Chapter 37 Nursing Care of Patients with Endocrine Disorders
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Transcript Chapter 37 Nursing Care of Patients with Endocrine Disorders
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Chapter 39
Nursing Care of Patients
with Endocrine Disorders
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Endocrine Disorders
Too Much or Too Little Hormone Activity
Production/Secretion
Tissue Sensitivity
Primary Disorder
Secondary Disorder
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ADH
Too Little = Diabetes Insipidus
Too Much = SIADH
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Diabetes Insipidus
Pathophysiology
Insufficient ADH
Kidneys Do Not Reabsorb Water
Diurese 3–15 L per Day
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Causes
Pituitary Tumor or Trauma
Drugs
Psychogenic
Nephrogenic
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Signs and Symptoms
Polyuria
Polydipsia
Nocturia
Dilute Urine
Dehydration
Hypovolemic Shock
Decreased LOC
Death
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Diagnosis
Urine Specific Gravity <1.001
Plasma Osmolality Increased
CT or MRI for Cause
Water Deprivation Test
ADH
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Therapeutic Interventions
Hypotonic IV Fluids
Hypophysectomy if Tumor
IV or SQ Vasopressin
Intranasal DDAVP
Thiazide Diuretics if Nephrogenic
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Nursing Diagnoses
Risk for Deficient Fluid Volume
Risk for Ineffective Self Health
Management
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SIADH
Pathophysiology
Too Much ADH
Water Retention
Hyponatremia
Decreased Serum Osmolality
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Causes
Cancers
Bronchogenic Lung Cancer
Drugs
Head Trauma
Brain Tumor
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Signs and Symptoms
Weight Gain Without Edema
Dilutional Hyponatremia
Serum Osmolality <275 mOsm/kg
Concentrated Urine
Muscle Cramps and Weakness
Brain Swelling, Seizures, Death
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Diagnostic Tests
Serum/Urine Sodium
Serum/Urine Osmolality
Water Load Test
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Therapeutic Interventions
Eliminate Cause
Surgical Removal of Tumor
Fluid Restriction
Hypertonic Saline IV
Lasix or Declomycin
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Nursing Diagnoses
Excess Fluid Volume
Risk for Ineffective Self Health
Management
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Growth Hormone Imbalance
Too Little = Short
Stature
Too Much =
Gigantism,
Acromegaly
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Growth Hormone Deficiency
Pathophysiology
Deficient GH in Childhood
Growth Not Affected in Adults
Causes
Pituitary Tumor
Failure of Pituitary to Develop
Psychosocial
Malnutrition
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Signs and Symptoms
Grow Only to 3 to 4 Feet (5th Percentile)
Slowed Sexual Maturation
May Have Mental Retardation
Other Symptoms, Depending on Other
Pituitary Hormones Involved
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Signs and Symptoms in Adults
Fatigue, Weakness
Excess Body Fat
Hypercholesterolemia
Decreased Muscle
and Bone Mass
Sexual Dysfunction
Risk for
Cardiovascular
Disease
Risk for
Cerebrovascular
Disease
Decreased Quality of
Life
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Diagnosis
GH Level
GH Response to Induced Hypoglycemia
MRI for Tumor
X-Rays
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Therapeutic Interventions
Synthetic GH (Somatrem) SQ or IM
Surgery if Tumor
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Nursing Diagnosis
Risk for Ineffective Self Health
Management
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Acromegaly
Pathophysiology
Excess Growth Hormone in Adults
Bones Grow in Width, Not Length
Organs and Connective Tissues Also Enlarge
Causes
Pituitary Hyperplasia
Pituitary Tumor
Hypothalamic Dysfunction
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Signs and Symptoms
Change in Shoe or
Ring Size
Nose, Jaw, Brow
Enlarge
Teeth May Be
Displaced
Difficulty Speaking
and Swallowing
Sleep Apnea
Headaches, Visual
Changes
Diabetes Mellitus
Arthritis
Sexual Dysfunction
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Example of Acromegaly
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Diagnosis
GH Level
GH Response to Oral Glucose
Bone X-Rays
CT Scan or MRI
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Therapeutic Interventions
Treat Cause
Hypophysectomy
Lifelong TH, Steroid, Sex Hormone
Replacement
Octreotide (Sandostatin)
Bromocriptine (Parlodel)
Pegvisomant (Somavert)
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Hypophysectomy
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Nursing Diagnoses
Disturbed Body Image
Risk for Injury
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Care of the Patient Undergoing
Hypophysectomy
Baseline Neurological Assessment
Preoperative Teaching
Deep Breathing, Incentive Spirometry
Avoid Coughing, Sneezing, Straining Postop
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Postoperative Care
Neurologic Assessment
Urine for Specific Gravity (Risk for DI)
Nasal Packing and Mustache Dressing
No Coughing, Sneezing, Blowing,
Straining, Bending
Report CSF Drainage
HRT with Target Hormones
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Patient Education
Blow Nose Gently
Take Stool Softeners and Antitussives prn
Care with Brushing Teeth
Take Hormones as Prescribed
Call if Fever, Drainage, Frequent Urination,
Thirst
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Thyroid Hormone Imbalance
Hypothyroidism
Hyperthyroidism
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Hypothyroidism
Pathophysiology
TH Deficiency
Metabolic Rate Reduced
Primary = Not Enough TH
Secondary = Not Enough TSH
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Causes
Congenital
Inflammatory
Iodine Deficiency
Thyroidectomy
Autoimmune (Hashimoto’s Thyroiditis)
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Signs and Symptoms
Fatigue
Bradycardia
Constipation
Mental Dullness
Cold Intolerance
Hypoventilation
Dry Skin and Hair
Weight Gain
Heart Failure
Hyperlipidemia
Myxedema
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Complications
Myxedema Coma
Hypothermia
Decreased VS and LOC
Respiratory Failure
Death
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Diagnosis
T3 and T4 Low
TSH High in Primary
TSH Low in Secondary
Serum Cholesterol and Triglycerides
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Therapeutic Interventions
Hormone
Levothyroxine/Synthroid
Maintain 0.1–0.2 mg/day
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Therapeutic Interventions for
Myxedema Coma
Monitor VS
Warming Blanket
Mechanical Ventilation
IV Levothyroxine (Synthroid)
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Nursing Diagnoses
Activity Intolerance
Constipation
Risk for Impaired Skin Integrity
Imbalanced Nutrition
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Hyperthyroidism
Pathophysiology
Increased Metabolic Rate
Increased Beta Receptors
Primary = Too Much TH
Secondary = Too Much TSH
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Causes
Autoimmune (Grave’s Disease)
Multinodular Goiter
Toxic Adenoma
Thyroiditis
Pituitary Tumor (Secondary)
Synthroid Overdose
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Signs and Symptoms
Hypermetabolic State
Heat Intolerance
Increased Appetite
Weight Loss
Frequent Stools
Nervousness
Tachycardia,
Palpitations
Tremor
Heart Failure
Warm Smooth Skin
Exophthalmos
(Grave’s Disease)
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Exophthalmos
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Signs and Symptoms in Elderly
Heart Failure
Atrial Fibrillation
Fatigue
Apathy
Depression
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Diagnosis
Elevated T3 and T4
TSH Low in Primary
TSH High in Secondary
TRH Stimulation Test
TSI
CT/MRI if Tumor Suspected
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Complications
Thyrotoxic Crisis (Thyroid Storm)
Tachycardia, Hypertension
Fever, Dehydration
Coma
Death
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Therapeutic Interventions
PTU
Tapazole
Propranolol (Inderal)
Oral Iodine
Radioactive Iodine (I 131)
Thyroidectomy
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Therapeutic Interventions for
Thyrotoxic Crisis
IV Fluids
Cooling Blanket
Iodine
Propranolol (Inderal)
Acetaminophen (Avoid ASA) for Fever
Oxygen
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Nursing Diagnoses
Hyperthermia
Diarrhea
Imbalanced Nutrition
Disturbed Sleep Pattern
Anxiety
Risk for Injury
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Nursing Care of the Patient
Receiving Radioactive Iodine
In Hospital
Limit Time Spent with
Patient
Glove and Gown
Avoid if Pregnant
Take Precautions
with Urine, Emesis,
Body Fluids
Double Flush Toilet
Call RSO for Emesis
or Incontinence
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Nursing Care of the Patient
Receiving Radioactive Iodine
(cont’d)
At Home
Avoid Close Contact for a Week
Sleep Alone
Wash Hands Carefully After Urinating
Avoid Oral Contact
Drink Fluids
Avoid Pregnancy for at Least a Year
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Goiter
Pathophysiology
Enlarged Thyroid
Gland
Elevated TSH
Hyperplasia
Causes
Low TH
Iodine Deficiency
Virus
Genetic
Goitrogens
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Signs and Symptoms
Enlarged Thyroid
Hypo or Hyperthyroid,
or Euthyroid
Dysphagia
Difficulty Breathing
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Diagnosis
Thyroid Scan
TSH, T3, and T4
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Therapeutic Interventions
Treat Cause
Avoid Goitrogens
Treat Hypo or Hyperthyroidism
Thyroidectomy if Size Causing Symptoms
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Nursing Care
Monitor Breathing (Stridor)
Swallowing Evaluation
Dietary Consult
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Cancer of the Thyroid Gland
Tumor of the Thyroid Gland
Usually Benign
More Common in Women
Causes
Hyperplasia
Radiation
Iodine Deficiency
Goitrogens
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Signs and Symptoms
Hard Painless Nodule
Dysphagia
Dyspnea if Obstruction
TH Usually Normal
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Diagnosis
Thyroid Scan Shows “Cold Spot”
Biopsy
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Therapeutic Interventions
Radioactive Iodine
Chemotherapy
Thyroidectomy (Partial or Total)
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Thyroidectomy
Preoperative Nursing Care
Monitor Breathing and Swallowing
Assess Nutrition Status
Monitor Vital Signs
Iodine or Antithyroid Drugs to Achieve
Euthyroid State
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Preoperative Teaching
Teach Postop Care
Gentle ROM
Support Neck During Position Changes
Incentive Spirometer
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Postoperative Diagnoses
Risk for Ineffective Airway Clearance
Risk for Injury: Tetany,Thyrotoxic Crisis
Acute Pain
Risk for Ineffective Self Health
Management
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Complications
Thyrotoxic Crisis
Tetany
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Parathyroid Hormone
Hypoparathyroidism
Hyperparathyroidism
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Hypoparathyroidism
Pathophysiology
Decrease in PTH
Calcium Stays in Bones
Hypocalcemia
Hyperphosphatemia
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Causes
Heredity
Accidental Removal of Parathyroids During
Thyroidectomy
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Signs and Symptoms
Tetany
Neuromuscular Irritability
Numbness and Tingling of Fingers and Perioral Area
Muscle Spasms
Cardiac Dysrhythmias
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Signs and Symptoms (cont’d)
Positive Chvostek’s
Sign
Positive Trousseau’s
Sign
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Diagnosis
PTH Low
Serum Calcium Low
Positive Chvostek’s Sign
Positive Trousseau’s Sign
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Therapeutic Interventions
Acute
IV Calcium Gluconate
Long Term
Calcium with Vitamin D
Thiazide Diuretics
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Nursing Diagnosis
Risk for Injury: Hypocalcemia and Tetany
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Hyperparathyroidism
Pathophysiology
Parathyroid Overactivity
Increased PTH
Hypercalcemia
Hypophosphatemia
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Causes
Parathyroid Hyperplasia
Benign Parathyroid Tumor
Heredity
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Signs and Symptoms
Fatigue
Depression
Confusion
Nausea and Vomiting
Kidney Stones
Joint Pain
Pathologic Fractures
Dysrhythmias
Coma
Cardiac Arrest
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Diagnosis
Serum Calcium Elevated
24-Hour Urine for Calcium
Phosphate Decreased
PTH Elevated
X-Rays for Bone Density
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Therapeutic Interventions
IV NS to Dilute Calcium
Furosemide (Lasix)
Calcitonin, Alendronate
Estrogen Therapy (Women)
Parathyroidectomy
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Nursing Diagnosis
Risk for Injury: Fracture, Complications of
Hypercalcemia
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Adrenal Medulla Disorders
Pheochromocytoma
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Pheochromocytoma
Tumor of Chromaffin Cells of Adrenal
Medulla
Secretes Epinephrine and Norepinephrine
Usually Benign
Cause Unknown
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Signs and Symptoms
Fight or Flight
Hypertension
Tachycardia
Palpitations
Tremor
Diaphoresis
Anxiety
Hyperglycemia
Headache
Vision Changes
Risk for Stroke
Risk for Organ
Damage
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Diagnosis
24-Hour Urine for Metanephrines and VMA
No Caffeine or Medications Before Test
CT or MRI to Find Tumor
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Therapeutic Interventions
Beta Blockers (Propranolol [Inderal])
Alpha Blockers (Phenoxybenzamine
[Dibenzyline])
Adrenalectomy
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Nursing Diagnosis
Risk for Injury Related to Hypertensive
Crisis
Monitor VS
Quiet, Calm Environment
No Caffeine
Replacement Corticosteroids Postop
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Adrenal Cortex Hormone
Imbalance
Hyposecretion = Addison’s Disease
Hypersecretion = Cushing’s Syndrome
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Addison’s Disease
Pathophysiology
Deficient Cortisol
and/or Aldosterone
and/or Androgens
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Causes
Autoimmune
AIDS
CA
Pituitary or Hypothalamus Problem
Abrupt Discontinuance of Steroids
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Signs and Symptoms
Hypotension
Sodium Loss
Potassium Retention
Hypoglycemia
Weakness
Fatigue
Bronze Skin
Nausea and Vomiting
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Diagnosis
Serum and Urine Cortisol Level
Blood Glucose
Electrolytes
BUN/HCT
ACTH Stimulation Test
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Complications
Adrenal Crisis
Profound Dehydration
Hypotension
Hypoglycemia
Shock
Coma
Death
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Therapeutic Interventions
Glucocorticoids and Mineralocorticoids
Daily for Life
Two-thirds in AM, One-third in PM
Double or Triple in Times of Stress
May Be Placed on High Sodium Diet
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Nursing Diagnoses
Risk for Deficient Fluid Volume
Risk for Ineffective Self-Health
Management
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Crisis Prevention
NEVER ABRUPTLY
DISCONTINUE STEROIDS!
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Cushing’s Syndrome
Pathyphysiology
Excess Adrenal Cortex Hormones
Cortisol
Aldosterone
Androgens
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Causes
Hypersecretion of ACTH
Hypersecretion of Cortisol
Prolonged Use of Exogenous
Glucocorticoids
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Signs and Symptoms
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Signs and Symptoms (cont’d)
Salt and Water Retention
Hypokalemia
Thin, Fragile Skin
Acne
Facial Hair in Women
Amenorrhea
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Diagnosis
Based on Appearance
Plasma and Urine Cortisol
ACTH
Dexamethasone Suppression Test
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Therapeutic Interventions
Surgery if Tumor
Reduce Dose of Steroid
Change Schedule of Administration
Symptom Control
Diabetes Treatment
Low-sodium, High-potassium Diet
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Nursing Diagnoses
Risk for Excess Fluid Volume
Risk for Impaired Skin Integrity
Risk for Infection
Risk for Unstable Blood Glucose
Body Image Disturbance
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Adrenalectomy
Preoperative Care
Monitor Electrolytes, Glucose
Preoperative Teaching
Postoperative Care
Monitor for Adrenal Crisis
Lifelong Hormone Replacement
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