetite/ satiety center polyuria (Hypothalamus) Cellular dehydration Polyphagia Stimulates thirst center (hypothalamus) Polydipsia

Increased CHON catabolism Lead to (-) nitrogen balance

Tissue wasting (cachexia)

Increase fat catabolism Free fatty acids Cholesterol ketones DKA coma death

Atherosclerosis

HPN

MI

stroke

DIABETIC KETOACIDOSIS (DKA) Acute complication of Type I DM due to severe hyperglycemia leading to CNS depression & Coma. Ketones- a CNS depressant Predisposing factor:

Stress between stress and infection, stress causes DKA more. Hyperglycemia Infection

S/Sx: 3 Ps & 1G Polyuria Polydipsia Polyphagia Glycosuria Wt loss Anorexia, N/V (+) Acetone breath odor- fruity odor --pathognomonic DKA Kussmaul's resp-rapid shallow respiration CNS depression Coma

Dx Proc: FBS increase, Hct increase (compensate due to dehydration) N =BUN 10 -20 mg/100ml --increased due to severe dehydration Crea - .8 1 mg/100ml Hct 42% (should be 3x high)-nto hgb

Nsg Mgt: Can lead to coma assist mechanical ventilation Administer .9NaCl isotonic solution Followed by .45NaCl hypotonic solution To counteract dehydration. Monitor VS, I&O, blood sugar levels Administer meds as ordered: Insulin therapy IV push Regular Acting Insulin clear (2-4hrs, peak action) To counteract acidosis Na HCO3 Antibiotic to prevent infection
Insulin Therapy Sources: Animal source beef/ pork-rarely used. Causes severe allergic reaction. Human has less antigenecity property Cause less allergic reaction. Humulin If kid is allergic to chicken dont give measles vaccine due it comes from chicken embryo. Artificially compound

Types of Insulin Rapid Acting Insulin - Ex. Regular acting I Intermediate acting I - Ex. NPH (non-protamine Hagedorn I) Long acting I - Ex. Ultra lente Types of Insulin 1. Rapid-acting 5 Humalog, Novolog 2. Short-acting Regular (Humulin R, Novolin R) 2. Intermediate NPH (Humulin N) Lente (Humulin L) 3. Long acting Ultralente (Humulin U) onset peak 15 minutes duration

to 1

4-

5 to 10 minutes

to 1 hour

2-4

5-7

1-2 hours 1-3 hours 6 hours

6-14 6-14

24 24 18-24

36

Ex. 5am Hemoglucose test (HGT)

250 mg/dl Adm 5 units of RA I Peak 5:30-6:30 monitor hypoglycemic reaction at this time- TIRED

Nsg Mgt: upon injection of insulin: 1.Administer insulin at room temp! To prevent lipodystrophy = atrophy/ hypertrophy of SQ tissues 2. Insulin is only refrigerated once opened! 3. Gently roll vial bet palms. Avoid shaking to prevent formation of bubbles. 4. Use gauge 25 26needle tuberculin syringe 5. Administer insulin at either 45(for skinny pt) or 90 (taba pt)depending on the client tissue deposit. 6. Dont aspirate after injection 7. Rotate injection site to prevent lipodystrophy 8. Most accessible site abdomen 9. When mixing 2 types of insulin, aspirate 1st regular/ clear before cloudy to prevent contaminating clear insulin & to promote accurate calibration. 10. Monitor signs of complications: a. Allergic reactions lipodystrophy b. Somogyis phenomenon normal or elevated blood glucose levels are present at bedtime; hypoglycemia occurs at 2 to 3 am. By 7 am, hyperglycemia rebounds significantly 11. 1ml or cc of tuberculin = 100 units of insulin

Most Feared Complication of Type II DM

Hyper osmolarity = severe dehydration

Osmolar Non - absence of lipolysis Ketotic - no ketone formation Coma S/Sx: headache, restlessness, seizure, decrease LOC = coma

Nsg Mgt; - same as DKA except dont give NaHCO3! 1.Can lead to coma assist mechanical ventilation 2. Administer .9NaCl isotonic solution Followed by .45NaCl hypotonic solution To counteract dehydration. 3.Monitor VS, I&O, blood sugar levels 4.Administer meds

Insulin therapy IV Antibiotic to prevent infection

Tx: O ral H ypoglycemic A gents Stimulates pancreas to secrete insulin

Classifications of OHA First generation Sulfonylureas

Chlorpropamide (diabenese) Tolbutamide (orinase) Tolazamide (tolinase)

2nd generation sulfonylurea Diabeta (Micronase) Glipizide (Glucotrol)

Non sulfonylureas Acarbose (Precose) Metformin (Glucophage) Rosiglitazone (Avandia)

Nsg Mgt or OHA Administer with meals to lessen GIT irritation & prevent hypoglycemia Avoid alcohol (alcohol + OHA = severe hypoglycemic reaction=CNS depression=coma) Antabuse-Disulfiram Dx for DM FBS N 80 120 mg/dl = Increased for 3 consecutive times =confirms DM!! + 3 Ps & 1G Oral glucose tolerance (OGTT) - Most sensitive test Random blood sugar increased Alpha Glycosylated Hgb elevated (N 4% to 6%)

Nsg Mgt; Monitor for PEAK action of OHA & insulin Notify Doc Monitor VS, I&O, neurocheck, blood sugar levels. Administer insulin & OHA therapy as ordered. Monitor signs of hyper & hypoglycemia. Pt DM hinimatay You dont know if hypo or hyperglycemia. Give simple sugar (Brain can tolerate high sugar, but brain cant tolerate low sugar!) Cold, clammy skin hypo Orange Juice or simple sugar / warm to touch hyper adm insulin Provide nutritional intake of diabetic diet: CHO 50% CHON 30% Fats 20% -Or offer alternative food products or beverage. -Glass of orange juice.

Exercise after meals when blood glucose is rising. Monitor complications of DM Atherosclerosis HPN, MI, CVA Microangiopathy small blood vessels Eyes diabetic retinopathy , premature cataract & blindness Kidneys recurrent pyelonephritis & Renal Failure (2 common causes of Renal Failure : DM & HPN) Gangrene formation Peripheral neuropathy
Diarrhea/ constipation Sexual impotence

Shock due to cellular dehydration Foot care mgt

Avoid waking barefooted Cut toe nails straight Apply lanolin lotion prevent skin breakdown Avoid wearing constrictive garments

Annual eye & kidney exam Monitor urinalysis for presence of ketones Blood or serum more accurate Assist in surgical wound debridement Monitor signs or DKA & HONKC Assist surgical procedure BKA or above knee amputation

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