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  1. 1. By Dr./ Mona Nadr Assessment and Management of Patients with Endocrine Disorders ADVANCED ADULT CARE NURSING Third year / bachelor
  2. 2.  Outline
  3. 3. Figure 42-2 The pituitary gland, the relationship of the brain to pituitary action, and the hormones secreted by the anterior pituitary and the posterior pituitary.
  4. 4. Glands of the Endocrine System  Hypothalamus  Posterior Pituitary  Anterior Pituitary  Thyroid  Parathyroids  Adrenals  Pancreatic islets  Ovaries and testes
  5. 5. Hypothalamus  Releasing and inhibiting hormones  Corticotropin-releasing hormone  Thyrotropin-releasing hormone  Growth hormone-releasing hormone  Gonadotropin-releasing hormone  Somatostatin-=-inhibits GH and TSH
  6. 6. Anterior Pituitary  Growth Hormone--  Adrenocorticotropic hormone  Thyroid stimulating hormone  Follicle stimulating hormone—ovary in female, sperm in males  Luteinizing hormone—corpus luteum in females, secretion of testosterone in males  Prolactin—prepares female breasts for lactation
  7. 7. Posterior Pituitary  Antidiuretic Hormone  Oxytocin—contraction of uterus, milk ejection from breasts
  8. 8. Adrenal Cortex  Mineralocorticoid—aldosterone. Affects sodium absorption, loss of potassium by kidney  Glucocorticoids—cortisol. Affects metabolism, regulates blood sugar levels, affects growth, anti-inflammatory action, decreases effects of stress  Adrenal androgens—dehydroepiandrosterone and androstenedione. Converted to testosterone in the periphery.
  9. 9. Adrenal Medulla  Epinephrine and norepinephrine serve as neurotransmitters for sympathetic system
  10. 10. Thyroid  Follicular cells—excretion of triiodothyronine (T3) and thyroxine (T4)—Increase BMR, increase bone and calcium turnover, increase response to catecholamines, need for fetal G&D  Thyroid C cells—calcitonin. Lowers blood calcium and phosphate levels
  11. 11. Parathyroid  Parathyroid hormone—regulates serum calcium
  12. 12. Pancreatic Islet cells  Insulin  Glucagon—stimulates glycogenolysis and glyconeogenesis  Somatostatin—decreases intestinal absorption of glucose
  13. 13. Kidney  1, 25 dihydroxyvitamin D—stimulates calcium absorption from the intestine  Renin—activates the RAAS  Erythropoietin—Increases red blood cell production
  14. 14. Ovaries  Estrogen  Progesterone—inportant in menstrual cycle,*maintains pregnancy,
  15. 15. Testes  Androgens, testosterone—secondary sexual characteristics, sperm production
  16. 16. Assessment  Health history—energy level, hand and foot size changes, headaches, urinary changes, heat and cold intolerance, changes in sexual characteristics, personality changes, others  Physical assessment—appearance including hair distribution, fat distribution, quality of skin, appearance of eyes, size of feet and hands, peripheral edema, facial puffiness, vital signs
  17. 17. Diagnostic Evaluation  Serum levels of hormones  Detection of antibodies against certain hormones  Urinary tests to measure by-products (norepinephrine, metanephrines, dopamine)  Stimulation tests—determine how an endocrine gland responds to stimulating hormone. If the hormone responds, then the problem lies w/hypothalmus or pituitary  Suppression tests—tests negative feedback systems that control secretion of hormones
  18. 18. Diabetes Insipidus  Diabetes Insipidus is a disorder of water metabolism caused by deficiency of ADH (Antidiuretic hormone), also called vasopressin, secreted by the posterior pituitary or by inability of the kidneys to respond to ADH (nephrogenic DI). Causes  1. Secondary to head trauma, brain tumor, or surgical ablation or irradiation of the pituitary gland.  2. Infections of the central nervous system (meningitis, encephalitis, tuberculosis) or with tumors (metastatic disease, lymphoma of the breast or lung)  3. Failure of the renal tubules to respond to ADH.
  19. 19.  Clinical Manifestations 1. Polyuria – daily output of 5 to 20L of dilute urine 2. Polydipsia (intense thirst) – drinks 4 to 40L of fluids daily, has craving for cold water. 3. High serum osmolality and high serum sodium level.  Diagnostic Evaluation  1. Serum osmolality  2. Water deprivation test: test—withhold fluids for 8-12 hours. Weigh patient frequently. Inability to slow down the urinary output and fail to concentrate urine are diagnostic. Stop test if patient is tachycardic or hypotensive
  20. 20. Pharmacologic Tx and Nursing Management  DDAVP—intranasal bid  Can be given IM if necessary. Every 24-96h. Can cause lipodystrophy.  Can also use Diabenese and thiazide diuretics in mild disease as they potentiate the action of ADH  If renal in origin—thiazide diuretics, NSAIDs (prostaglandin inhibition) and salt depletion may help
  21. 21. Nursing Interventions 1. Polyuria - Measure intake and output accurately. - Measure specific gravity of urine (normal specific gravity is 1.003 to 1.030. - Observe patient for signs of circulatory shock due to dehydration. 2. Severe dehydration - Administer fluids orally and intravenously to replace fluid lost. - Administer appropriate electrolytes to replace those lost through excessive urination. - Monitor laboratory test results. - Obtain daily weights and record.
  22. 22. Complications of diabetes mellitus : 1.Acute complications:  Diabetic ketoacidosis.  Hyperglycemic Hyperosmolar Non-Ketotic Syndrome  Hypoglycemia. 2.Chronic complications -Microvascular  retinopathy  nephropathy  neuropathy - Macrovascular  cerbrovascular, cardiovascular, peripheral vascular disease
  23. 23. Hypoglycemia Hypoglycemia: Usually present with insulin treated patients. Causes of hypoglycemia  Due to too much insulin/oral medication is used or too little glucose  Delayed ingestion of meal and increased physical activity. Symptoms of hypoglycemia include:  Confusion  Nausea  Hunger  Tiredness  Perspiration  Headache  Heart palpitation  numbness around the mouth  Tingling in the fingers, tremors  Muscle weakness, blurred vision  Cold temperature  Irritability, and loss of consciousness Treatment of hypoglycemia  50 % glucose I.V  Glucagon IM
  24. 24. Diabetic ketoacidosis:  This more common in type I diabetes  Is caused by the breakdown of fatty acids into ketones when there is not enough glucose stored in the cells for energy. Predisposing factors for diabetic ketoacidosis  Acute infection.  Injuries.  Emotional stress. Clinical features for diabetic ketoacidosis  Acetone smell.  Marked dehydration.  Orthostatic hypotension.  Clouding of consciousness which can lead to coma. Investigations for diabetic ketoacidosis  Increased ketone bodies in blood and urine Treatment for diabetic ketoacidosis  Fluid and electrolyte replacement  Insulin replacement
  25. 25.  1. Rehydration – important for maintaining tissue perfusion. Fluid replacement enhances the excretion of excessive glucose by the kidneys. The patient may need as much as 6 to 10 L of I.V. fluid to replace fluid losses caused by polyuria, hyperventilation, diarrhea, and vomiting.  Initially, 0.9% Normal Saline Solution is administered at a rapid rate, usually 0.5 to 1 L/hour for 2 to 3 hours. Half- strength normal saline (0.45%) solution (also known as hypotonic saline solution) may be used for patients with hypertension or Hypernatremia and those at risk for heart failure.  After the first few hours, half-strength normal saline solution is the fluid of choice for continued rehydration, provided the blood pressure is stable and the sodium level is not low.  Moderate to high rates of infusion (200 to 500 ml/hour) may continue for several more hours.  When blood glucose level reaches 300 mg/dL or less, the IV solution may be changed to dextrose 5% in water (D5W)
  26. 26. Hyperglycemic hyperosmolar non-ketotic syndrome (HHNS):  Hyperglycemia predominate, with alterations of the sensorium (sense of awareness). At the same time, ketosis is minimal or absent.  Predisposing factors are same as ketoacidotic coma.  Clinical features of diabetic ketoacidosis  Marked dehydration - hyperglycemia – seizures- stupor-coma.  Treatment: same as ketoacedotic coma.
  27. 27. Chronic complications of diabetes (macrovascular):  Diabetic macrovascular complications result from changes in the medium to large blood vessels.  Blood vessel walls thicken, sclerose, and become occluded by plaque that adheres to the vessel walls. Eventually, blood flow is blocked.  Coronary artery disease, cerebrovascular disease, and peripheral vascular disease are the three main types of macrovascular complications that occur more frequently in the diabetic population.
  28. 28. Chronic complications of diabetes (microvascular):  Diabetic retinopathy is caused by a blockage of blood vessels within the eye that leads to the blood vessels leaking into the retina. This eventually leads to blindness.  Diabetic nephropathy or Kidney Failure. Diabetes Mellitus is the number one cause of kidney failure and develops in 40 to 50% of all diabetics. It is also the most common cause of death in type I diabetics.  Diabetic neuropathy :Diabetes can also cause damage the peripheral nervous system (arms and legs) causing diabetic neuropathy. This leads to loss of nerve function that either results in: Constant pain or loss of feeling. Erectile Dysfunction
  29. 29. Nutritional therapy  Diet is the corner stone of diabetes treatment.  Weight loss is a goal for most patients with type II diabetes.  The individual diet is based on:  The patients' types of diabetes.  Height to weight ratio.  Usual dietary intake.  Cultural and personnel preference.  Life style component: eating pattern.  For diabetic patient diet must contain:  50 % to 55 % of carbohydrate.  12 % to 20 % protein.  And 30 % of fat (unsaturated fat).  Fiber diet: This type of diet plays a role in lowering total cholesterol and low-density lipoprotein cholesterol in the blood, may also improve blood glucose levels and decrease the need for exogenous insulin.
  30. 30. Exercise therapy  Exercise is an important part of managing diabetes.  The exercise program should be designed for the individual patient.  All exercise programs should begin with milder forms of exercise and gradually increase.  Program should not be stated until the blood glucose is under control.  Exercises are performed at the some time everyday.  Blood glucose should lie checked before beginning to exercise.  Every diabetic patient should have emergency supplies for treatment for hypoglycemia available when exercising.  Benefits of exercises for person with diabetes:  Improve glucose utilization for energy and also improves circulation.  Improve insulin sensitivity.  Improve lipid profile.  May improve hypertension.  Increase energy expenditure to assist with weight loss and preserve lean body mass.  Promotes cardiovascular fitness.  Increases strength and flexibility.  Improve sense of well being  General precautions for exercise in people with diabetes:  Use proper footwear and, if appropriate, other protective equipment.  Avoid exercise in extreme heat or cold.  Inspect feet daily after exercise.  Avoid exercise during periods of poor metabolic control.
  31. 31. Insulin Action Action Name Colour Onset Peak Duration Short Humulog Clear Immediate 0.5-1.5 hr 2-4 hr Interm ediate NPH Cloudy 2-4 hr 4-10 hr 10-16 hr Long Ultralente Cloudy 6-10 hr None 18-20 hr
  32. 32. Side effects of insulin  Hypoglycemia is the most common side effect that may occur during insulin therapy or oral hypoglycemic agents.  Insulin resistance: this is the result of antibodies binding to insulin molecules and rendering them inactive this response is seem with patients who require 100 – 200 units a day.  Insulin hypersensitivity: (allergic reaction)  Local reaction (itching and erythema at the injection site).  Systemic response (anaphylactic reaction)  4.Lipodystrophy: Atrophy or hypertrophy of the subcutaneous tissue at the injection site.
  33. 33. Patient education for diabetes mellitus  Education for diabetic patient:  Basic definition of diabetes (having a high blood glucose level)  Normal blood glucose ranges  Effect of insulin and exercise (decrease glucose)  Effect of food and stress, including illness and infections (increase glucose)  Treatment modalities  Administration of insulin and oral antidiabetes medications  Meal planning (food groups, timing of meals)  Monitoring of blood glucose and urine ketones  Where to buy and store insulin, syringes, and glucose monitoring supplies  When and how to contact the physician  Recognition, treatment, and prevention of acute complications If hypoglycemia occurs at home:  If the patient is able to swallow give:  ½ cup of juice ( apple or orange )  ½ cup of 2% or skim milk.  ½ cup of regular soda ( not sugar free)  6-7 hand candies.  3 glucose tablets.  1 table spoon of honey.  1 table spoon of sugar.  If the patient is unable to swallow (unconscious):  Turn the patient on the side.  Administer 1 mg of glycogen by injection.  Feed the patient as soon as he or she is awake and able to swallow.  Give a fast acting source of sugar and a longer acting source such as crackers and cheese or a meat sandwich.  If the patient does not awaken within 15 min give another dose of glycogen and inform physician immediately or call an emergency service.
  34. 34. Patient education for diabetes mellitus Skin and foot care:  Inspect feet daily for temperature, cuts blisters, abrasions or discoloration of the toes.  Tell any abnormalities to the health care provider.  Use a mirror if unable to bend to see the bottom of the foot.  Be certain to check between the toes.  Wash the feet in warm water (not hot) using mild soap; do not soak the feet to avoid cracking of the skin.  Thoroughly dry the feet after washing.  Pay attention to dry between the toes.  on medicated cream if the skin is dry, do not put the cream between toes.  Cut the nails straight a cross.  Wear properly fitted shoes, never walk barefoot.  Bread in new shoes gradually.  Never wear open sandals or sandals with straps between the toes.  Use socks and blankets to warm the feet, do not use a heating bad or hot water bottle near them.  Test the temperature of bath water before stepping into tub or shower.  Elevate the feet wherever possible to improve circulation. Pointers for traveling:  Carry extra medication or insulin in a case bottle gets lost or broken.  Wear Medic- Alert tag.  Carry an emergency supply of fast, acting sugar at all times.  Obtain sufficient rest and avoid stressful situations as much as possible to prevent stress included hypoglycemia.  Drink a glass of water every 2 hrs to
  35. 35. CUSHING’S SYNDROME Definition: is a condition in which the plasma cortisol levels are elevated, causing signs and symptoms of hypercortisolism. Pathophysiology  The normal feedback mechanisms that control adrenocortical function are ineffective resulting in excessive secretion of adrenal cortical hormones. Clinical Manifestations  Manifestations caused by Excess Glucocorticoids  1. Weight gain or obesity  2. Heavy trunk; thin extremities  3. “Buffalo hump” (fat pad) in neck and supraclavicular area  4. Rounded face (moon face); plethoric, oily  5. Fragile and thin skin, striae and ecchymosis, acne  6. Muscles wasted because of excessive catabolism  7. Osteoporosis – kyphosis, backache  8. Mental disturbances – mood changes, psychosis  9. Increased susceptibility to infections
  36. 36.  Manifestations caused by Excess Mineralocorticoids  1. Hypertension  2. Hypernatremia, hypokalemia  3. Weight gain  4. Expanded blood volume  5. Edema  Manifestations caused by Excess Androgens  1. Women experience virilism (masculinization)  a. Hirsutism – excessive growth of hair on the face and midline of trunk  b. Breasts – atrophy  c. Clitoris – enlargement  d. Voice – masculine  e. Loss of Libido
  37. 37.  Diagnostic Evaluation: 1. Dexamethasone suppression test – Dexamethasone (1mg) is administered orally at 11 PM, and a blood sample is taken to measure the plasma cortisol level, obtained at 8AM the next morning.
  38. 38. Nursing intervention  1. Mild, moderate, or severe weakness and muscle wasting.  - Help patient to perform active and passive range-of-motion exercises to maintain muscle tone.  - Alternate periods of rest and exercise to avoid fatigue.  - Encourage patient to ambulate.  2. Susceptibility to develop fractures due to osteoporosis.  - Handle patient gently while moving.  - Assist with ambulation.  - Provide walker or cane to increase stability.  - Provide firm mattress and bed board.  - Keep side rails in raised position.  - Put bed in lowered position.  - Keep call bell within easy reach of patient at all times.  3. Decreased ability to fight infection due to immunosuppressive and anti- inflammatory effects of excessive cortisol.  - Avoid exposing patient to unnecessary risks by protecting patient from other patients visitors, and staff who have respiratory infections - Observe patient for signs and symptoms of infections.  - Avoid catheterizations.  4. Fragile and thin skin; prone to breakdown, easy bruising, and infection.  - Avoid use of harsh, drying soaps.  - Avoid use of adhesive tapes.  - Institute nursing measures to prevent skin breakdown.  - Use air mattress, sheepskins, heel and elbow protectors.  - Turn patient every hour.  - Apply direct pressure over all injection and venipuncture sites.  - Avoid repeated venipuncture.
  39. 39. Nursing intervention 5. Susceptibility to development of hyperglycemia and glucosuria. - Check urine for sugar and acetone before meals and at bed time. - Monitor blood glucose levels. - Institute diabetic diet and diabetic teaching if necessary. - Reassure patient that diabetic condition will probably disappear when condition is controlled. 6. Susceptibility to ulcer formation. - Give small, frequent feedings. - Administer antacids, as ordered. - Monitor stools for occult blood. - Report immediately any vomiting of blood or passing of black, tarry stools. 7. Susceptibility to development of hypokalemia, with subsequent changes in cardiac function. - Monitor serum K+ levels. - Offer high-potassium diet (oranges, bananas, tomatoes). - Monitor apical pulse for regularity. 8. Susceptibility to development of hypertension and edema due to sodium and water retention. - Weigh patient daily, early in the morning. - Monitor blood pressure at least four times daily. - Restrict sodium intake. - If patient is on diuretic therapy, monitor potassium level and supplement diet with potassium. 9. Altered body image due to physical changes. - Reassure patient that physical changes may be reversible with treatment. 10. Mood swings, with periods of euphoria, irritability, and depression. - Allow patient to express feelings. - Do not reprimand patient for inappropriate behavior. - Explain to family and encourage acceptance on the part of family and staff.
  40. 40. PHEOCHROMOCYTOMA  Pheochromocytoma is a catecholamine- secreting neoplasm associated with hyper-function of the adrenal medulla. Tumors located in the adrenal medulla produce both increased epinephrine and norepinephrine; those located outside the adrenal gland tend to produce epinephrine only.
  41. 41. Clinical Manifestations  Variation in signs and symptoms depends on the predominance of norepinephrine or epinephrine secretion and on whether secretion is continuous or intermittent.  1. Hypertension  2. Orthostatic hypotension, dizziness, and syncope  3. Palpitations; chest pain  4. Hypermetabolism manifested by tremor, nervousness, weight loss, heat intolerance,  diaphoresis, and exhaustion.  5. Fasting hyperglycemia and glycosuria  6. Diarrhea, nausea, abdominal pains, possible symptoms of bowel obstruction  7. Headaches and migraines
  42. 42. Diagnostic Evaluation 1. VMA (vanillylmandelic acid) and metanephrine (metabolites of epinephrine and norepinephrine) are elevated in 24-hour urine sample. 2. Epinephrine and norepinephrine in urine and blood are elevated while patient is symptomatic. 3. CT scan and magnetic resonance imaging (MRI) of the adrenal glands or of the entire abdomen are done to identify tumor. 
  43. 43. Nursing intervention 1.Withhold coffee, tea, bananas, chocolate, citrus fruits, aspirin, foods containing vanilla, and antihypertensive medications for three days prior to and during urine specimen collection. 2. Help patient avoid excessive physical and emotional stress 3. Collect 24-hour urine specimen in a bottle that contains a preservative.  1. Hypertension  - Monitor and record vital signs.  - Administer antihypertensive medications, as ordered, and observe for therapeutic effectiveness.  - Watch for signs and symptoms of cardiovascular accident or congestive heart failure.  2. Orthostatic hypotension, dizziness, and syncope.  - Instruct patient to change positions slowly, especially when getting out of bed.  - Take safety precautions; for example, raise side rails to prevent injury.  3. Palpitations; chest pain  - Check apical and radial pulse for 1 full minute.
  44. 44. Nursing intervention  4. Hypermetabolic state manifested by tremor, nervousness, weight loss, heat intolerance, diaphoresis, and exhaustion.  - Provide a quiet, nonstimulating, nonstressful environment.  - Offer diet high in calories, vitamins, and minerals.  - Omit coffee, tea, and cola from the diet to prevent their stimulating effects.  - Weigh patient daily and record weight.  - Promote rest and assess patient for need of sedation.  - Keep room cool.  - Offer frequent bathing and hygienic measures.  5. Fasting hyperglycemia and glycosuria  - Monitor blood glucose levels.  - Check urine for glycosuria before meals and at bedtime.  - Record results and report abnormal findings to physician.  6. Diarrhea, nausea, abdominal pains  - Check bowel sounds daily.  - Check and keep an accurate record of bowel movements.  - Administer antidiarrherial medication, as ordered.  7. Pounding headaches and migraines  - Assess blood pressure during pain episodes.  - Assure patient that headaches will cease once hypertension is controlled