MED SURG II CHAPTER 56

							     MED SURG II
     CHAPTER 56

  CARING FOR CLIENTS WITH
DISORDERS OF THE ENDOCRINE
          SYSTEM
            PITUITARY GLAND
               DISORDERS
   ACROMEGALY                    S/S: see fig 56-1, 56-2;
    (hyperpituitarism)             changes are irreversible
     occurs when there is        Treatment-surgical
    an oversecretion of            removal of the pituitary
                                   gland, radiation therapy
    growth hormone (GH)            and use of Parlodel
    after the epiphyses of
                                  Nursing Care: correct
    the long bones have            fluid volume excess or
    sealed/adulthood               deficit, pain relief,
   Causes: tumor of               improve nutrition
    anterior pituitary gland
           SIMMOND’S DISEASE
            Panhypopituitarism
                                  Treatment: replace the
    Very rare disorder; the       needed hormones such
    pituitary gland is             as GH in children,
    destroyed and there is         estrogen in women,
    resulting total lack of        testosterone in men
    pituitary hormonal             if untreated is fatal
    activity                      Nursing: medication
   Causes: postpartum             administration
    emboli, surgery, tumor
    or TB
   S/S: atrophy of gonads
    & genitalia, premature
    aging
         DIABETES INSIPIDUS
   Develops when there is         treatment: nasal
    an insufficient amt of         administration of
    ADH by the pituitary           Desmopressin (DDAVP)
    gland                          and lypressin (Diapid)
     causes: head trauma,         to replace the ADH;
    brain tumors, after            nursing guidelines 56-1
    removal of the pituitary
    gland                         Nursing care: Closely
   Results in production of       monitor I & O, daily wt
    large amts of dilute,          administration of nasal
    urine, as much as              spray
    20L/24 hrs, extreme
    thirst; dilute urine
    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’           Metabolic rate increases
    disease, Basedow’s disease,      More common in women
    thyrotoxicosis, or               S/S: restless, agitation, heat
    exophthalmic goiter               intolerance, increased
   May be caused by                  appetite with wt loss,
    autoimmune disorder,              exophthalmos – see fig 56-4
    heredity, thyroid tumors,        Treatment: use of
    pituitary tumors,                 antithyroid drugs; therapy
    hypothalamic disorders,           table 56-1; radiation, and
    stress or infection               either partial or total
                                      thyroidectomy
    Thyroidectomy, nursing care
   Avoid stimulation of      Postop: assess airway,
    the thyroid gland          assess for hemorrhage,
    during exam to             ability to speak, s/s of
    prevent                    thyrotoxic crisis, s/s of
    oversecretion of           tetany such as muscle
    thyroid hormones &         cramps, numbness &
    resulting thyroid          tingling of the arms &
    storm                      legs
                              See nursing care plan
   Routine preop
                               56-1
    teaching
THYROTOXIC CRISIS OR STORM

   Rare event – life            S/S: Temp as high as
    threatening                   106, rapid pulse,
    Thyroid oversecretes         cardiac arrhythmias,
    T3 & T4                       extreme restlessness &
   Causes: extreme stress,       delirium, chest pain,
    infection, DKA, trauma,       dyspnea
    toxemia of pregnancy,        Treatment: antithyroid
    manipulation of an            drugs, IV corticosteroids
    overactive thyroid            & sodium iodide,
    during surgery or             Propranolol, IV fluids,
    physical exam                 antipyretic measures,O2
                                 Nursing care: monitor
                                  temp & S/S
               Hypothyroidism

   when the thyroid gland         S/S: lethargic, lacks
    does not secrete                energy, forgetful,
    adequate amounts of             chronic headaches,
    thyroid hormone                 dozes frequently during
                                    the day, wt gain, cold
   Severe cases are called         intolerance, dry skin
    myxedema                       Treatment: thyroid
   Results in slowing of all       replacement therapy
    metabolic processes            Nursing care: monitor
   See nursing process             medication
                                    management, may take
                                    time to get the dose of
                                    thyroid hormone correct
            THYROID TUMORS
   Usually benign, but can        If malignant or
    cause hyperthyroidism
                                    symptomatic,
     papillary carcinoma
    most common                     removal of the
    malignant type which            tumor and/or
    usually develops in             thyroid gland & the
    persons who have been
    treated with radiation to
                                    client will have to
    the head & neck                 receive thyroid
   Treatment: none if              replacement therapy
    benign & asymptomatic           the rest of their lives
                        GOITER
    Enlargement of the           S/S: asymptomatic or if
    thyroid gland:                 gets too large can
    endemic, nontoxic,             cause dysphagia,
    nodular                        difficulty breathing
   Causes: deficiency of         Treatment depends on
    iodine in the diet,            the cause. May take
    inability of the thyroid       iodine in salt, foods
    to use iodine, or by           high in iodine, or a
    relative iodine                thyroidectomy may be
    deficiency caused by           done
    increasing body               Nursing: treat
    demands for thyroid            symptoms, increase
    hormones                       iodine in diet
  Disorders of the Parathyroid
            Glands
Hyperparathyroidism
 Primary – most              Secondary – in
  common cause is              response to
  adenoma of one of the        hypocalcemia due to
  parathyroid glands &         vitamin D deficiency,
  results in increased         chronic renal failure,
  urinary excretion of         large doses of thiazide
  phosphorus & loss of         diuretics & excessive
  calcium from the bones       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               S/S: tetany, numbness,
    parathyroid hormone          tingling in fingers or
    which results in             toes or around the lips
    hypocalcemia                 Assess for Chvostek’s or
    Causes: trauma to the       Trousseau’s sign; see
    glands or inadvertent        fig 18-11, 18-12
    removal of all or most      Treatment is IV calcium
    of the gland during          gluconate followed by
    thyroidectomy or             long term
    parathroidectomy             administration of oral
   Affects neuromuscular        calcium supplements,
    function                     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     S/S-see box 56-1
    Addison’s Disease           Medical treatment:
     primary cause:            corticosteriod
    destruction of the           replacement therapy for
    adrenal cortex by            a lifetime (Florinef)
    diseases such as TB         Nursing care:
    secondary cause:            medication
    surgical removal of the      administration. Never
    glands, hemorrhagic          suddenly DC drug.
    infarction,                  Must be tapered see
    hypopituitarism, or          client & family teaching
    suppression of the
    adrenal gland due
     ACUTE ADRENAL CRISIS OR
        ADDISONIAN CRISIS
   A life threatening           May occur suddenly or
                                  gradually & requires
    emergency that may            immediate intervention
    develop due to adrenal       Medical mgmt: IV
    insufficiency                 administration of
                                  corticosterioids, antibiotics
    Causes: severe stress,      S/S: anorexia, n/v, diarrhea,
    salt deprivation,             abd pain, profound
    infection, trauma, cold       weakness, h/a, drop in blood
                                  pressure & shock as the last
    exposure, overexertion,       sign
    or when                      Nursing interventions: early
    corticosteroid                recognition of s/s of crisis &
    therapy is suddenly           medication teaching
    stopped
           Pheochromocytoma
   A tumor, usually              S/S: elevated BP,
    benign, of the adrenal         tremors,
    medulla that causes
    hyperfunction of the
                                   nervousness
    adrenal gland that leads      Treatment is
    to:                            surgical removal of
    an excessive secretion        the tumor
    of epinephrine &              Nursing care: close
    norepinephrine which
    leads to HTN, CVA,             monitoring of BP,
    palpitations &                 medication
    tachycardia                    administration
        CUSHING’S SYNDROME
    Adrenocortical               S/S: muscle wasting,
    hyperfunction                  weakness, symptoms of
     caused by                    DM, moon face, buffalo
    overproduction of ACTH         hump, thin skin, high
    by the pituitary gland,        susceptibility to
    benign or malignant            infection see fig 56-8
    tumors of the adrenal
    cortex or prolonged           Medical treatment
    administration of high         depends on the cause
    doses of corticosteroids      Nursing care: obtain a
   Cushingoid syndrome –          thorough hx, v/s q 4
    fig 56-7                       hrs, assess for s/s of
                                   peptic ulcer dz, DM; see
                                   nursing process.
           Hyperaldosteronism
   Hypersecretion of            S/S: h/a, muscle
    aldosterone creates           weakness, increased
    severe electrolyte            uop, fatigue, HTN,
    imbalances                    cardiac dysrhythmmias
   Causes:                      Medical treatment:
   Primary: tumors or            unilateral
    unknown                       adrenalectomy,
   Secondary: pregnancy,         medications
    CHF, narrowing of the        Nursing: v/s, I&O, wt,
    renal artery, cirrhosis       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.