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
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Understanding Medical Surgical Nursing, 4th Edition
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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

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

Pituitary Tumor or Trauma
Drugs
Psychogenic
Nephrogenic
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Signs and Symptoms
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Polyuria
Polydipsia
Nocturia
Dilute Urine




Dehydration
Hypovolemic Shock
Decreased LOC
Death
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Diagnosis
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Urine Specific Gravity <1.001
Plasma Osmolality Increased
CT or MRI for Cause
Water Deprivation Test
ADH
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Therapeutic Interventions
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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

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
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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
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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

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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
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Pituitary Tumor
Failure of Pituitary to Develop
Psychosocial
Malnutrition
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Signs and Symptoms
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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
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 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
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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

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TH Deficiency
Metabolic Rate Reduced
Primary = Not Enough TH
Secondary = Not Enough TSH
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Causes
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Congenital
Inflammatory
Iodine Deficiency
Thyroidectomy
Autoimmune (Hashimoto’s Thyroiditis)
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Signs and Symptoms
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Fatigue
Bradycardia
Constipation
Mental Dullness
Cold Intolerance
Hypoventilation
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Dry Skin and Hair
Weight Gain
Heart Failure
Hyperlipidemia
Myxedema
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Complications
 Myxedema Coma
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Hypothermia
Decreased VS and LOC
Respiratory Failure
Death
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Diagnosis

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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
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Activity Intolerance
Constipation
Risk for Impaired Skin Integrity
Imbalanced Nutrition
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Hyperthyroidism
 Pathophysiology



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Increased Metabolic Rate
Increased Beta Receptors
Primary = Too Much TH
Secondary = Too Much TSH
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Causes
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
Autoimmune (Grave’s Disease)
Multinodular Goiter
Toxic Adenoma
Thyroiditis
Pituitary Tumor (Secondary)
Synthroid Overdose
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Signs and Symptoms
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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
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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)



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Tachycardia, Hypertension
Fever, Dehydration
Coma
Death
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Therapeutic Interventions
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PTU
Tapazole
Propranolol (Inderal)
Oral Iodine
Radioactive Iodine (I 131)
Thyroidectomy
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Therapeutic Interventions for
Thyrotoxic Crisis
 IV Fluids


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Cooling Blanket
Iodine
Propranolol (Inderal)
Acetaminophen (Avoid ASA) for Fever
Oxygen
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Nursing Diagnoses


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
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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
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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
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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

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

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

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Hyperplasia
Radiation
Iodine Deficiency
Goitrogens
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Signs and Symptoms

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

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
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


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
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Fatigue
Depression
Confusion
Nausea and Vomiting
Kidney Stones

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Joint Pain
Pathologic Fractures
Dysrhythmias
Coma
Cardiac Arrest
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Diagnosis

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

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



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
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


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
Monitor VS
Quiet, Calm Environment
No Caffeine
Replacement Corticosteroids Postop
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Adrenal Cortex Hormone
Imbalance
 Hyposecretion = Addison’s Disease
 Hypersecretion = Cushing’s Syndrome
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Addison’s Disease
 Pathophysiology
 Deficient Cortisol
 and/or Aldosterone
 and/or Androgens
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Causes
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Autoimmune
AIDS
CA
Pituitary or Hypothalamus Problem
Abrupt Discontinuance of Steroids
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Signs and Symptoms
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Hypotension
Sodium Loss
Potassium Retention
Hypoglycemia

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Weakness
Fatigue
Bronze Skin
Nausea and Vomiting
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Diagnosis
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Serum and Urine Cortisol Level
Blood Glucose
Electrolytes
BUN/HCT
ACTH Stimulation Test
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Complications
 Adrenal Crisis
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Profound Dehydration
Hypotension
Hypoglycemia
Shock
Coma
Death
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
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
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Nursing Diagnoses
 Risk for Deficient Fluid Volume
 Risk for Ineffective Self-Health
Management
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Crisis Prevention
NEVER ABRUPTLY
DISCONTINUE STEROIDS!
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Cushing’s Syndrome
 Pathyphysiology
 Excess Adrenal Cortex Hormones
 Cortisol
 Aldosterone
 Androgens
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Causes
 Hypersecretion of ACTH
 Hypersecretion of Cortisol
 Prolonged Use of Exogenous
Glucocorticoids
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Signs and Symptoms
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Signs and Symptoms (cont’d)
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Salt and Water Retention
Hypokalemia
Thin, Fragile Skin
Acne
Facial Hair in Women
Amenorrhea
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Diagnosis
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
Based on Appearance
Plasma and Urine Cortisol
ACTH
Dexamethasone Suppression Test
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Therapeutic Interventions
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Surgery if Tumor
Reduce Dose of Steroid
Change Schedule of Administration
Symptom Control
Diabetes Treatment
Low-sodium, High-potassium Diet
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Nursing Diagnoses
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
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Risk for Excess Fluid Volume
Risk for Impaired Skin Integrity
Risk for Infection
Risk for Unstable Blood Glucose
Body Image Disturbance
Copyright © 2011. F.A. Davis Company
Understanding Medical Surgical Nursing, 4th Edition
Linda S. Williams / Paula D. Hopper
Adrenalectomy
 Preoperative Care
 Monitor Electrolytes, Glucose
 Preoperative Teaching
 Postoperative Care
 Monitor for Adrenal Crisis
 Lifelong Hormone Replacement
Copyright © 2011. F.A. Davis Company