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.