Post on 24-Apr-2015
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MED SURG IICHAPTER 56
CARING FOR CLIENTS WITH DISORDERS OF THE ENDOCRINE SYSTEM
PITUITARY GLAND DISORDERS
ACROMEGALY (hyperpituitarism)
occurs when there is an oversecretion of growth hormone (GH) after the epiphyses of the long bones have sealed/adulthood
Causes: tumor of anterior pituitary gland
S/S: see fig 56-1, 56-2; changes are irreversible
Treatment-surgical removal of the pituitary gland, radiation therapy and use of Parlodel
Nursing Care: correct fluid volume excess or deficit, pain relief, improve nutrition
SIMMOND’S DISEASEPanhypopituitarism
Very rare disorder; the pituitary gland is destroyed and there is resulting total lack of pituitary hormonal activity
Causes: postpartum emboli, surgery, tumor or TB
S/S: atrophy of gonads & genitalia, premature aging
Treatment: replace the needed hormones such as GH in children, estrogen in women, testosterone in men
if untreated is fatal Nursing: medication
administration
DIABETES INSIPIDUS
Develops when there is an insufficient amt of ADH by the pituitary gland
causes: head trauma, brain tumors, after removal of the pituitary gland
Results in production of large amts of dilute, urine, as much as 20L/24 hrs, extreme thirst; dilute urine
treatment: nasal administration of Desmopressin (DDAVP) and lypressin (Diapid) to replace the ADH; nursing guidelines 56-1
Nursing care: Closely monitor I & O, daily wt administration of nasal spray
Sydrome of Inappropriate ADH Secretion (SIADH)
Characterized by renal reabsorption of water instead of it’s secretion; increasing fluid volume & causing hyponatremia
Causes: lung tumors, CNS disorders, brains tumors, CVAs
S/S: water retention, h/a, muscle cramps, anorexia; n/v, changes is LOC
Medical treatment: eliminate the underlying cause; diuretics; use of IV NaCl if hyponaremia is extreme
Nursing mgmt: I&O, v/s, assessment of LOC,
HYPERTHYROIDISM
Allso known as Graves’ disease, Basedow’s disease, thyrotoxicosis, or exophthalmic goiter
May be caused by autoimmune disorder, heredity, thyroid tumors, pituitary tumors, hypothalamic disorders, stress or infection
Metabolic rate increases More common in women S/S: restless, agitation,
heat intolerance, increased appetite with wt loss, exophthalmos – see fig 56-4
Treatment: use of antithyroid drugs; therapy table 56-1; radiation, and either partial or total thyroidectomy
Thyroidectomy, nursing care
Avoid stimulation of the thyroid gland during exam to prevent oversecretion of thyroid hormones & resulting thyroid storm
Routine preop teaching
Postop: assess airway, assess for hemorrhage, ability to speak, s/s of thyrotoxic crisis, s/s of tetany such as muscle cramps, numbness & tingling of the arms & legs
See nursing care plan 56-1
THYROTOXIC CRISIS OR STORM
Rare event – life threatening
Thyroid oversecretes T3 & T4
Causes: extreme stress, infection, DKA, trauma, toxemia of pregnancy, manipulation of an overactive thyroid during surgery or physical exam
S/S: Temp as high as 106, rapid pulse, cardiac arrhythmias, extreme restlessness & delirium, chest pain, dyspnea
Treatment: antithyroid drugs, IV corticosteroids & sodium iodide, Propranolol, IV fluids, antipyretic measures,O2
Nursing care: monitor temp & S/S
Hypothyroidism
when the thyroid gland does not secrete adequate amounts of thyroid hormone
Severe cases are called myxedema
Results in slowing of all metabolic processes
See nursing process
S/S: lethargic, lacks energy, forgetful, chronic headaches, dozes frequently during the day, wt gain, cold intolerance, dry skin
Treatment: thyroid replacement therapy
Nursing care: monitor medication management, may take time to get the dose of thyroid hormone correct
THYROID TUMORS
Usually benign, but can cause hyperthyroidism
papillary carcinoma most common malignant type which usually develops in persons who have been treated with radiation to the head & neck
Treatment: none if benign & asymptomatic
If malignant or symptomatic, removal of the tumor and/or thyroid gland & the client will have to receive thyroid replacement therapy the rest of their lives
GOITER
Enlargement of the thyroid gland: endemic, nontoxic, nodular
Causes: deficiency of iodine in the diet, inability of the thyroid to use iodine, or by relative iodine deficiency caused by increasing body demands for thyroid hormones
S/S: asymptomatic or if gets too large can cause dysphagia, difficulty breathing
Treatment depends on the cause. May take iodine in salt, foods high in iodine, or a thyroidectomy may be done
Nursing: treat symptoms, increase iodine in diet
Disorders of the Parathyroid Glands
Hyperparathyroidism
Primary – most common cause is adenoma of one of the parathyroid glands & results in increased urinary excretion of phosphorus & loss of calcium from the bones
Secondary – in response to hypocalcemia due to vitamin D deficiency, chronic renal failure, large doses of thiazide diuretics & excessive use of laxatives & calcium supplements
HYPERPARATHYROIDISM
S/S: fatigue, muscle weakness, cardiac dysrhythmias, skeletal weakness, pain, pathological fractures, n/v, constipation & kidney stones
Med/Surg treatment: primary – surgical removal of tissue secondary – correct the cause Monitor I & O, s/s of renal calculi, pain
management, encourage fluids, importance of following treatment plan, safety
HYPOPARATHYROIDISM
Deficiency of parathyroid hormone which results in hypocalcemia
Causes: trauma to the glands or inadvertent removal of all or most of the gland during thyroidectomy or parathroidectomy
Affects neuromuscular function
S/S: tetany, numbness, tingling in fingers or toes or around the lips Assess for Chvostek’s or Trousseau’s sign; see fig 18-11, 18-12
Treatment is IV calcium gluconate followed by long term administration of oral calcium supplements, vit D or Vit D2
Nursing management of hypoparathyroidism
Assess for s/s of tetany or muscle hypertonia with spasm & tremor
Be prepared to administer IV Calcium Gluconate & assess for adverse reactions
Assess for muscle spasm Assess v/s with particular attention to heart
rate & rhythm Keep emergency equipment available in case
of respiratory distress Long term care: stress importance of diet &
drug therapy
DISORDERS OF THE ADRENAL GLANDS
Adrenal Insufficiency or Addison’s Disease
primary cause: destruction of the adrenal cortex by diseases such as TB
secondary cause: surgical removal of the glands, hemorrhagic infarction, hypopituitarism, or suppression of the adrenal gland due corticosteroid admin
S/S-see box 56-1 Medical treatment: corticosteriod
replacement therapy for a lifetime (Florinef)
Nursing care: medication administration. Never suddenly DC drug. Must be tapered see client & family teaching
ACUTE ADRENAL CRISIS OR ADDISONIAN CRISIS
A life threatening emergency that may develop due to adrenal insufficiency
Causes: severe stress, salt deprivation, infection, trauma, cold exposure, overexertion, or when corticosteroid therapy is suddenly stopped
May occur suddenly or gradually & requires immediate intervention
Medical mgmt: IV administration of corticosterioids, antibiotics
S/S: anorexia, n/v, diarrhea, abd pain, profound weakness, h/a, drop in blood pressure & shock as the last sign
Nursing interventions: early recognition of s/s of crisis & medication teaching
Pheochromocytoma
A tumor, usually benign, of the adrenal medulla that causes hyperfunction of the adrenal gland that leads to:
an excessive secretion of epinephrine & norepinephrine which leads to HTN, CVA, palpitations & tachycardia
S/S: elevated BP, tremors, nervousness
Treatment is surgical removal of the tumor
Nursing care: close monitoring of BP, medication administration
CUSHING’S SYNDROME
Adrenocortical hyperfunction
caused by overproduction of ACTH by the pituitary gland, benign or malignant tumors of the adrenal cortex or prolonged administration of high doses of corticosteroids
Cushingoid syndrome – fig 56-7
S/S: muscle wasting, weakness, symptoms of DM, moon face, buffalo hump, thin skin, high susceptibility to infection see fig 56-8
Medical treatment depends on the cause
Nursing care: obtain a thorough hx, v/s q 4 hrs, assess for s/s of peptic ulcer dz, DM; see nursing process.
Hyperaldosteronism
Hypersecretion of aldosterone creates severe electrolyte imbalances
Causes: Primary: tumors or
unknown Secondary:
pregnancy, CHF, narrowing of the renal artery, cirrhosis
S/S: h/a, muscle weakness, increased uop, fatigue, HTN, cardiac dysrhythmmias
Medical treatment: unilateral adrenalectomy, medications
Nursing: v/s, I&O, wt, assess for edema
ADRENALECTOMY
Usually done to remove a cancerous tumor
Preoperative: reduce anxiety, bedrest Postoperative: note if 1 or both
adrenals were removed, observe for s/s of adrenal insufficiency which may be caused by inappropriate dosing of replacement corticosteroid medication
See nursing process See client & family teaching, pg 878
General Nutritional Considerations
Clients with hyperthyroidism may need 4500 to 5000 cal/day or more to maintain normal weight; encourage intake of frequent meals & nutritionally dense foods
Clients with hyperparathyroidism should drink at least 3-4 litres fluid/daily to dilute urine & prevent renal stones
Clients with Addison’s dz who are being treated with cortisone may require a high Na+ diet; but high Na+ diets are contraindicated in those taking Florinef because it is a Na+ retaining hormone
General Pharmalogical Considerations
Substances that contain iodine like some cough meds & dyes can interfere with some thyroid tests
The most serious adverse effect of antithyroid drugs is agranulocytosis. Instruct the client to report sore throat, fever, chills, h/a, malaise or weakness.
Potassium iodide can protect thyroid gland from effects of radiation exposure after release of radiation in a power plant accident or nuclear bomb.
During initial thyroid replacement therapy the most common side effect is s/s of hyperthyroidism
The dose of thyroid replacement therapy may need to be adjusted over time until the optimal dose is attained.
The most common adverse effects of Florinef are frontal & occipital h/a, athralgia, edema & HTN.
General Gerontological Considerations
The symptoms of thyroid disease in older adults are atypical or minor & easily attributed to other problems.
Typical symptoms are anorexia, wt loss, palpitations & angina.
Hypothyroidism is also difficult to diagnose in older adults because symptoms mimic normal aging-anorexia, constipation, joint stiffness & apathy
Dosages of thyroid replacement therapy are lower in older adults, and it’s initiated slowly & increased cautiously.