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Nursing of Adults with Medical & Surgical Conditions

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Presentation on theme: "Nursing of Adults with Medical & Surgical Conditions"— Presentation transcript:

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

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

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