Med/Surg Nursing

1. Med/Surg Nursing Endocrine System-2013

2. Endocrinologist- specialist (MD) trained in the specialty of endocrine glands and hormones Endocrine disorders are caused by overproduction or underproduction of specific hormones

3. Dx TEST • Blood, urine tests • CT's, xrays • Indirect/direct observation (d/t growth or appearance abnormalities)

4. Pituitary Function TestXrays, CT's, blood test, urine test

5. Thyroid Function Test • Lab test • Several different blood test may be done • Thryoid Scan (Radioscan or Scintiscan)-client ingests radioactive iodine or IV. A scanogram is then done to determine the amount of radioactive activity in the body. If the thyroid absorbs most of the iodine, the thyroid is then said to be hyperactive. If the thyroid does not absorb the iodine it is then hypoactive

6. RAIU Test • Measures thyroid gland activity • A scan is done of the thyroid to determine how much radioactive material it removes from the bloodstream and absorbs • Check for allergies to shellfish, or iodine!! • Ask them not to eat shellfish 1 week prior to test • Test can be altered by the use of BCP's, anticoagulants, salicylates and propylthiouracil derivatives

7. Thyroid Ultrasound • Determines the size of the thyroid gland, its shape and position • May be done to monitor the effectiveness of therapy or evaluate thyroid function during pregnancy • Uses a gel to transmit sound waves that are then interpreted by radiologist or physician

8. Parathyroid Function Test • Lab: serum PH, PTH, phosphate and calcium levels • Urinary calcium and serum alkaline phosphatase  • Other test: US, MRI, biopsy; this can localize cysts, tumors and hyperplasia (abnormal increase in size) • PTH: increased calcium levels in blood aids in regulating calcium function

9. Adrenal Function Test • Blood Tests: ACTH stimulation test, serum ACTH test, plasma cortisol test • Measured during the diurnal period (0800 and 1600) to determine if the ACTH and plasma cortisol levels are normal • Urine Tests: 24 hour urine specimen to test for vanillylmandelic acid a metabolite of catecholamines • ~clonidine suppression test to determine pheochromocytoma (catecholamine-secreting adrenal tumor) • phentolamine (Regitine) can be given to cause a hypotensive situation , the drop in BP is indicative of pheochromocytoma

10. Radiographic Evaluations • Adrenal angiogram or venogram-insertion of a catheter and injection of a contrast (dye) so that x-rays can be taken for studies • Complication-allergy to dye • Premedicate with diphenydramine (Benadryl) or propranolol (Inderal) • Contraindicated in unstable, pregnant clients, hemophiliacs, bleeding disorders

11. General Pancreatic Function Tests • Pancreatic enzymes: lipase (fat digestion), amylase (CHO metabolism) • Elevations suggest pancreatitis

12. DM Tests • Blood test: Fasting plasma glucose or fasting blood sugar is used for diabetic screening • ~Fasting elevation usually indicates DM >126 • ~Normal range is 65-115mg/dl (depends on source)

13. OGTT • Timed test to confirm the Dx of DM, can also diagnose functional hypoglycemia • Plasma glucose levels peak at 140-180 ml within 30 minutes to 1 hour after administration of oral glucose solutions and levels should return to normal in 2-3 hours

14. Glycosated Hemoglobin (Hb A1c) • Blood sugar reflection over the previous 6-10 weeks • Measurements detect the amount of glucose attached to a portion of the hgb in RBC's • Range should be between 5-7% out of a scale of 13%

15. Glycemic Index • Measurement of how foods containing CHO’s (starchy foods) raise blood glucose levels • CHO’s are compared with a standard known CHO, such as glucose or white bread • Foods known to raise BG level significantly have a high GI level

16. Urine Tests • Glucose can spill over into the urine from the blood, acetone is a by-product of faulty metabolism • Most common test is for ketones if blood glucose level is consistently high • Monitor for readings in excess of 240 mg/dl

17. Keto-Diastix • Measures for acetones (ketone bodies) in urine • Buildup of acetone ketones acidosis • Vomiting or excessive perspiration can alter electrolytes

18. Pituitary Gland “The Master Gland” • Anterior lobe produces • GH • ACTH (stress situations) • TSH • Prolactin • FSH • LH • All of the above are involved in growth, maturation, and reproduction

19. Disorders of the Anterior Pituitary • Hyperpituitarism • Gigantism – children • Acromegaly – adults • Cause – Overproduction of growth hormone STH

20. Gigantism/Acromegaly • S/S: • Thick lips • Massive lower jaws • Bulbous nose • Enormous hands and feet • Bulging forehead • H/A • Visual loss • Impotence • Amenorrhea • Facial hair in females (hirsuitism)

21. Gigantism/Acromegaly • Tx: Pituitary irritation • Drugs – bromocriptinemesylate (parlodel), lowers STH levels • Tx can stop progression of disease but can not alter abnormal growth that has occurred

23. Posterior Pituitary Secretes: • ADH – regulate the passage of H2O through kidneys • Vasopressin • Oxytocin

24. Disorders of the Posterior Pituitary • SIADH • Increase secretion of ADH, unable to excrete dilute urine • Fluid retention and intoxication can occur • Cause – CNS disorders, chemo, vasopressin overuse • S/S: • Concentrated urine • Edema • Decreased urine output • HA • Wt. gain • Decreased LOC (lethargy) • Confusion • Hyponatremia diarrhea

25. SIADH • Tx – Monitor I & O • Fluid restriction • Hypertonic IV solutions • Meds: demeclocycline (Declomycin) or lithium carbonate interfere antidiuretic action of ADH

26. Diabetes Insipidus • Lack of production of ADH which regulates passage of water through the kidneys • S/S: • Huge urinary output • (15-20 liters in 24 hrs.) • Thirsty • May need to restrict fluids • Urine SG lowers 1.006 (very dilute • Normal = 1.030) • Increased appetite • Weakness • Tx: • Vasopressin (Pitressin) Subq, IM or nasally to control urine output • Monitor Pitressin closely because it can cause coronary artery constriction • Weigh every day

27. Pituitary Neoplasms • Gigantism – overgrowth of eosinophilic cells • Cushing syndrome – hyperadrenalism from basophilic tumor • Hypopituitarism (pituitary can be destroyed by chromophobic tumor) • Change body temperature • Scant, fine body hair • Obese • Slow movements

28. Hypophysectomy • Surgical removal of the pituitary • To control pain in breast or prostate Ca • If malignant tumor is present • Decrease diabetic retinopathy • Postop ICU admit

29. Adrenal Gland Disorders • Cushing’s syndrome (hyperadrenalism) • Cause: overproduction of hormones secreted from the adrenal cortex, excessive steroidal use, tumors of the adrenal glands • Steroids may cause hyperglycemia • S/S: rounded “moon” face, heavy abdomen that hangs down, thin arms and legs, backache as the disease worsens, edema, decreased urinary output, hypokalemia, hypernatremia, hyperglycemia, HTN, poor wound healing, ecchymosis, “Buffalo hump”, easy bruising • DX-Lab – elevated cortisol level • If develop during childhood, puberty begins early for boys and the girls develop masculine traits.

30. Cushing’s (cont.) • Tx: depend on cause, removal, of adrenal gland, adrenocortical hormones are given. • Nursing Considerations • Prevent injury and infection • Monitor weight, v/s, labs: electrolytes, glucose levels (hyperglycemia)

32. Primary Aldosteronism • Cause – excessive aldosterone secretion • S/S-HTN, muscle weakness secondary to low potassium levels.

33. Addison’s Disease • Destruction or degeneration of the adrenal cortex • Cause-TB, CA, infection or the gland atrophies for unknown reasons • S/S-Decreased production of adrenal hormones which results in fluid and electrolyte imbalances, hypoglycemia • Darkening of the skin and mucosa • Dehydration, anemia and wt. Loss • BP decreases • Thin hair • Stress may cause adrenal shock (low BP, n/v/d, h/a, restless

34. Addison’s Disease • Addisonian Crisis- function falls to a critically low point • s/s: nausea, vomiting, wt. loss, extreme hypotension leading to vascular shock • Tx: IV hydrocortisone, IV fludrocortisone acetate (Florinef) to restore fluid and electrolyte balance, vasopressors (raise BP), diet high in protein and low in potassium

35. Addison’s Disease • Nursing Considerations • Replace fluid • 5-6 small meals/day with snacks • Monitor for decreased blood pressure of dizziness • Protect from falls • Accurate I & O’s including food • Specific gravity of urine • Daily wt’s • Teach importance of follow up visits • Protect from stressful situations such as overwork, infection or exposure to cold

37. Adrenal Neoplasms • Pheochromocytoma – benign tumor (usually) originating from the adrenal medulla • This tumor will increase epinephrine and norepinephrine secretion that results in HTN, h/a, n/v, tremor, dizziness, increased urination. • Tx: surgical removal of tumor (dangerous d/t BP variations), IVP, CT scan may be used to locate the tumor, if a bilateral adrenalectomy of performed, the clients must be treated for Addison’s disease postop • Will need adrenal hormones for life

38. Thyroid Gland Disorders • Thyroid secretes T3 and T4 which regulate metabolism by stimulating catabolism

39. Hyperthyroidism • Overproduction of T4 • Graves’ disease • Exopthalmic or toxic diffuse goiter is most common • Cause is unknown but it is thought to be manifested by infection, physical or emotional strain, changes r/t puberty or pregnancy

40. Hyperthyroidism • S/S: tremors, tachycardia, SBP elevated, feel hot, lose weight despite eating, sensitivity to heat • Exopthalmos noted in women with Graves’ disease, may lead to blindness, the neck is swollen • use artificial tears (need MD order) • If left untreated, may cause nervousness, delirium and death

41. Hyperthyroidism • Tx: medical or surgical • Antithyroid drugs: PTU or methimozole (inhibits synthesis of thyroid hormones) may be given daily over a long time and may have toxic effects. • RAI may be given to destroy the thyroid gland’s ability to make T4 and T3 • Thyroidectomy may be done if all else fails • Artificial tears may be given for dry eyes

42. Nursing Considerations: • Minimize overactivity, provide calm environment • Provide increased calories-proteins, vitamin D and B complex, minerals, fluids • Monitor T4 level

44. Hypothyroidism • Deficiency of T4 which slows down the metabolic process • D/T removal of the thyroid gland or a decrease in its activity • Affects women more than men • Congenital form of the deficiency is cretinism; advanced from is myxedema

45. Hypothyroidism • S/S: untreated results in dystrophy of bones and soft tissues – the person is dwarfed with a large head, short arms and legs, puffy eyes, the skin is dry and movement is uncoordinated • If discovered early, can be treated with T4 replacement and continued for life • Myxedema in adults • S/S: slowing physical and mental activity, mask like expression, dry skin, hoarse and low voice, hair coarse and falls out, weight gain • RAIU uptake is normal and menorrhagia can occur

46. Hypothyroidism • Tx: • Oral thyroid-Armour Thyroid or proloaid may be ordered • Synthetic thyroid hormones may be ordered; levothyroxine sodium (Levothroid) or Cytomel to supply the deficiency and must be done gradually • Effective treatment will show an increased alertness and appearance will be normal • NURSING CONSIDERATIONS • If taking a thyroid replacement, Assess for respiratory depression form sedatives or hypnotics • Be alert for signs of MI, report any complaints of anginal pain, which can occur when thyroid hormone therapy begins. Teach the client signs and symptoms of angina

47. Hypothyroidism • Nursing Considerations: • Focus on improvements in activity tolerance and independence, thyroid deficiency clients are a risk for respiratory depression • F/u visits to PCP • If left untreated, may result in myxedema coma, a medical emergency requiring immediate care • Avoid sedatives, narcotics as these drugs decrease HR and RR, with hypothyroidism, the HR and RR is already low.

48. Hashimoto's ThyroiditisAutoimmune hypothroidism disorder • Simple Goiter-thyroid gland enlarges and fills with colloid • Affects women more than men and usually occurs during pregnancy, infection or adolescence • No harmful affects on health unless it enlarges and obstructs breathing • Diet is deficient in iodine which is needed to produce thyroid hormones • Toxic goiter occurs when there is too much T4 (hyperthyroidism) • Tx: Iodine for 2-3 weeks, repeating tx 3-4x/year

49. Thyroid Neoplasms • Liquid or semisolid cyst forming in the thyroid • Aspiration can be performed on a simple cyst • semisolid cyst is usually malignant and must be removed • if thyroid tumor is cancerous, it must be treated with radioactive isotopes • most often thyroid cancers grow slowly

50. Thyroidectomy • Surgical removal of thyroid gland, client will need thyroid supplements for life • Only part of the thyroid gland is removed (subtotal thyroidectomy) • Thyroid hormone levels must be normal prior to surgery to reduce the risk of a thyroid storm (Thyroid crisis) • Caused by sudden increase in T4; s/s: tachycardia, anxiety, elevation in v/s, heart failure • Tx: Maintain 02 and glucose levels, reduce fever – place in semi- fowler’s • Lugol’s solution preop to decrease size and vascularity of the gland