NUR 329 ADULT II ENDOCRINE DISORDERS I

NUR 330 ADULT II Handout # IASSESSMENT OF THE ENDOCRINE SYSTEMNegative Feedback: EX: pancreas secretes insulin when eating, enough to bring glucose back to normal and then it stops; similar to a thermostatA & P Review: Endocrine problems are serious, life-long and require medical managementGeneral Nursing Assessments:

Prodromal S/S ;

GENERAL INTERVENTIONS: Life-long Therapy:

Hypofunction: Manage with replacement therapy; make sure dont get too much; teach

manifestations if body gets too much.Hyperfunction: more difficult to achieve homeostasis; usually means surgery causing some Destruction of gland or removal/partial removal of gland Management of Complications: consistent follow up care (frequent assessment, lab work, diagnostic

Tests); strict compliance of medical regimenComfort Measures: Emotional and/or physiological, give positive feedbackPatient Education: Educate on side effects, meds, follow-up care, self management skillsDIAGNOSTIC TESTING AND NURSING ROLES:

STIMULATION trying to stimulate gland; usually uses releasing hormones; EX: give patient

thyroid releasing hormone and expect T3 & T4 to be released. If released then gland is normal and the problem is with the pituitary, if it didnt respond then the problem is with the gland.

SUPPRESSION assesses negative feedback system and if working properly or not; EX: in previous example, if gland keeps producing then its either overactive or negative feedback isnt working.RADIOGRAPHIC STUDIES:

X-Rays

Nuclear Imaging Studies

CT Scans/MRIs

SERUM STUDIES:

Electrolytes

Blood Chemistries

Hematology

Handout 2CARE OF PATIENTS WITH PITUITARY AND ADRENAL GLAND PROBLEMSOverview of Pituitary Gland and Hormones:ANTERIOR PITUITARY:Major Hormone GROWTH HORMONE (GH)

Hyperpituitarism Secretion of too much GH (usually r/t a tumor)

If growth plates have NOT closed= Gigantism

If growth plates have closed= Acromegaly Assessment

Increased lip & nose size

Think and more prominent brow bones

Increases in head, hand, and foot sizes

Backache & arthralgias (joint pain)

Become hyperglycemicInterventions

Drugs= dopamine agonists (Bromocriptine)

Hypophysectomy (removal of pituitary gland)

Post-op:

Monitor neuro status hourly first 24 hrs then q4h Keep HOB elevated

Monitor fluid balance (output greater than intake may cause transient DI)

Deep-breathing exercises hourly while awake

Do NOT cough, blow nose, or sneeze

Use dental floss & oral mouth rinses b/c teeth brushing is not allowed

Avoid bending at the waist

Monitor nasal drip pad (a light yellow color is called the halo sign indicates CSF fluid).Hypopituitarism insufficient secretion of GH (results in dwarfism)

Assessment Decreased bone density

Pathologic fractures

Decreased muscle strength

Increased cholesterol levelsInterventions

Injections of GH but is very expensivePOSTERIOR PITUITARY:

Major Hormone VASOPRESSIN (ADH)

Hyperfunction SIADHAssessment Loss of appetite, N/V may occur first

Decreased urination Fluid retention

Dilutional Hyponatremia

Concentrated urine

Lethargy, HA, change in LOC, hostility, & disorientation

Full, bounding pulse & hypothermiaInterventions

Fluid restriction, I&O, & daily weights Keep mucous membranes moist by offering frequent oral rinsing

DRUGS:

Vasopression: promotes water excretion w/out causing sodium loss

Diuretics: when sodium levels are near normal

Hypertonic saline (3%NaCl) can be used when sodium level is very low

Monitor for increased fluid overload q2h

Assess for subtle changes such as muscle twitching before they progress to seizure/coma

Reduce environmental noise & lighting to prevent overstimulation

Perform neuro checks q4h for pt. who is hyponatremic but alert, awake, and oriented

Perform neuro checks q1h for pt. who has a change in LOC

Hypofunction DIABETES INSIPIDUS (DI)Assessment

Polyuria (increased urination)

Polydipsia (excessive thirst)

Hypotension

Tachycardia

Hyperthermia

RF: dehydrationInterventions

Dx: by injecting ADH

Drugs:

Vasopressin: polyuria & polydipsia are signals for needing another dose

Can lead to fluid overload

Replace fluids

I&O and daily weights

PITUITARY TUMORS (USUALLY CAUSING HYPERFUNCTION):

Assessment:

Anterior tumor

Posterior tumor

Diagnostic Tests

Medical Interventions: Usually surgery access through nose to the pituitary gland PRE-OP: tell pt. what to expect post-op, cant cough or sneeze, no toothbrush use, tell about medications

POST-OP: airway, bleeding, CSF leaking out (dont assume clear liquid is water), infection, painComplications of Hypophysectomy:

Transient diabetes insipidus

Monitor fluid balance

CSF leak

Increase HOB

Avoid coughing

Infection

Assess for manifestations of meningitis (HA, fever, and nuchal rigidity)

May need antibiotics, analgesics, and antipyretics

Increased ICP

Avoid bending at the waist

Avoid straining during bowel movements

Avoid activities that increase ICP for 2 months after surgeryADRENAL GLAND DISORDERS

Adrenal Cortex: secretes 3 things: 1.) mineralcorticoids (aldosterone) 2.) glucocorticoid (cortisol..cant function without cortisol) 3.) sex hormones (androgen & estrogen)Adrenal Medulla: secretes epinephrine and norepinephrine Cortical Hyperfunction CUSHINGS

Hormone: CORTISOLAssessment Water & sodium are retained Osteoporosis is common (increasing risk for fractures)

Fat redistribution

Buffalo hump

Moon face

Truncal obesity

Reddish purple striae (stretch marks) on abdomen, thighs, & upper arms

Hypertension & full bounding pulse

Hypervolemia & edema

Immunosuppression

LAB findings:

Increased glucose and sodium levels

Decreased lymphocyte count, calcium, and potassium levels.Interventions

Monitor for increased fluid overload q2h May need fluid & sodium restrictions

Urine specific gravity below 1.005 may indicate fluid overload

Rapid weight gain is the best indicator of fluid retention and overload

Daily weights

Keep skin clean and dry

Use soft toothbrush & electric shaver

Use lift sheet to move patient in bed

Anyone with upper respiratory tract infection who enters room must wear a mask

Perform pulmonary hygiene q2-4hr

Urge pt. to cough & deep breath or perform sustained maximum inhalations qhr while awakeCortical Hypofunction ADDISONS

Hormone: CORTISOLAssessment Lethargy, fatigue, & muscle weakness

Hypotension

tachycardia

Addisonian crisis (decreased sodium, increased potassium, hypovolemia) Happens with stopping of medsInterventions Replacement therapy

Most common drug is prednisone

Give 2/3 of dose in am and 1/3 in afternoon

Emergency care of addisonian crisis

Hormone replacement

Start rapid infusion of NS or dextrose 5% in NS

Initial dose of hydrocortisone is 100-300 mg or dexamethasone 4-12mg IV bolus

Infuse additional 100 mg of hydrocortisone by continuous IV drip over the next 8hrs

Give hydrocortisone 50 mg IM q12h Initiate an H2 histamine blocker IV for ulcer prevention

Hyperkalemia management

Administer insulin with dextrose in NS to shift potassium into cells

Administer potassium binding & excreting resin (Kayexalate)

Give loop or thiazide diuretics

Avoid potassium sparing diuretics as prescribed

Initiate potassium restriction

Monitor I&O

Monitor HR, rhythm, & ECG for manifestations of hyperkalemia (slow HR, heart block, tall peaked T waves, fibrillation, asystole)

Hypoglycemia management

Administer IV glucose as prescribed

Administer glucagon as needed & prescribed

Maintain IV access

Monitor blood glucose level hourly

Adrenal Medulla PHEOCHROMOCYTOMA

Hormone: catecholamine producing tumor (HYPERFUNCTIONING)Assessment Usually benign but atleast 10% are malignant Tumors produce store and release epinephrine & norepinephrine

Intermittent episodes of HTN

May have severe HA, palpitations, diaphoresis, flushing, apprehension, sense of impending doom, or chest pain during HTN episodesIntervention Surgery=main treatment (1 or both adrenal glands are removed)

HTN is most common serious complication after surgery

Monitor BP regularly

Place cuff consistently on same arm with pt in standing and lying position

DO not smoke, drink caffeine beverages, or change positions suddenly

DO NOT PALPATE the abdomen of a pt. with pheochromocytoma (this could trigger sever HTN by sudden release of catecholamines)

Provide a diet rich in calories, vitamins, & minerals

Nursing care after surgery is similar for pt. who has undergone adrenalectomyHYPERALDOSERONISM: (also known as CONNs syndrome)

Assessment Hypokalemia

Hypernatremia

Metabolic alkalosis

Hypertension

DX= lab studies, Xrays, & CT or MRI

Intervention-

Surgery is the most common= ADRENALECTOMY

Surgery is not performed until potassium levels are normal

Potassium sparing diuretic and aldactone antagonist are given to increase levelsNURSING CARE S/P ADRENALECTOMY:

Complications:

CORTICOSTEROID THERAPY:

Indications

Side Effects

Dosage and Tapering

Nursing Interventions -

Handout 3CARE OF PATIENTS WITH PROBLEMS OF THE THYROID AND PARATHYROID GLANDSTHE ROLES OF THYROID HORMONES AND IODINE:

T3 (TRIIODOTHYRONINE): more active and potent than T4, rapid metabolic affect, increased in hyperthyroidism and decreased in hypothyroidism

T4(THYROXINE): less active; may act as a circulating reservoir for T3TSH (FROM PITUITARY): thyroid stimulating hormone; have to be present to stimulate production of T3 & T4

TRH (FROM HYPOTHALMUS):

IODINE: Synthesis of thyroid hormone

CALCITONIN: thyroid hormone, helps to regulate levels of serum calciumASSESSMENT OF THYROID GLAND:

DIAGNOSTIC TESTING OF THYROID FUNCTION AND THE NURSES ROLE:

THYROID FUNCTION TESTS: TFT free T3 (which means unbound T3) and TSHRADIOACTIVE IODINE UPTAKE: Small levels of radioactive iodine injected. Will accumulate in thyroid gland if hyperactive; if not hyperactive and no tumor present there wont be an excessive accumulationNEEDLE BIOPSY: reserved for suspected tumors, nursing concerns= bleeding b/c thyroid gland is vascularRADIOGRAPIC/NUCLEAR MEDICINE TESTS:

THYROID SCAN

CT/MRI

ULTRASOUND

HYPERFUNCTION = HYPERTHYROIDISM:GRAVES DISEASE: Autoimmune disorder caused by immunoglobulins stimulating TSH receptors Increased production of T3 & T4 leading to hyperthyroidism

Second common endocrine disorder (DM is first)ASSESSMENT/THYROTOXICOSIS: Manifestations of hyperthyroidism are called THYROTOXICOSIS

Hallmark=HEAT INTOLERANCE

Diaphoresis

Hyperglycemia

Hypermetabolism

Goiter

Exophthalmos

Chest pain/ palpitations

Increases systolic BP

Tachycardia & dysrhythmiasINTERVENTIONS:

Keep environment as quite as possible

Reduce room temp to decrease discomfort caused by heat intolerance

Prevent eye dryness by taping eyelids closed for sleep

Drug therapy with anti-thyroid drugs in the initial treatmentTHYROID CRISIS/STORM = SEVERE HYPERFUNCTION:

Characterized by high fever and sever HTN

Immediately report temp. increases of even 1 degree

If temp increase is reported IMMEDIATELY assess cardiac statusASSESSMENT:

Fever, tachycardia, systolic HTN

As crises progresses pt. may become: restless, confused, or psychotic and may have seizures

LIFE THREATENING EVENT!!!!INTERVENTIONS:

Maintain patent airway and adequate ventilation

Give antithyroid drugs as prescribed

Administer sodium iodide solution as prescribed (2 g IV daily)

Give propranolol as prescribed (1-3mg IV)

Give slowly over 3 minutes

Give glucocorticoids as prescribed (IV)

Monitor continually for cardiac dysrhythmias

Monitor vital q 30 minutes

Provide comfort measures; including a cooling blanket

Give non-salicylate antipyretics as prescribed Correct dehydration with normal saline infusions

Apply cooling blanket or icepacks to reduce feverGOITER:

THYROIDECTOMY:

NURSING INTERVENTIONS:

PRE-OP:

POST-OP: Monitor for complications:

HYPOFUNCTION = HYPOTHYROIDISM:

Etiology

ASSESSMENT:

INTERVENTIONS:

MYXEDEMA/MYXEDEMA COMA:

ASSESSMENT:

INTERVENTIONS:

PARATHYROID DISORDERS:PARATHYROID HORMONE (PARATHORMONE):ASSESSMENT OF THE PARATHYROID GLAND:

HYPOFUNCTION = HYPOPARATHYROIDISM:

ASSESSMENT:

INTERVENTIONS:

HYPERFUNCTION = HYPERPARATHYROIDISM:

ASSESSMENT:

INTERVENTIONS:

HYPERCALCEMIC CRISIS:

PARATHYROIDECTOMY: