MED SURG IICHAPTER 56

CARING FOR CLIENTS WITH DISORDERS OF THE ENDOCRINE SYSTEM

PITUITARY GLAND DISORDERS

ACROMEGALY (hyperpituitarism)

occurs when there is an oversecretion of growth hormone (GH) after the epiphyses of the long bones have sealed/adulthood

Causes: tumor of anterior pituitary gland

S/S: see fig 56-1, 56-2; changes are irreversible

Treatment-surgical removal of the pituitary gland, radiation therapy and use of Parlodel

Nursing Care: correct fluid volume excess or deficit, pain relief, improve nutrition

SIMMOND’S DISEASEPanhypopituitarism

Very rare disorder; the pituitary gland is destroyed and there is resulting total lack of pituitary hormonal activity

Causes: postpartum emboli, surgery, tumor or TB

S/S: atrophy of gonads & genitalia, premature aging

Treatment: replace the needed hormones such as GH in children, estrogen in women, testosterone in men

if untreated is fatal Nursing: medication

administration

DIABETES INSIPIDUS

Develops when there is an insufficient amt of ADH by the pituitary gland

causes: head trauma, brain tumors, after removal of the pituitary gland

Results in production of large amts of dilute, urine, as much as 20L/24 hrs, extreme thirst; dilute urine

treatment: nasal administration of Desmopressin (DDAVP) and lypressin (Diapid) to replace the ADH; nursing guidelines 56-1

Nursing care: Closely monitor I & O, daily wt administration of nasal spray

Sydrome of Inappropriate ADH Secretion (SIADH)

Characterized by renal reabsorption of water instead of it’s secretion; increasing fluid volume & causing hyponatremia

Causes: lung tumors, CNS disorders, brains tumors, CVAs

S/S: water retention, h/a, muscle cramps, anorexia; n/v, changes is LOC

Medical treatment: eliminate the underlying cause; diuretics; use of IV NaCl if hyponaremia is extreme

Nursing mgmt: I&O, v/s, assessment of LOC,

HYPERTHYROIDISM

Allso known as Graves’ disease, Basedow’s disease, thyrotoxicosis, or exophthalmic goiter

May be caused by autoimmune disorder, heredity, thyroid tumors, pituitary tumors, hypothalamic disorders, stress or infection

Metabolic rate increases More common in women S/S: restless, agitation,

heat intolerance, increased appetite with wt loss, exophthalmos – see fig 56-4

Treatment: use of antithyroid drugs; therapy table 56-1; radiation, and either partial or total thyroidectomy

Thyroidectomy, nursing care

Avoid stimulation of the thyroid gland during exam to prevent oversecretion of thyroid hormones & resulting thyroid storm

Routine preop teaching

Postop: assess airway, assess for hemorrhage, ability to speak, s/s of thyrotoxic crisis, s/s of tetany such as muscle cramps, numbness & tingling of the arms & legs

See nursing care plan 56-1

THYROTOXIC CRISIS OR STORM

Rare event – life threatening

Thyroid oversecretes T3 & T4

Causes: extreme stress, infection, DKA, trauma, toxemia of pregnancy, manipulation of an overactive thyroid during surgery or physical exam

S/S: Temp as high as 106, rapid pulse, cardiac arrhythmias, extreme restlessness & delirium, chest pain, dyspnea

Treatment: antithyroid drugs, IV corticosteroids & sodium iodide, Propranolol, IV fluids, antipyretic measures,O2

Nursing care: monitor temp & S/S

Hypothyroidism

when the thyroid gland does not secrete adequate amounts of thyroid hormone

Severe cases are called myxedema

Results in slowing of all metabolic processes

See nursing process

S/S: lethargic, lacks energy, forgetful, chronic headaches, dozes frequently during the day, wt gain, cold intolerance, dry skin

Treatment: thyroid replacement therapy

Nursing care: monitor medication management, may take time to get the dose of thyroid hormone correct

THYROID TUMORS

Usually benign, but can cause hyperthyroidism

papillary carcinoma most common malignant type which usually develops in persons who have been treated with radiation to the head & neck

Treatment: none if benign & asymptomatic

If malignant or symptomatic, removal of the tumor and/or thyroid gland & the client will have to receive thyroid replacement therapy the rest of their lives

GOITER

Enlargement of the thyroid gland: endemic, nontoxic, nodular

Causes: deficiency of iodine in the diet, inability of the thyroid to use iodine, or by relative iodine deficiency caused by increasing body demands for thyroid hormones

S/S: asymptomatic or if gets too large can cause dysphagia, difficulty breathing

Treatment depends on the cause. May take iodine in salt, foods high in iodine, or a thyroidectomy may be done

Nursing: treat symptoms, increase iodine in diet

Disorders of the Parathyroid Glands

Hyperparathyroidism

Primary – most common cause is adenoma of one of the parathyroid glands & results in increased urinary excretion of phosphorus & loss of calcium from the bones

Secondary – in response to hypocalcemia due to vitamin D deficiency, chronic renal failure, large doses of thiazide diuretics & excessive use of laxatives & calcium supplements

HYPERPARATHYROIDISM

S/S: fatigue, muscle weakness, cardiac dysrhythmias, skeletal weakness, pain, pathological fractures, n/v, constipation & kidney stones

Med/Surg treatment: primary – surgical removal of tissue secondary – correct the cause Monitor I & O, s/s of renal calculi, pain

management, encourage fluids, importance of following treatment plan, safety

HYPOPARATHYROIDISM

Deficiency of parathyroid hormone which results in hypocalcemia

Causes: trauma to the glands or inadvertent removal of all or most of the gland during thyroidectomy or parathroidectomy

Affects neuromuscular function

S/S: tetany, numbness, tingling in fingers or toes or around the lips Assess for Chvostek’s or Trousseau’s sign; see fig 18-11, 18-12

Treatment is IV calcium gluconate followed by long term administration of oral calcium supplements, vit D or Vit D2

Nursing management of hypoparathyroidism

Assess for s/s of tetany or muscle hypertonia with spasm & tremor

Be prepared to administer IV Calcium Gluconate & assess for adverse reactions

Assess for muscle spasm Assess v/s with particular attention to heart

rate & rhythm Keep emergency equipment available in case

of respiratory distress Long term care: stress importance of diet &

drug therapy

DISORDERS OF THE ADRENAL GLANDS

Adrenal Insufficiency or Addison’s Disease

primary cause: destruction of the adrenal cortex by diseases such as TB

secondary cause: surgical removal of the glands, hemorrhagic infarction, hypopituitarism, or suppression of the adrenal gland due corticosteroid admin

S/S-see box 56-1 Medical treatment: corticosteriod

replacement therapy for a lifetime (Florinef)

Nursing care: medication administration. Never suddenly DC drug. Must be tapered see client & family teaching

ACUTE ADRENAL CRISIS OR ADDISONIAN CRISIS

A life threatening emergency that may develop due to adrenal insufficiency

Causes: severe stress, salt deprivation, infection, trauma, cold exposure, overexertion, or when corticosteroid therapy is suddenly stopped

May occur suddenly or gradually & requires immediate intervention

Medical mgmt: IV administration of corticosterioids, antibiotics

S/S: anorexia, n/v, diarrhea, abd pain, profound weakness, h/a, drop in blood pressure & shock as the last sign

Nursing interventions: early recognition of s/s of crisis & medication teaching

Pheochromocytoma

A tumor, usually benign, of the adrenal medulla that causes hyperfunction of the adrenal gland that leads to:

an excessive secretion of epinephrine & norepinephrine which leads to HTN, CVA, palpitations & tachycardia

S/S: elevated BP, tremors, nervousness

Treatment is surgical removal of the tumor

Nursing care: close monitoring of BP, medication administration

CUSHING’S SYNDROME

Adrenocortical hyperfunction

caused by overproduction of ACTH by the pituitary gland, benign or malignant tumors of the adrenal cortex or prolonged administration of high doses of corticosteroids

Cushingoid syndrome – fig 56-7

S/S: muscle wasting, weakness, symptoms of DM, moon face, buffalo hump, thin skin, high susceptibility to infection see fig 56-8

Medical treatment depends on the cause

Nursing care: obtain a thorough hx, v/s q 4 hrs, assess for s/s of peptic ulcer dz, DM; see nursing process.

Hyperaldosteronism

Hypersecretion of aldosterone creates severe electrolyte imbalances

Causes: Primary: tumors or

unknown Secondary:

pregnancy, CHF, narrowing of the renal artery, cirrhosis

S/S: h/a, muscle weakness, increased uop, fatigue, HTN, cardiac dysrhythmmias

Medical treatment: unilateral adrenalectomy, medications

Nursing: v/s, I&O, wt, assess for edema

ADRENALECTOMY

Usually done to remove a cancerous tumor

Preoperative: reduce anxiety, bedrest Postoperative: note if 1 or both

adrenals were removed, observe for s/s of adrenal insufficiency which may be caused by inappropriate dosing of replacement corticosteroid medication

See nursing process See client & family teaching, pg 878

General Nutritional Considerations

Clients with hyperthyroidism may need 4500 to 5000 cal/day or more to maintain normal weight; encourage intake of frequent meals & nutritionally dense foods

Clients with hyperparathyroidism should drink at least 3-4 litres fluid/daily to dilute urine & prevent renal stones

Clients with Addison’s dz who are being treated with cortisone may require a high Na+ diet; but high Na+ diets are contraindicated in those taking Florinef because it is a Na+ retaining hormone

General Pharmalogical Considerations

Substances that contain iodine like some cough meds & dyes can interfere with some thyroid tests

The most serious adverse effect of antithyroid drugs is agranulocytosis. Instruct the client to report sore throat, fever, chills, h/a, malaise or weakness.

Potassium iodide can protect thyroid gland from effects of radiation exposure after release of radiation in a power plant accident or nuclear bomb.

During initial thyroid replacement therapy the most common side effect is s/s of hyperthyroidism

The dose of thyroid replacement therapy may need to be adjusted over time until the optimal dose is attained.

The most common adverse effects of Florinef are frontal & occipital h/a, athralgia, edema & HTN.

General Gerontological Considerations

The symptoms of thyroid disease in older adults are atypical or minor & easily attributed to other problems.

Typical symptoms are anorexia, wt loss, palpitations & angina.

Hypothyroidism is also difficult to diagnose in older adults because symptoms mimic normal aging-anorexia, constipation, joint stiffness & apathy

Dosages of thyroid replacement therapy are lower in older adults, and it’s initiated slowly & increased cautiously.