1. Nursing of Adults with Medical & Surgical Conditions
Endocrine
Disorders

2. Acromegaly Etiology/Pathophysiology
Overproduction of growth hormone in the adult
Idiopathic hyperplasia of the anterior pituitary gland
No known cause
Tumor growth in the anterior pituitary gland
Changes are irreversible

3. Acromegaly Signs & Symptoms Enlargement of the cranium and lower jaw
Separation and malocclusion of the teeth
Bulging forehead
Bulbous nose
Thick lips
Enlarged tongue
Generalized coarsening of the facial features
Enlarged hands and feet
Enlarged heart, liver, and spleen

4. Acromegaly Muscle weakness
Hypertrophy of the joints with pain and stiffness
Males – impotence
Females – deepened voice, increased facial hair, amenorrhea
Partial or complete blindness with pressure on the optic nerve due to tumor
Severe headaches

5. Acromegaly Treatment Medications Cryosurgery
Parlodel
Sandostatin
Inhibit production of growth hormone
Cryosurgery
Destroy tissue by freezing
Transphenoidal removal of tissue
Proton beam therapy
Low doses of radiation
Soft easy to chew diet
Analgesics

6. Giantism Etiology/Pathophysiology Overproduction of growth hormone
Caused by hyperplasia of the anterior pituitary gland
Occurs in a child before closure of the epiphyses
Other causes
Genetic disorders
Disturbances in sex hormone production

7. Giantism Signs & Symptoms Great height
Increased muscle and visceral development
Increased weight
Normal body proportions
Weakness

8. Giantism Treatment Surgical removal of tumor
Irradiation of the anterior pituitary gland
Requires replacement of pituitary hormones

9. Dwarfism Etiology/Pathophysiology Deficiency in growth homone
Usually idiopathic

10. Dwarfism Signs & Symptoms Abnormally short height
Normal body proportion
Appear younger than age
Dental problems due to underdeveloped jaws
Delayed sexual development

11. Dwarfism Treatment Growth hormone injections
Removal of tumor if present

12. Diabetes Insipidus Etiology/Pathophysiology
Transient or permanent metabolic disorder of the posterior pituitary
Deficiency of antidiuretic hormone
Primary
Secondary
Head injury; intracranial tumor, aneurysm, or infarct; encephalitis or meningitis

13. Diabetes Insipidus Signs & Symptoms Polyuria Polydipsia
Urine very dilute
May exceed 10 L in 24 hours
Polydipsia
Craves cold water
Up to 40 L of fluid daily
May become severly dehydrated
Lethergic
Dry skin
Poor skin tugor
Constipation

14. Diabetes Insipidus Treatment ADH preparations
Vasopressin
IV, SQ, nasal spray
Limit caffeine due to diuretic properties

15. Graves’ Disease Etiology/Pathophysiology
Overproduction of the thyroid hormones
Exaggeration of metabolic processes
Exact cause unknown
Risk factors
Physical or emotional stress
Pregnancy
Adolescence
Infection
Genetic
Autoimmune

16. Graves’ Disease Signs & Symptoms
Edema of the anterior portion of the neck
Enlargement of the thyroid
Exphtalmos
Bulging of the eyeballs due to periorbital edema
Inablility to concentrate
Memory loss
Dysphagia
Hoarsness
Increased appetite
Weight loss
Nervousness

17. Graves’ Disease Insomnia Tachycardia Hypertension Warm, flushed skin
Fine hair
Amenorrhea
Elevated temperature
Diaphoresis
Hand tremors

18. Graves’ Disease Treatment Medications Radioactive iodine
Propylthiouracil
Methimazole
Block production of thyroid hormones
Radioactive iodine
Destroys part of thyroid tissue
Subtotal thyroidectomy
Part of thyroid is removed

19. Graves’ Disease Post-Op Voice rest Voice checks
Avoid hyperextention of neck
Tracheotomy tray at bedside
Assess for s/s of internal and external bleeding
High risk of hemorrhage
Assess for tetany
May occur due to accidental removal of parathyroid glands
Decreases serum calcium levels
Chvostek’s Sign
Abnormal spasm of facial muscles elicited by light tap on the facial nerve
Trousseau’s Sign
Carpal spasm induced by inflation of B/P cuff on the upper arm for 3 minutes

20. Chvostek’s Sign

21. Trousseau’s Sign

22. Graves’ Disease Thyroid Crisis Caused by manipulation of thyroid
Releases large amounts of thyroid hormones
Usually occurs within first 12 hrs
Exaggerated symptoms of hyperthyroidism
Can be fatal if untreated

23. Hypothyroidism Etiology/Pathophysiology
Insufficient secretion of thyroid hormones
Slowing of all metabolic processes
Failure of thyroid or insufficient secretion of TSH from pituitary gland
Myxedema
Adults
Cretinism
Newborns; congenital

24. Hypothyroidism Signs & Symptoms
Depends on degree of thyroid hormone deficiency
Hypothermia
Intolerance to cold
Weight gain
Depression
Impaired memory
Slow thought process
Lethargic
Anorexia
Constipation

25. Hypothyroidism Decreased libido Menstrual irregularities Thin hair
Skin thick and dry
Enlarged facial appearance
Low hoarse voice
Bradycardia
Hypotension

26. Hypothyroidism Treatment Medications Symptomatic treatment Synthroid
Levothyroid
Proloid
Cytomel
Symptomatic treatment

27. Simple Goiter Etiology/Pathophysiology
Enlarged thyroid due to low iodine levels
Enlargement is caused by the accumulation of colloid in the thyroid follicles
Usually cause by insufficient dietary intake of iodine

28. Simple Goiter Signs & Symptoms Enlargement of the thyroid gland
Dysphagia
Hoarseness
Dyspnea

29. Simple Goiter Treatment Potassium iodide Diet high in iodine Surgery
Thyroidectomy

30. Cancer of the Thyroid Etiology/Pathophysiology
Malignancy of thyroid tissue
Very rare

31. Cancer of the Thyroid Signs & Symptoms
Firm, fixed, small, rounded mass or nodule of thyroid

32. Cancer of the Thyroid Treatment Total thyroidectomy
Thyroid hormone replacement
If metastasis is present:
Radical neck dissection
Radiation therapy, chemotherapy, and radioactive iodine

33. Hyperparathyroidism Etiology/Pathophysiology
Overactivity of the parathyroid, with increased production of parthormone
Hypertrophy of one or more of the parathyroid glands
Usually due to an adenoma

34. Hyperparathyroidism Signs & Symptoms Hypercalcemia Skeletal pain
Calcium leaves the bones and enters the bloodstream
Skeletal pain
Pain on weight bearing
Pathological fractures
Kidney stones
Fatigue
Drowsiness
Nausea
Anorexia

35. Hyperparathyroidism Treatment Removal of tumor
Removal of one or more parathyroid glands

36. Hypoparthyroidism Etiology/Pathophysiology
Decreased parathyroid hormone
Decreased serum calcium levels
Inadvertent removal or destruction or one or more gland during thyroidectomy

37. Hypoparthyroidism Signs & Symptoms Neuromuscular hyperexcitability
Involuntary and uncontrollable muscle spasms
Tetany
Laryngeal spasms
Stridor
Cyanosis
Parkinson-like syndrome
Bizarre posturing
Spastic movements
Chvosteck’s sign &Trousseau’s sign

38. Hypoparthyroidism Treatment Calcium gluconate or calcium chloride IV
Must be given very slowly due to irritation of vessel
Rate should not exceed 1 ml/min
Can precipitate cardiac arrest
Vitamin D
Increases absorption of calcium

39. Adrenal Hyperfunction Cushing’s Syndrome
Etiology/Pathophysiology
Plasma levels of adrenocortical hormones are increased
Hyperplasia of adrenal tissue due to overstimulation by the pituitary gland
Tumor of the adrenal cortex
ACTH secreting tumor outside the pituitary
Overuse of corticosteriod drugs

40. Adrenal Hyperfunction Cushing’s Syndrome
Signs & Symptoms
Moonface
Buffalo hump
Thin arms and legs
Hypokalemia
Proteinuria
Increased urinary calcium excretion
Susceptible to infections
Depression
Loss of libido

41. Cushing’s Syndrome

42. Adrenal Hyperfunction Cushing’s Syndrome
Ecchymoses and petechiae
Weight gain
Abdominal enlargement
Hirsutism in women
Exessive hair in a masculine distribution
Menstrual irregularities
Deepening of the voice

43. Adrenal Hyperfunction Cushing’s Syndrome
Treatment
Treat causative factor
Adrenalectomy for adrenal tumor
Radiation or surgical removal for pituitary tumors
Lysodren
Cytotoxic agent to decrease production of adrenal steroids
Low sodium, high potassium diet

44. Adrenal Hypofunction Addison’s Disease
Etiology/Pathophysiology
Adrenal glands do not secrete adequate amounts of glucocorticoids and mineralocorticoids
May result from
Adrenalectomy
Pituitary hypofunction
Long standing steroid therapy

45. Adrenal Hypofunction Addison’s Disease
Signs & Symptoms
Related to imbalances of hormones, nutrients, and electrolytes:
Nausea
Anorexia
Postural hypotension
Headache
Disorientation
Abdominal pain
Lower back pain
Anxiety

46. Adrenal Hypofunction Addison’s Disease
Darkly pigmented skin and mucous membranes
Weight loss
Vomiting
Diarrhea
Hypoglycemia
Hyponatremia
Hyperkalemia

47. Adrenal Hypofunction Addison’s Disease
Adrenal Crisis
Sudden, severe drop in B/P
Nausea & vomiting
Extremely high temperature
Cyanosis
Death

48. Adrenal Hypofunction Addison’s Disease
Treatment
Restore fluid and electrolyte balance
Replacement of adrenal hormones
Florinef
Diet high in sodium and low in potassium
Adrenal Crisis
IV corticosteroids in a solution of saline and glucose

49. Diabetes Mellitus Type I and Type II
Etiology/Pathophysiology
Unknown
Risk Factors
Heredity
Blood relatives of people who have DM (esp Type II) are more likely to develop DM
Environment and lifestyle
Overweight, sedentary lifestyle are more prone to Type I DM
Viruses
Chickenpox-type viruses have been associated with the development of Type I DM
Malignancy or Surgery of Pancreas
Decreased functioning ability

50. Diabetes Mellitus Type I and Type II
Pathophysiology
Insulin deficiency
May be decreased or none
Insulin is secreted by the beta cells in the islets of Langerhans
Insulin is necessary for the cells to combine O2 and glucose to produce energy
If insulin is not present or is reduced, glucose accumulates in the blood and is excreted in the urine
The body then uses proteins and fat for energy which can cause acidosis

51. Diabetes Mellitus Type I and Type II
Classifications
Type I
Insulin Dependent (IDDM)
Type II
Non-insulin Dependent (NIDDM)
Signs & Symptoms
Type I & Type II
Polyuria
Polydypsia
Polyphagia

52. Diabetes Mellitus Type I and Type II
Sudden onset
Weight loss
Hyperglycemia
Under 40 years old
Type II
Slow onset
May go undetected for years
“3 P’s” are usually mild
Untreated may have skin infections & arteriosclerotic conditions

53. Diabetes Mellitus Type I and Type II
Diagnostic Tests
Urine glucose and acetone
Neither are normally in urine
Glucose in urine means the blood glucose has exceeded the “renal threshold”
Blood glucose
Venipuncture or capillary
Glucose is always present in the blood
Amount can fluctuate according to how much and what type of foods have been eaten
Normal values
mg/dl

54. Oral glucose tolerance test
Fasting (NPO for at least 8 hours)
Fasting blood sugar is drawn
Glucose drink administered
Blood drawn at 1 hr, 2 hrs, and 3 hrs after drink
1hr: elevated
2hr: essentially normal
3hr: within normal limits
2 hour post-parandial blood sugar
Blood sugar drawn 2 hours after a normal meal
Values should be within normal limits
Glycohemoglobin
Glucose in hemoglobin
Elevation means that the patient’s blood sugar levels were consistantly high for 6-8 weeks previously
Values
Non-diabetic adult: %
Good diabetic control: %
Fair diabetic control: %
Poor diabetic control above 8%

55. Treatment Diet The cornerstone of treatment
Usually based on caloric needs (pt. size, activity, etc)
Type II may be controlled by diet alone
Type I diet is calculated and then the amount of insulin required to metabolize it is established
ADA diet (American Diabetes Association)
7 Exchanges
Free calories
Vegetables
Fruits
Bread
Meat
Fats
Milk
Quantitative Diet
Carbohydrates – 45-50% of calories
Proteins – 10-20% of calories
Fats – no more than 30% of calories
Need 3 regular meals with snacks between meals and at bedtime to maintain constant glucose levels

56. Carbohydrate Counting
Adults with Type 2 diabetes generally need to limit carbohydrates to no more than grams per meal and grams for a snack.
Eat three meals a day with one to three snacks.  Try to eat around the same times every day.
Avoid skipping meals.
Follow the food guide pyramid.  Pay attention to carbohydrate choices.  Stay within your recommended serving ranges.
Limit foods that are high in added sugars and fats.  If you do consume foods with added sugar, be sure to count them into your carbohydrate choices.
Avoid drinking high sugar beverages such as regular sodas, fruit juices, lemonade and punch.  All of these can be substituted with diet, low calorie, low sugar or light alternatives.

57. These foods count as one (1) carbohydrate choice:
1 oz dinner roll
1 cup (8 oz) milk 
1/2 cup beans
1 slice bread
1 cup (8 oz) soy milk 
1/2 cup corn 
1/2 cup cooked cereal
8 oz yogurt (no added sugar)
1/2 cup green peas 
3/4 cup dry cereal (varies) 
1 taco 
3 oz baked potato 
2 - 4" pancakes
1 slice thin crust pizza 
1 cup winter squash
1/2 cup pasta or potato salad
1 cup bean or noodle soup
1/2 cup canned fruit  
1/2 cup pasta
1 granola bar
1/4 cup dried fruit
1/3 cup rice
3 graham cracker squares
1 cup berries
1 - 6" tortilla
1/2 cup sugar free pudding 
1/2 medium grapefruit 
1 - 4" waffle
10-15 potato chips 
3 prunes 
3 cups popcorn
1/2 cup ice cream
12-15 cherries or grapes
4-5 crackers 
1 - 3" cookie
1 small apple or orange
1 small muffin
1 Tbsp syrup, honey, or sugar
1 cup melon
15 pretzels
1/3-1/2 cup fruit juice
2 Tbsp raisins

58. These foods count as two (2) carbohydrate choices:
1 - 8 to 11 oz frozen dinner
1 hamburger with bun
1 - 2-oz English muffin
1 cup lasagna (3" x 4" piece)
1 - 2-oz hamburger or hotdog bun
1 cup macaroni and cheese
1 cup sweetened yogurt 
1 slice thick crust pizza
1 - 7" meat burrito
1/2 large bag light popcorn
1 medium banana or pear
1 small bagel
1 cup chili
1 cup casserole

59. Insulin Classified by Action Classified by Type Regular Lente & NPH
Fast acting
Peek action 2-4 hours
Duration 5-8 hours
Lente & NPH
Intermediate acting
Peek action 4-12 hours
Duration hours
Ultralente
Long acting
Peek action hours
Duration hours
Classified by Type
Beef/Pork
derived from the pancreas of a pig or cow
Humulin/Novolin
synthetic human insulin

60. Regular Insulin is the ONLY form that can be given IV!
Should be administered at room temperature
Should be discarded after open for 3 months
Standardized Dose
100 units/ml (U100)
Use ONLY insulin syringes
Administer subcutaneous

61. Insulin Injection Sites
Should be rotated to prevent scar tissue formation
Insulin is not well absorbed in scar tissue
Sites
Lateral surface of the upper arms
Abdomen just below the rib cage
Buttocks
Anterior surface of thighs

62. Sliding Scale Insulin is given according to blood glucose levels
Regular insulin is only type that should be given to scale
Scales will vary on different patients, physicians, etc.
Sample Scale
Blood Sugar Insulin
units
units
units
units
above 300 Call MD

64. Alternate Methods of Insulin Administration
Insulin Pump

65. Alternate Methods of Insulin Administration

66. Alternate Methods of Insulin Administration

67. Combined blood glucose monitoring and insulin dosing system

68. Oral hypoglycemic agents
Stimulate islet cells to secrete more insulin
Must have some production of insulin by pancreas
Only for Type II DM
NOT insulin
Side Effects
hypoglycemia
Types
Orinase short acting 6-12 hours
Tolinase interm. acting hours
Diabinease long acting up to 60 hours

69. Hygiene Exercise Prevention more than treatment
Decreased resistance to infection
Wounds heal more slowly
Proper care of feet
Clean
Nail care
Proper fitting shoes
No heating pads
Do NOT trim nails - MD only
Exercise
Promotes movement of glucose into the cell by changing the cell permeability
Lowers blood glucose
Lowers insulin needs

70. Insulin Reaction Hypoglycemia
May be due to a sudden drop to below normal or may be due to a sudden drop from extremely high to normal
Pathophysiology
Too little circulating glucose
Cause
Too much insulin OR not enough food

71. Signs and Symptoms Trembling Perspiration Irrritability Dizziness
Muscle weakness
Headache
Blurred vision
Hunger
Confusion
Comatose
Convulsions

72. Treatment Increase blood glucose High calorie drink Orange juice Cola
Concentrated sugar
Candy
Jelly
Then complex foods
Carbohydrates
Proteins
If unconsious
50% dextrose IV

73. Diabetic Acidosis/Ketoacidosis
Hyperglycemia
Usually occurs in Type I (IDDM)
Cause
Lack of insulin
Accumulation of glucose and wastes from fat and protein metabolism

74. Signs & Symptoms Polyuria Polydipsia Polyphagia Nausea & vomiting
Weakness
Headache
Flushed face
Late Symptoms
Sweet fruity breath
Hypotension
Tachycardia
Kussmaul’s Respirations
Loud, deep and rapid resp. followed by apnea
BS may be as high as 1000mg/dl

75. Treatment Regular insulin IV Fluids and electrolyte replacement
Find cause and educate patient

76. Chronic Complications
Macrovascular changes
Caused by atherosclerosis
Intermittent claudication
Stroke
Gangrene
Coronary artery disease
Microvascular changes
Caused by changes in the capillaries
Eyes
diabetic retinopathy
cateracts
Kidneys
nephropathy
Infection
High BS levels cause poor circulation and decreased sensation
CNS disturbances
Metabolic imbalances affects the sensory and motor fibers

77. Other Complications Surgery Tests “Sick Days” Stresses the body
Pts. who required no insulin, may now require insulin
Pts. who were on insulin, will probably require increased doses
Tests
NPO
Need to consider how long they will be NPO and what type insulin they are taking
“Sick Days”
Increased risk of ketoacidosis (hyperglycemia)
Glucose must be monitored closely

78. Patient Education Diet Exercise Medications Hygiene Consider
Intellect
Motivation
Physical ability (vision, etc)
Social and personal resources
Success depends on ability and willingness