Chapter 11 Care of the Patient with an Endocrine Disorder

Chapter 11 Care of the Patient with an Endocrine Disorder
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.

Overview of Anatomy and Physiology
Endocrine glands and hormones The endocrine system is composed of a series of ductless glands It communicates through the use of hormones Hormones are chemical messengers that travel though the bloodstream to their target organ The body’s glands are divided into two categories: endocrine and exocrine. Review how these two types differ.

Pituitary gland—“master gland” Anterior pituitary gland Posterior pituitary gland Thyroid gland Parathyroid gland Adrenal gland Adrenal cortex Adrenal medulla Pancreas The pituitary gland is known as the “master gland.” Why has this moniker been applied?

Figure 11-2 Pituitary hormones.
The pituitary gland is responsible for the secretion of eight different hormones. Hormones play a vital function in the human body. What is the definition of hormones and the roles they play? (From Thibodeau, G.A., Patton, K.T. [2008]. Structure and function of the body. [13th ed.]. St. Louis: Mosby.) Pituitary hormones.

Female sex glands Ovaries Placenta Male sex glands Testes Thymus gland Pineal gland The endocrine glands are responsible for the regulation of numerous physiological processes in the body, including reproductive functions. The ovaries, located in the lower abdomen, secrete estrogen, which is responsible for the development of secondary sexual characteristics. The placenta is a unique organ. It is present in the woman only during pregnancy. What are the functions of the placenta? What hormones are secreted by the placenta? What hormone is secreted by the testes? What bodily changes result from this substance?

Location of the endocrine glands in the female and male bodies.
Figure 11-1 (From Thibodeau, G.A., Patton, K.T. [2008]. Structure and function of the body. [13th ed.]. St. Louis: Mosby.) Location of the endocrine glands in the female and male bodies.

Disorders of the Pituitary Gland
Acromegaly Etiology/pathophysiology Overproduction of growth hormone in the adult Idiopathic hyperplasia of the anterior pituitary gland Tumor growth in the anterior pituitary gland Changes are irreversible Acromegaly is a relatively rare disorder. Onset of the disorder is usually in the third or fourth decade of life.

Acromegaly (continued) Clinical manifestations/assessment 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 The characteristic clinical manifestations of acromegaly occur throughout the body. When collecting information from patients, what subjective data should be obtained? What questions should be asked of this patient?

Acromegaly (continued) Clinical manifestations/assessment (continued) 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 The significant changes in appearance associated with acromegaly have the potential to have psychosocial implications. What nursing diagnoses may be applicable to the psychosocial needs of the patient diagnosed with acromegaly?

(Courtesy of the Group for Research in Pathology Education.)
Figure 11-6 The photograph on the left represents the individual prior to the diagnosis of acromegaly. The physiological impact of the disease is apparent in the photograph on the right side. (Courtesy of the Group for Research in Pathology Education.) Right: Coarse facial features typical of acromegaly. Left: Patient’s face several years before she developed the pituitary tumor.

Acromegaly (continued) Medical management/nursing interventions Pharmacological management Parlodel Sandostatin Analgesics Cryosurgery Transsphenoidal removal of tissue Proton beam therapy Soft, easy-to-chew diet The patient experiencing acromegaly will often experience 7 to 9 years between the diagnosis of the disorder and the onset of clinical manifestations. What factors could be associated with this delay in a definitive diagnosis? When acromegaly is suspected, the diagnosis will be made based upon the patient’s health history, clinical manifestations, and the results of screening tests. What tests can be anticipated? What findings will support a positive diagnosis? Why are analgesics prescribed for the patient with acromegaly? After diagnosis and treatment, what prognosis can the acromegalic patient anticipate?

Gigantism Etiology/pathophysiology Overproduction of growth hormone Caused by hyperplasia of the anterior pituitary gland Occurs in a child before closure of the epiphyses The secretion of growth hormone is responsible for the growth and development of the body’s tissues. When growth hormone is produced in excess, gigantism can result. Review the epiphyses. What are they, and why is gigantism impacted by their development?

Gigantism (continued) Clinical manifestations/assessment Great height Increased muscle and visceral development Increased weight Normal body proportions Weakness Medical management/nursing interventions Surgical removal of tumor Irradiation of the anterior pituitary gland Clinical manifestations associated with gigantism resemble an “overgrowth.” Despite their large size, the affected patients experience weakness. What causes this weakness? What nursing care will be needed for the patient diagnosed with gigantism?

Dwarfism Etiology/pathophysiology Deficiency in growth hormone; usually idiopathic Some cases attributed to autosomal recessive trait Clinical manifestations/assessment Abnormally short height Normal body proportion Appear younger than age Dental problems due to underdeveloped jaws Delayed sexual development` A deficiency in growth hormone can result in dwarfism. Dwarfism is associated with the expected short stature. What other body systems will be affected?

Dwarfism (continued) Diagnostic tests Medical management/nursing interventions Growth hormone injections Removal of tumor, if present When a deficiency of growth hormone occurs, what diagnostic workup can be anticipated? What psychosocial implications are associated with a diagnosis of dwarfism? When diagnosed and treated, what is the long-term prognosis?

Diabetes insipidus Etiology/pathophysiology Transient or permanent metabolic disorder of the posterior pituitary Deficiency of antidiuretic hormone (ADH) Primary or secondary Diabetes insipidus results when antidiuretic hormone secretion or function goes awry. What physiological function does antidiuretic hormone have in the body? What factors can cause this dysfunction?

Diabetes insipidus Clinical manifestations/assessment Polyuria; polydipsia May become severely dehydrated Lethargic Dry skin; poor skin turgor Constipation Medical management/nursing interventions ADH preparations Limit caffeine due to diuretic properties Patients experiencing diabetes insipidus might feel the need to consume several liters of fluid and then void thousands of milliliters daily. Review the physiological significance caused by this massive fluid output. Which electrolytes are most compromised with the condition? If the patient wishes to drink so much fluid, what are the dangers of being allowed to do so?

Disorders of the Thyroid and Parathyroid Glands
Hyperthyroidism Etiology/pathophysiology Also called Graves’ disease, exophthalmic goiter, and thyrotoxicosis Overproduction of the thyroid hormones Exaggeration of metabolic processes Exact cause unknown Hyperthyroidism occurs more commonly in women than men. It results when there is an elevation in thyroid hormone secretion. Although there is no exact known cure, there are supported theories in existence. Discuss these circulating theories.

Hyperthyroidism (continued) Clinical manifestations/assessment Edema of the anterior portion of the neck Exophthalmos Inability to concentrate; memory loss Dysphagia Hoarseness Increased appetite Weight loss Nervousness When collecting data, what subjective data should be solicited? Provide examples of questions to include in the patient interview.

Hyperthyroidism (continued) Clinical manifestations/assessment (continued) Insomnia Tachycardia; hypertension Warm, flushed skin Fine hair Amenorrhea Elevated temperature Diaphoresis Hand tremors

Hyperthyroidism (continued) Medical management/nursing interventions Pharmacological management Propylthiouracil Methimazole Radioactive iodine Subtotal thyroidectomy When hyperthyroidism is suspected, a full diagnostic workup is warranted. What tests can be anticipated? What findings will support a positive diagnosis for the condition? The condition can be managed with the use of medications as well as surgical intervention. When medications are prescribed, what is their mode of action?

Hyperthyroidism (continued) Medical management/nursing interventions (continued) Postoperative Voice rest; voice checks Avoid hyperextension of the neck Tracheotomy tray at bedside Assess for signs and symptoms of internal and external bleeding Assess for tetany Chvostek’s and Trousseau’s signs Assess for thyroid crisis Surgical intervention is indicated for those cases for which drug therapy is not appropriate. When surgery is planned, what are the preoperative goals for the patient? During the postoperative period the patient’s environment is monitored. What characteristics are desired for the patient’s care environment? Why? Outline the critical elements in the postoperative assessment. Demonstrate the assessment for Chvostek’s and Trousseau’s signs.

Hypothyroidism Etiology/pathophysiology Insufficient secretion of thyroid hormones Slowing of all metabolic processes Failure of thyroid or insufficient secretion of thyroid-stimulating hormone from pituitary gland Hypothyroidism is a common disorder. What populations are affected most? What conditions can cause hypothyroidism?

Hypothyroidism (continued) Clinical manifestations/assessment Hypothermia; intolerance to cold Weight gain Depression Impaired memory; slow thought process Lethargic Anorexia Constipation Hypothyroidism can affect both newborns and adults. What medical terminology is used to refer to the condition in newborns? In adults?

Hypothyroidism (continued) Clinical manifestations/assessment Decreased libido Menstrual irregularities Thin hair Skin thick and dry Enlarged facial appearance Low, hoarse voice Bradycardia Hypotension The reduction of thyroid hormone will result in a generalized slowing of metabolic processes. All systems are implicated in the condition. In addition to determining the physical signs and symptoms, what psychosocial factors should be assessed? What nursing care will be indicated to meet both the physical and psychological needs of the patient?

Hypothyroidism (continued) Medical management/nursing interventions Pharmacological management Synthroid Levothyroid Proloid Cytomel Symptomatic treatment When hypothyroidism is suspected, a series of tests will be performed to make a diagnosis. What tests can be anticipated? What results will support a diagnosis of hypothyroidism? When medications are prescribed to treat the disorder, what patient teaching is indicated?

Simple goiter Etiology/pathophysiology Enlarged thyroid due to low iodine levels Enlargement is caused by the accumulation of colloid in the thyroid follicles Usually caused by insufficient dietary intake of iodine A simple goiter is also known as a colloid goiter. What does the term colloid mean? Explain the interrelationship between the T3 levels and TSH secretion.

Simple goiter (continued) Clinical manifestations/assessment Enlargement of the thyroid gland Dysphagia Hoarseness Dyspnea Medical management/nursing interventions Pharmacological management Potassium iodide Diet high in iodine Surgery—thyroidectomy The diagnosis is usually made based upon the clinical presentation of the patient. What are potential topics for patient education concerning the diagnosis? When considering a diet high in iodine, what should be encouraged in the patient’s intake? What is the prognosis for a simple goiter?

Figure 11-10 (Courtesy of L. V. Bergman & Associates, Inc., Cold Springs, New York.) Simple goiter.

Cancer of the thyroid Etiology/pathophysiology Malignancy of thyroid tissue; very rare Clinical manifestations/assessment Firm, fixed, small, rounded mass or nodule on thyroid Medical management/nursing interventions Total thyroidectomy Thyroid hormone replacement If metastasis is present: radical neck dissection; radiation, chemotherapy, and radioactive iodine While there are few cases of thyroid cancer in the United States, there is an anticipated increase on the horizon. To what factors is this expected increase attributed? There are populations in which thyroid cancer occurs more frequently: females and whites. When thyroid cancer is suspected, diagnostic tests are used to make a positive diagnosis. What results will confirm a diagnosis? Review the prognosis associated with a diagnosis of thyroid cancer.

Hyperparathyroidism Etiology/pathophysiology Overactivity of the parathyroid, with increased production of parathyroid hormone Hypertrophy of one or more of the parathyroid glands Hyperparathyroidism results when the parathyroid gland produces the parathyroid hormone in excess. This disorder affects women between the ages of 30 and 70 years of age. What underlying conditions can cause this to occur?

Hyperparathyroidism (continued) Clinical manifestations/assessment Hypercalcemia Skeletal pain; pain on weight-bearing Pathological fractures Kidney stones Fatigue Drowsiness Nausea Anorexia Hypercalcemia is the primary manifestation. What series of events will accompany hypercalcemia? Why is there pain associated with this disease? The cardiovascular system may be impacted by hyperparathyroidism. What will occur if this system becomes involved?

Hyperparathyroidism (continued) Medical management/nursing interventions Removal of tumor Removal of one or more parathyroid glands When hyperparathyroidism is suspected, a series of diagnostic tests will be performed. A radiographic examination of the skeleton might be ordered. What results would be anticipated to support a positive diagnosis? Additional tests will include serum alkaline phosphate and calcium levels.

Hypoparathyroidism Etiology/pathophysiology Decreased parathyroid hormone Decreased serum calcium levels Inadvertent removal or destruction of one or more parathyroid glands during thyroidectomy A reduction of parathyroid hormones will result in hypoparathyroidism. What will cause this disorder to occur?

Hypoparathyroidism (continued) Clinical manifestations/assessment Neuromuscular hyperexcitability Involuntary and uncontrollable muscle spasms Tetany Laryngeal spasms Stridor Cyanosis Parkinson-like syndrome Chvostek’s and Trousseau’s signs The signs and symptoms of this disorder occur when the serum levels of calcium become compromised. In addition to the objective manifestations, what subjective signs might be present?

Hypoparathyroidism (continued) Medical management/nursing interventions Pharmacological management Calcium gluconate or intravenous calcium chloride Vitamin D The management of hypoparathyroidism involves the administration of calcium gluconate or calcium chloride. What nursing implications accompany these medications? When developing a plan of care for this patient, what dietary recommendations should be made?

Disorders of the Adrenal Glands
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 Adrenocorticotropic hormone (ACTH) secreting tumor outside the pituitary Overuse of corticosteroid drugs The adrenal cortex consists of three layers. A specific hormone is secreted by each layer. The hormones secreted by the adrenal cortex are steroids. Identify the hormones produced by the adrenal cortex.

Adrenal hyperfunction (Cushing’s syndrome) (continued) Clinical manifestations/assessment Moonface Buffalo hump Thin arms and legs Hypokalemia; proteinuria Increased urinary calcium excretion Susceptible to infections Depression Loss of libido The changes exhibited by an oversecretion of adrenal hormones often cause a drastic change in appearance. In addition to the outward manifestations exhibited, there are blood imbalances. The blood glucose is elevated. What causes this to occur? Discuss the changes in electrolyte balance.

Adrenal hyperfunction (Cushing’s syndrome) (continued) Clinical manifestations/assessment Ecchymoses and petechiae Weight gain Abdominal enlargement Hirsutism in women Menstrual irregularities Deepening of the voice

Adrenal hyperfunction (Cushing’s syndrome) (continued) Medical management/nursing interventions Treat causative factor Adrenalectomy for adrenal tumor Radiation or surgical removal for pituitary tumors Lysodren Dietary recommendations: Low-sodium High-potassium The diagnosis of Cushing’s syndrome is made by combining the patient’s physical symptoms with diagnostic tests for confirmation. The diagnostic tests that might be performed include serum levels and scanning tests. What tests can be anticipated to confirm a diagnosis? What are the goals of nursing care for the Cushing’s syndrome patient in the initial period after diagnosis?

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 What populations have the greatest incidence of Addison’s disease?

Adrenal hypofunction (Addison’s disease) (continued) Clinical manifestations/assessment Related to imbalances of hormones, nutrients, and electrolytes Nausea; anorexia Postural hypotension Headache Disorientation Abdominal pain; lower back pain Anxiety Patients experiencing hypofunction of the adrenal glands present with a broad range of symptoms. What electrolytes are imbalanced? What manifestations will be noted with these imbalances? Anxiety is a chief concern for these patients. What should the nurse assess to determine the coping abilities of the patient?

Adrenal hypofunction (Addison’s disease) (continued) Clinical manifestations/assessment Darkly pigmented skin and mucous membranes Weight loss Vomiting Diarrhea Hypoglycemia Hyponatremia Hyperkalemia Assess for adrenal crisis The patient suspected of Addison’s disease can present with integumentary changes. Hyperpigmentation often results. What causes this to occur? When assessing the patient for these changes, where should the nurse focus the observations? Assessment of vital signs is also important as the patient could experience alterations in body temperature. Review the physiological changes that cause an adrenal crisis to occur.

Adrenal hypofunction (Addison’s disease) (continued) Treatment Restore fluid and electrolyte balance Replacement of adrenal hormones Diet high in sodium and low in potassium Adrenal crisis IV corticosteroids in a solution of saline and glucose After diagnosis, the patient with Addison’s disease will require close nursing assessments. Identify the primary patient-centered goals.

Pheochromocytoma Etiology/pathophysiology Chromaffin cell tumor; usually found in the adrenal medulla Causes excessive secretion of epinephrine and norepinephrine Clinical manifestations/assessment Hypertension Medical management/nursing interventions Surgical removal of tumor Pheochromocytoma is a rare occurrence. The tumor may be benign or malignant. Most are benign. What complications may result from this condition?

Disorders of the Pancreas
Diabetes mellitus Etiology/pathophysiology A systemic metabolic disorder that involves improper metabolism of carbohydrates, fats, and proteins Insulin deficiency Risk factors Heredity Environment and lifestyle Viruses Malignancy or surgery of pancreas Diabetes is a chronic metabolic disorder. The exact cause of diabetes is unknown, although there are several factors that are associated with its development.

Diabetes mellitus (continued) Types of diabetes mellitus Type I—insulin dependent (IDDM) Type II—non-insulin dependent (NIDDM) Clinical manifestations/assessment Type I and type II “3 Ps” Polyuria Polydipsia Polyphagia There are several types of diabetes mellitus. Although each type is different, the common theme involves the body’s inability to adequately metabolize glucose. The two most common types of DM are type I diabetes mellitus (IDDM) and type II (noninsulin dependent) diabetes mellitus. How do these types differ in presentation?

Diabetes mellitus (continued) Clinical manifestations/assessment (continued) Type I Sudden onset Weight loss Hyperglycemia Under 40 years old Typically Type I diabetes mellitus demonstrates a rapid onset. It is characterized by a progressive destruction of beta-cell function. What theories explain potential causes of this type of DM? This type of DM is significantly less common than type II.

Diabetes mellitus (continued) Clinical manifestations/assessment (continued) Type II Slow onset May go undetected for years “3 Ps” are usually mild If untreated, may have skin infections and arteriosclerotic conditions What populations are most affected by type II diabetes?

Diabetes mellitus (continued) Diagnostic tests Fasting blood glucose (FBG) Oral glucose tolerance test (OGTT) 2-hour postprandial blood sugar Patient self-monitoring of blood glucose (SMBG) Glycosylated hemoglobin (HbA1c) C-peptide test When making a diagnosis for diabetes mellitus, both the patient’s clinical manifestations and the diagnostic screening test results will be utilized. What glucose screening results signify a probable diagnosis of diabetes? When tests are scheduled, what patient education is required to ensure preoperative compliance and dependable results?

Diabetes mellitus (continued) Medical management/nursing interventions Diet A goal of nutritional therapy is to achieve a blood glucose level of <126 mg/dL Balanced diet should include proteins, carbohydrates, and fats 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 One of the largest components of diabetic management involves the diet. The diet will need to be individualized. What factors should be assessed concerning individual dietary preferences? What role will culture play?

Diabetes mellitus (continued) Medical management/nursing interventions (continued) Diet (continued) American Diabetes Association (ADA) diet Seven exchanges Quantitative diet Need three regular meals with snacks between meals and at bedtime to maintain constant glucose levels The exchange system is a common means of developing a diet for patients. What are the underlying principles to this type of diet?

Diabetes mellitus (continued) Medical management/nursing interventions (continued) Exercise Promotes movement of glucose into the cell Lowers blood glucose Lowers insulin needs Stress of acute illness and surgery Extra insulin may be required Increased risk of ketoacidosis (hyperglycemia) Glucose must be monitored closely Successful diabetes management involves control of a series of interrelated factors. In addition to diet, exercise, illness, and stress play a role in the body’s glucose levels. What advice should be given to patients regarding the incorporation of exercise into their plan of care?

Diabetes mellitus (continued) Medical management/nursing interventions (continued) Medications Insulin Classified by action: Regular; Lente and NPH; Ultralente Classified by type: beef/pork: Humulin/Novolin Injection sites should be rotated to prevent scar tissue formation Sliding scale Insulin administration is needed to sustain the lives of type I diabetes mellitus patients. The type of insulin prescribed will be based upon the individual needs of the patients. Review the types of insulin.

Figure 11-16 A, Rotation of sites for insulin injections.
Insulin is administered via subcutaneous injection. The selection of the site for administration is vital for a diabetic. Where in the body can insulin be injected? How do these sites differ? Discuss the means to rotate injection sites. (From Potter, P.A., Perry, A.G. [2003]. Basic nursing: essentials for practice. [5th ed.]. St. Louis: Mosby.) A, Rotation of sites for insulin injections. B, Injection diagram to track rotation of injection sites.

Diabetes mellitus (continued) Medical management/nursing interventions (continued) Medications Oral hypoglycemic agents Stimulate islet cells to secrete more insulin Only for type II diabetes mellitus Oral hypoglycemic medications are used by those diagnosed with type II diabetes mellitus. How do these medications work? In what patient populations are they contraindicated?

Diabetes mellitus (continued) Medical management/nursing interventions (continued) Patient teaching Good skin care Report any skin abnormalities to physician Special foot care is crucial Do not trim toenails—go to podiatrist No hot water bottles or heating pads Assess for symptoms of hypoglycemia Successful management of diabetes requires patient teaching. The patient must be assessed for readiness to learn. Education is best completed with an emphasis on repetition. What behaviors signal a readiness to learn? How can learning be evaluated?

Diabetes mellitus (continued) Medical management/nursing interventions (continued) Acute complications Coma Diabetic ketoacidosis Hyperglycemic hyperosmolar nonketotic Hypoglycemic reaction Infection When diabetes is not successfully managed, life-threatening complications can result. What are the signs and symptoms of each complication?

Diabetes mellitus (continued) Medical management/nursing interventions (continued) Long-term complications Diabetic retinopathy Cardiovascular problems Renal failure The longer an individual lives with diabetes, the greater the risk of complications. Discuss the ways a patient can reduce long-term complications.

Nursing Process Nursing diagnoses Knowledge, deficient
Self-esteem, risk for situational low Sensory and perceptual alterations: visual Fluid volume, deficient, risk for Infection, risk for Sexual dysfunction Body image, disturbed Coping, ineffective Nutrition, imbalanced Activity intolerance

Chapter 11 Care of the Patient with an Endocrine Disorder

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