8F Endocrine Finalwithdx

7/29/2019 8F Endocrine Finalwithdx

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Endocrine

COMMON LAB TESTS FOR ENDOCRINE AND HORMONAL DISORDERS

1. Blood or seruma. Serum electrolytesb. Plasma Fasting ACTH

8 AM


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I. Anatomy and PhysiologyA. The endocrine system, together with the neurological system, functions as the

communication system for the bodyB. Endocrine glands secrete hormones

1. Secreted in very small amounts2. Alters the rate of many physiologic activities

a. reproduction

b. metabolismc. growth and developmentd. neurological and mental functions

3. Secreted into the blood4. Regulated by several methods

a. autonomic nervous systemb. changes in concentrations of specific substances in plasmac. feedback system

C. Glands


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D. Pituitary1. Lies in sella turcica above the sphenoid bone2. Consists of two lobes connected by the hypothalamus3. Regulates the other endocrine glands by stimulating target organs4. Controlled by releasing and inhibiting hormones from the hypothalamus

E. Thyroid gland

1. Located at the level of the cricoid cartilage in front of the trachea2. Two highly vascular lobes3. Controls the rate of the body metabolism and blood calcium levels

F. Parathyroid glands - parathormone (PTH)

1. Four small glands located near the thyroid gland2. Controls calcium and phosphorus metabolism

G. Adrenal glands

1. Two small glands lying in the retroperitoneal region2. Functions


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a. cortex - promotes organic metabolism, regulates sodium and potassium,response to stress, preadolescent growth spurt, steroid production

b. medulla - stimulation of sympathetic nervous system, responds to stressH. Pancreas

1. Lies retroperitoneally, with the head of the gland in the duodenal cavity and thetail lying against the spleen

2. Insulin, glucagon secretion into the blood, an endocrine function

3. Excretion of enzymes and bicarbonate that aid digestion and controlscarbohydrate metabolism as an exocrine functionI. Gonads - ovaries, estrogen, progesterone, inhibin - decreases secretion of follicle-

stimulating hormone (FSH); testes, testosterone1. Location: two ovaries are situated in the lower abdomen on each side of the

uterus. The testes are the pair of male sex organs that form within the abdomenbut descend into the scrotum

2. Responsible for secondary sex characteristics and reproductive function


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II. General ConceptsA. Endocrine glands must maintain homeostasis of about 50 billion cells.B. Endocrine glands are ductless, and secrete many hormones directly into the blood or

lymph.

Endocrine Glands and their Secretions

C. These hormones regulate growth; maturation; reproduction; metabolism; the balancesof electrolytes, water, and nutrients; and the balances of behavior and energy

D. Concentration in the bloodstream of most hormones is maintained at a constant level

1. if the hormone concentration rises further, production of that hormone isinhibited - negative feedback

2. if the hormone concentrate lowers in some cases, the hormone production isincreased positive feedback

3. each hormone may be governed by positive or negative feedback

E. Unlike the endocrine, exocrine glands secrete their products through duct(s) into thebody's cavities or onto its surface. Exocrine glands produce sweat (sweat glands), skinoils (sebaceous glands), mucus (mucous membranes), and digestive juices (forexample, the pancreas in its exocrine function).

III. Disorders of the Anterior PituitaryA. Hypopituitarism

1. Definition - underactivity of the front (anterior) pituitary glanda. classifications of pituitary tumors

i. functioning: hormone present in insufficient quantitiesii. non-functioning: hormone absentiii. if in childhood - decreased growth hormone results in dwarfism
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2. Etiology - most common cause: neoplasms, usually benign as a pituitaryadenoma

3. Findings - result from hormone deficiency (hypogonadism)a. hypogonadism, female:

i. amenorrheaii. infertilityiii. decreased libido

iv. breast and uterine atrophyv. loss of axillary and pubic hairvi. vaginal dryness

b. hypogonadism, malei. decreased libidoii. impotenceiii. small, soft testiclesiv. loss of axillary and pubic hair

c. hypothyroidism (because pituitary regulates thyroid glands by thyroidstimulating hormone (TSH))

d. hypoadrenalism (because pituitary regulates adrenal glands by ACTHproduction)

e. may see signs of increased intracranial pressure (ICP)f. SIADH - fluid overload and dilutional hyponatremia related to increased

ADH levels4. Diagnostics

a. history and physical examb. neuro-ophthalmological examc. x-rays ofpituitary fossad. radioimmunoassays of anterior pituitary hormonese. computerized tomogram (CT) scan

5. Managementa. expected outcome: hormone deficiency correctedb. hormone replacement therapy

i. corticosteroid therapy

ii. thyroid hormone replacementiii. sex hormone replacement

c. surgical removal of tumor6. Nursing interventions

a. provide for

i. care of the client with increased ICP

CARE OF CLIENT ON STEROID THERAPY

Teach client to:

1. Never discontinue medications abruptly- could precipitate acute crisis.2. Take medication with breakfast - corresponds to biorhythms and reduces gastric

irritation.3. Take higher dose in AM and lower doses in PM.4. Always take medication with a meal or a snack.

5. Carry extra medication on self during travel.6. Adjust medications during periods of acute or chronic stress such as pregnancy orinfections; contact health care provider.

7. Wear medical identification jewelry or carry medical card .8. Avoid other people with infections or shopping malls, grocery stores, etc in times

when the flu or colds are most evident.

CARE OF THE CLIENT WITH INCREASED INTRACRANIAL PRESSURE

1. Monitor neuro vital signs as ordered2. Maintain fluid restriction as ordered3. Raise head of bed at 30-45 degrees4. Prevent any activities that increase ICP such as straining at stool, coughing, vomiting,

any restrictive clothing around neck, neck rotation, flexion, extension, anxiety5. Observe for herniation syndrome6. Monitor intracranial pressure7. Administer oxygen as ordered8. Seizure precautions
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ii. care of the client undergoing surgeryb. monitor for desired effects of administered medications as orderedc. provide emotional support with referral to support groupsd. teach client

i. medications desired effects and side effectsii. need for lifelong hormone replacement therapy and regular

checks of serum levels

B. Hyperpituitarism1. Definition - anterior pituitary secretes too much growth hormone and/or ACTH2. Etiology

a. usually caused by benign neoplasmb. growth hormone overproduction

i. acromegaly - if growth plates closedii. giantism - if growth plates open

c. ACTH overproduction leads adrenal gland to overproduce cortisone:Cushing's disease

3. Findingsa. may see signs of increased ICPb. acromegaly: excess longitudinal bone growth, increase in density and

size of organs and soft tissuec. prognathismd. coarse facial featurese. prominent forehead and orbital ridgef. large, broad, spade-like handsg. arthritis, kyphosish. prominent tonguei. change in ring or shoe size drastically over short period of time

4. Diagnosticsa. history and physical examb. computerized tomogram (CT) scanc. plasma hormone levels: increased growth hormone, ACTH

5. Managementa. expected outcome: remove tumor and restore hormonal balanceb. surgical removal of tumorc. irradiation of glandd. pharmacologic: growth hormone suppressant: bromocriptine (parlodel)e. physical changes of acromegaly are irreversible

6. Nursing interventionsa. provide

i. care of the client with increased ICPii. care of the client undergoing surgeryiii. care of the client undergoing radiation therapyiv. emotional support

b. assess for signs ofdiabetes insipidus, since removal of a pituitary tumormay injure the posterior pituitary glands and decrease antidiuretichormone (ADH) secretions - drastic fluid loss

c. teach client that treatment usually produces hypopituitarism so lifelonghormone replacement therapy with regular check-ups are required

IV. Disorders of the Posterior PituitaryA. Diabetes insipidus

1. Posterior pituitary gland makes too little antidiuretic hormone (ADH). Body losestoo much water in the urine; plasma osmolality and sodium levels increase.

2. Etiology can include tumor, trauma, inflammation, or psychogenic causes.3. Findings

a. excessive thirst (polydipsia)b. polyuria: as much as 20 liters per day with specific gravity below 1.006c. nocturiad. signs ofdehydratione. constipation

4. Diagnosticsa. water deprivation tests: inability to concentrate urine; also differentiates

between primary DI and nephrogenic DIb. osmotic stimulation
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c. administration of vasopressin (pitressin) or desmopressin acetate(stimate)

d. computerized tomogram (CT) scan5. Management

a. expected outcomes: to correct underlying cause and restore hormonalbalance

b. pharmacotherapy

i. desmopressin acetate (stimate)ii. vasopressin (pitressin) - antidiuretic hormoneiii. lypressin (diapid)iv. chloropropamide (chloronase)v. clofibrate (claripex)vi. carbamazapine (mazepine)

c. IV fluid replacement therapyd. surgical removal of tumor

6. Nursing interventionsa. monitor for findings of dehydration; measure urine; specific gravityb. administer medications as orderedc. monitor fluids and give IV fluids as ordered

d. measure intake and outpute. weigh client dailyf. care of the client with increased ICPg. care of the client undergoing surgeryh. teach client

i. to record intake and outputii. about medications and side effectsiii. to check urine specific gravityiv. the need to wear disease identification jewelry

V. Disorders of the Thyroid GlandA. Hypothyroidism

1. Definition - an underactive thyroid resulting in a lessened secretion of thyroidhormone

a. deficiency of thyroid hormones causing decreased metabolic ratei. affects more womenii. age group: 30 to 50 years of age

b. classificationsi. cretinism: hypothyroidism in children; leads to mental retardationii. hypothyroidism without myxedema: mild thyroid failureiii. hypothyroidism with myxedema: severe thyroid failure; usually

seen in older adultsiv. myxedema coma

I. most severe type of hypothyroidism

II. precipitated by stressIII. findings include:

I. hypothermiaII. bradycardia

III. hypoventilationIV. altered LOC leading to coma

IV. potentially life threatening condition2. Etiology

a. thyroid surgery - may cause hypothyroid state after surgery dependingon extent of thyroid removal

b. treatment for hyperthyroid conditionc. overdosage of thyroid medications

d. deficiency in dietary iodine3. Findings

a. cognitive impairmentb. constipation, fatigue, depressionc. intolerance to coldd. coarse, dry skin; periorbital edema; thick, brittle nailse. bradycardia; increased diastolic pressuref. menstrual changes - increased menstrual flowg. loss of the outer one-third of eyebrows
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h. weight gaini. fluid retention

4. Diagnostics

a. history and physical examb. increased TSHc. decreased serum T3 and T4d. anemiae. decreased basal metabolic rate (BMR)f. elevated cholesterol and triglyceridesg. hypoglycemia

5. Managementa. expected outcomes: to restore hormonal balance and prevent

complications

b. administer synthetic thyroid hormone: levothyroxine sodium (levothroid)c. myxedema coma:

i. IV fluids as orderedii. correct hypothermiaiii. give synthetic thyroid hormone

6. Nursing interventionsa. give medications as orderedb. watch client for signs ofmyxedemac. provide restful environmentd. teach client

i. how to conserve energyii. how to avoid stress

iii. about the medications and side effects - synthyroid is to be takenin the morning on an empty stomach at least one hour beforeany other medications or vitamins or ingestion of milk

iv. the importance of lifelong therapye. protect client from cold

B. Hyperthyroidism (Graves' disease, thyrotoxicosois)1. Definition - overactive thyroid over secretes hormones, and causes increased

basal metabolic rate or hyperactivity of thyroid as a primary disease state2. Etiology - considered autoimmune response

a. women affected more than menb. age group: 30 to 50 years

3. Findingsa. hyperphagia, weight loss, diarrheab. heat intolerancec. exophthalmosd. tachycardiae. palpitationsf. increased systolic BPg. difficulty concentratingh. irritability

TESTS OF THYROID FUNCTION

A. Blood tests1. Serum Thyroxine (T4)2. Thyroid-Binding Globulin (TBG)3. Serum Triiodothyronine (T3)4. T3 Resin Uptake5. Free Thyroid Index (FTI)6. Thyrotropin, Thyroid-Stimulating Hormone (TSH)7. Thyrotropin-Releasing Hormone (TRH) stimulation test8. Thyroid autoantibodies

B. Radiologic and imaging tests1. Radioactive Iodine Uptake (RAIU) I 131 uptake2. Thyroid scan

3. Thyroid ultrasound
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i. hyperactivityj. thin, brittle hair, pliable nails: plummer's nailsk. diaphoresisl. insomniam. reduced tolerance for stress

4. Diagnosticsa. history and physical exam: palpable thyroid enlargement: (goiter)

b. elevated serum T3 and T4 levelsc. elevated radioactive iodine uptaked. presence of thyroid autoantibodiese. decreased TSH (thyroid-stimulating hormone; comes from pituitary)

levels5. Complication: thyrotoxic crisis (thyroid storm)

a. rare but potentially fatalb. breakdown of body's tolerance to chronic hormone excessc. state of extreme hypermetabolismd. precipitating factors: stress, infection, pregnancye. findings include:

1. systolic hypertension

2. hyperthermia3. angina4. infarction or heart failure5. extreme anxiety6. even psychosis

6. Managementa. expected outcomes: to reduce the excess hormone secretion and to

prevent complicationsb. pharmacologic

1. sodium131I2. antithyroid agents: propylthiouracil (PTU)3. beta-adrenergic blocking agents: propranolol (inderol)4. iodides: useful adjunct to decrease vascularity of thyroid pre-

surgical removalc. surgical: thyroidectomy: partial or total removal of thyroid glandd. diet high in calories, protein, carbohydrates

7. Nursing interventionsa. monitor vital signs, especially blood pressure and heart rateb. provide quiet, restful, cool environmentc. monitor diet therapy

d. provide extra fluidse. provide emotional supportf. administer medications as orderedg. teach client

1. about medications and side effects2. stress avoidance measures3. energy conservation measures

h. care of the client undergoing surgeryi. assess for laryngeal nerve damage post-surgery

PHARMACOLOGIC INTERVENTIONS FOR THYROID DISORDERS

1. Propythiouracil (PTU)2. Methimazole (TAPAZOLE)3. Saturated solution of potassium iodide4. Radioactive iodine (131I)5. Levothyroxine sodium (SYNTHROID)6. Liothyronine sodium (CYTOMEL)7. Strong iodine solution (Lugol's solution)8. IV sodium iodide9. Propranolol (Inderal)
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j. assess for excessive swallowing or pooling of blood behind neckindicating hemorrhage

VI. Disorders of the Parathyroid GlandA. Hypoparathyroidism

1. Definition - parathyroid produces too little parathormone; results inhypocalcemia

2. Etiology unknowna. possibly an autoimmune disorderb. most often results from surgical removal of parathyroid glands

3. Findings (mild to severe order)a. neuromuscular

i. irritabilityii. personality changesiii. muscular weakness or crampingiv. numbness of fingersv. tetanyvi. carpopedal spasmsvii. laryngospasms

viii. seizuresb. dry, scaly skinc. hair lossd. abdominal cramping

4. Diagnostics

a. history and physical examb. positive Chvostek's sign (facial muscle twitching when cheek is stroked)c. positive Trousseau's sign (carpopedal spasm as inflated BP cuff is

released)d. decreased serum calciume. increased serum phosphate

5. Managementa. expected outcomes: to restore hormonal balance and prevent

complicationsb. calcium replacement therapy: ideal serum calcium level 8.6mg/dlc. vitamin D preparations facilitate uptake of calciumd. calcium-rich diet

6. Nursing interventionsa. monitor carefully for signs oftetanyb. place airway, suction and tracheotomy tray at bedsidec. institute seizure precautionsd. administer medications as orderede. calcium gluconate kept at bedsidef. teach client

i. about medications and side effectsii. signs of vitamin D toxicityiii. to consume more calcium and get vitamin D from sun exposure

to skiniv. to reduce phosphorus intake: minimize intake of fish, eggs,

cheese and cereals

B. Hyperparathyroidism1. Definition - parathyroid secretes too much parathormone; results in increased

serum calcium (hypercalcemia)2. Etiology

a. benign growth in parathyroid

TESTS OF PARATHYROID FUNCTION

1. Parathyroid hormone (PTH)2. Serum calcium, total3. Serum calcium, ionized

4. Serum phosphate
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b. secondarily as result of kidney disease or osteomalaciac. incidence increases dramatically in both sexes after age 50

3. Findingsa. many clients are asymptomaticb. gastrointestinal: constipation, nausea, vomiting, anorexiac. skeletal: bone pain, demineralization, pathological fracturesd. irritability

e. muscle weakness and fatigue4. Diagnostics

a. history and physical examb. elevated serum calciumc. decreased serum phosphate leveld. x-rays reveal bone demineralization

5. Management

a. expected outcomes: to restore hormonal balance and preventcomplications

b. surgery: removal of parathyroid glands - parathyroidectomy6. Nursing interventions

a. care of the client undergoing surgeryb. after surgery observe for signs ofhypocalcemiac. after surgery, teach client to consume diet rich in calcium

VII. Disorders of the Adrenal GlandA. Addison's disease

1. Definition

a. adrenal cortex secretes too little adrenocorticotropic hormone (ACTH)b. decreases secretion of other adrenal products: mineralocorticoid,

glucocorticoids, and sex hormonesc. relatively rare

2. Etiology - autoimmune adrenalitis3. Findings

a. acute adrenal insufficiency (Addisonian crisis)i. severe headache or back painii. severe generalized muscle weaknessiii. diarrhea or constipationiv. confusionv. lethargy

vi. severe hypotensionvii. circulatory collapse

b. adrenal insufficiencyi. vague complaints or findingsii. fatigueiii. muscle weaknessiv. vague abdominal complaints: anorexia, nausea, vomitingv. personality changesvi. skin pigmentation darkens

PHARMACOLOGIC INTERVENTIONS FOR HYPERPARATHYROIDISM

1. Hydration with 0.9% normal saline solution2. Diuretics3. Plicamycin4. Didronel5. Glucocorticoids6. Phosphate as antihypercalcemic agent7. Calcitonin8. Estrogen9. Etidronate disodium10. Phosphate-binding antacid11. Calcium supplement12. Vitamin D
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4. Diagnostics

a. history and physical examb. ACTH stimulation test: low cortisol level

c. low blood levels of sodium and glucose and high levels of potassiumd. 24-hour urine collection: decreased levels of free cortisol

5. Management

a. expected outcome: to return to hormonal balanceb. Addisonian crisis

i. emergency management ofcirculatory collapse

ii. intravenous hydrocortisonec. chronic insufficiencyi. glucocorticoid replacement therapy: hydrocortisone (cortef)ii. mineralocorticoid replacement therapy: fludrocortisone acetate

(florinef acetate)iii. diet high in protein, carbohydrates, and sodium

6. Nursing interventions during hospitalizationa. administer medications as orderedb. manipulate the environment to reduce stressorsc. preserve the client's energy by assisting with ADL as indicatedd. monitor diet therapy

e. measure intake and output and observe for signs ofhyponatremia,hyperkalemia, and hypoglycemia.f. teach client

i. about medications and side effectsii. the need for lifelong hormone-replacement therapyiii. the need for medical-alert jewelryiv. how to conserve energyv. how to avoid or minimize stressvi. guidelines for diet: high sodium

Test of Adrenal Function

A. Blood and Urine Tests1. Dexamethasone suppression test for cortisol levels2. Fasting prephlebotomy for cortisol plasma level

3. 17-hydroxycorticosterone (Porter-Silber test) 17-OCHS4. 17-ketosteroids5. Aldosterone6. Urinary cortisol level7. Renin level ACTH8. Captopril test

B. Radiologic and Imaging: Angiography of Adrenals

Pharmacologic Interventions for Adrenal Insufficiency

1. Glucocorticoids2. Betamethasone (CELESTONE)3. Cortisone (CORTONE)4. Dexamethasone (DECADRON)5. Hydrocortisone6. Methylprednisone (MEDROL)

7. Prednisolone (DELTA-CORTEF)8. Prednisone (DELTASONE tablets, liquid)9. Mineralocorticoids10. Desoxycorticosterone (DOCA PERCORTEN)11. Fludrocortisone (FLORINEF)
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2. Cushing's syndrome

1. Definition: adrenal gland secretes too much cortisol2. Etiology

f. average age of onset 20 to 40 years of ageg. affects women more often than menh. primary syndrome caused by tumor ofadrenal cortex

i. secondary syndrome caused by an ACTH-producing tumor of pituitaryj. long term steroid therapy

3. Findingsf. personality changesg. hypertensionh. metabolic alkalosisi. weight gain, buffalo hump, truncal obesity

j. change in libidok. moon facel. muscle weaknessm. virilization in women, amenorrhea, or menstrual irregularitiesn. osteoporosis

o. acne orhyperpigmentation4. Diagnostics

f. history and physical examg. blood tests show

i. increased levels of cortisol,ii. increased sodium and glucose,iii. decreased potassium

h. 24-hour urine collection:i. elevated free cortisolii. elevated 17-ketosteroidsiii. elevated 17-hydroxycorticosterone

5. Management

f. expected outcome: to restore hormonal balanceg. surgery for adrenal or pituitary tumorh. irradiation therapyi. pharmacologic

j. adrenal enzyme inhibitors that block enzymes needed for cortisolsynthesis

i. aminogluthemideii. metyraponeiii. mitotane

k. potassium supplementsl. high protein diet with sodium restriction

6. Nursing interventions

f. administer medications as orderedg. monitor diet therapyh. monitor for signs of hypokalemia, hypernatremiai. teach client

i. the need for lifelong treatmentii. about medications and side effectsiii. the need for medical alert jewelryiv. body changes may reverse but may take months to years

j. surgical treatment may cause adrenal or pituitary insufficiency

3. Pheochromocytoma1. Definition

Adrenal medulla secretes too much epinephrine and norepinephrine (called thecatecholamines). Causes excessive stimulation of the sympathetic nervoussystem

2. Etiologya. generally benign tumor of the adrenal medullab. curable, but fatal if untreated

3. Findingsa) severe stress responseb) panic metabolic state
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c) hypertensive crisisd) headache, usually severee) orthostatic hypotensionf) tachycardiag) pallor or flushingh) diaphoresisi) palpitations

j) anxiety, high and sustainedk) hyperglycemial) dysrhythmias

4. Diagnostics

a. increased BMRb. computerized tomogram (CT) scanc. 24-hour urine collection: increased urinary catecholamines

5. Managementf. expected outcomes: to remove the tumor and correct the imbalanceg. surgical removal of the tumor: scheduled only after client has been

normotensive for at least one weekh. antihypertensive agents as needed preopi. alpha-adrenergic blocking agent and beta adrenergic blocking agent

(beta blockers): phentolamine (regitine), nitroprusside (nitropress),propranolol (inderal)

j. tyrosine inhibitors: alphamethylparatyrosine decreases circulatingcatecholamines

k. antidysrhythmic agents as needed preop6. Nursing interventions

f. monitor vital signs, especially blood pressureg. administer medications as orderedh. provide care of the client undergoing surgeryi. if bilateral adrenalectomy performed, lifelong steroid therapy required

j. teach clienti. about medications and side effectsii. need for lifelong followup

VIII. Disorders of the PancreasA. Diabetes mellitus

1. Definition - a condition in which the pancreas produces too little insulin, or cellsstop responding to insulin; results in hyperglycemia

a. type 1 diabetes mellitus: genetic, auto-immune respones; severe insulindeficiency from beta cells stop production of insulin

b. type 2 diabetes mellitus: obesity; cells stop responding to insulin2. Diagnostics

TESTS OF ADRENAL MEDULLA FUNCTIONA. Blood tests

1. Epinephrine, norepinephrine levels2. Vanillylmandelic acid (VMA)

B. Radiologic and imaging: angiography of adrenals

TESTS FOR DIABETES MELLITUS (FUNCTION OF PANCREAS)

1. Glucose Tolerance Test (GTT)2. Glycated Hemoglobin (Glycohemoglobin, Glycosylated Hemoglobin, HbA) - gives

average glucose level for prior two to three months3. Blood glucose - fasting4. C-Peptide Assay (Connecting Peptide Assay)5. Fructosamine Assay6. Blood glucose monitoring - finger sticks7. Serum glucose and osmolarity8. Serum sodium and potassium9. BUN and creatinine10. Urine glucose and ketone monitoring11. Urine specific gravity
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a. history and physical examb. fasting blood sugar: elevated serum glucose levelsc. oral glucose tolerance test (GTT)d. after meal, serum glucose is elevated - post-prandial glucosee. glycosylated hemoglobin test (A1c test)

3. Data collectiona. hyperglycemiab. the 3 "polys" of diabetes mellitus: polydipsia, polyuria, polyphagiac. additional findings: fatigue, hunger, weight lossd. blurred visione. slow wound healing

4. Managementa. diet therapy and weight loss

I. the total number of calories is individualized according to theclient's weight

II. as prescribed by the care provider, the client may be advised tofollow dietary guidelines for Americans (food guide pyramid) or

individualized food exchanges from the American DiabeticAssociation

b. exerciseI. lowers glucose level and improves circulationII. decreases total cholesterol and triglycerides

III. instruct client to monitor glucose before exercisingIV. before exercise, clients who require insulin should eat a

carbohydrate snack with protein to prevent hypoglycemiac. insulin

I. used in type 1 diabetes mellitus (DM) and type 2 DM, if neededfor better control of blood glucose levels

II. regular insulin, the only insulin that is given IV, is used for

ketoacidosisIII. check other medications the client is takingIV. illness, infections, and stress increase the need for insulinV. instruct client about the importance of rotating injection within

one region (the abdomen absorbs insulin the most rapidly)VI. insulin administration: see Pharmacology section of this course

VII. insulin pens, jet injectors, and insulin pumps are used toadminister insulin

d. oral antidiabetic medicationsI. prescribed for clients with type 2 DMII. monitor blood glucose levels

III. check other medications the client is taking

IV. instruct the client to recognize manifestations for hypoglycemiaand hyperglycemia

V. pancreas transplantVI. islet cell transplant

VII. blood glucose monitoring - with different self-check systems5. Medications

a. type 1 DM: insulin therapyb. type 2 DM: oral hypoglycemic agents; late disease insulin may be added

to maintain glycemic control6. Complications

a. hypoglycemia (insulin shock)I. blood sugar falls below 50 mg / dl

II. caused by too much insulin, too little food, or excessive physicalactivity

III. may result from delayed meals, exercise, or vomitingIV. rapid onsetV. findings ofinsulin shock

I. diaphoresis; cold, clammy skinII. anxiety, tremor, slurred speech

III. weaknessIV. nausea
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V. mental confusion, personality changes, altered LOCVI. headache

VI. management of hypoglycemiaI. if client is conscious, give oral simple sugar: hard candy,

honey, Karo syrup, jelly, cola, juiceII. if unconscious: give one mg glucagon IM, IV or

subcutaneous (SC); or 20 to 50 ml 50% dextrose IV push

b. diabetic ketoacidosis (DKA) - an acute complicationI. results from severe insulin deficiencyII. findings

I. blood sugar levels > 350 mg/dlII. elevated ketone levels: sweet odor to breath may also

have odor of someone drinking alcoholIII. metabolic acidosis: Kussmaul's respirations, flushed

appearance, dry skinIV. thirstV. polyuriaVI. drowsiness

VII. anorexia, vomiting

VIII. may lead to shock and comaIX. usual causes:

I. undiagnosed diabetes mellitusII. inadequacy of prescribed therapy for diabetes

mellitusIII. physical stress such as surgery, illness, or trauma

in person with diabetes mellitusIV. caused by increased gluconeogenesis from amino

acids and glycogenolysis in the liverX. management:

I. correct fluid depletion - IV fluidsII. correct electrolyte depletion - replacement

particularly of potassiumIII. correct metabolic acidosis - insulin IV

c. hyperglycemic, hyperosmolar nonketotic coma (HHNKC)I. potentially fatalII. findings

I. severe hyperglycemia; usually > 600 mg/dlII. plasma hyperosmolarity

III. dehydrationIV. altered LOC - decreasedV. absence ofketoacidosis

III. usually precipitated by physical stress such as an infection;IV. in non-diabetics can be due to tube feedings without

supplemental water, or too rapid rate of infusion for parenteralnutritionV. occurs more often in the elderly, typicallyVI. expected: to correct fluid depletion, insulin deficiency, and

electrolyte imbalanced. other chronic complications

I. diabetic triopathyI. retinopathyII. nephropathy

III. neuropathyII. macrovascular disease in the

I. coronary artery

II. peripheral vascular7. Nursing interventionsa. give medications as orderedb. monitor for findings of hyperglycemia or hypoglycemiac. help client monitor blood glucosed. refer client to dietician for planing of mealse. support client emotionallyf. teach client
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I. the importance of balanced, consistent daily focus of diet,medication and exercise

II. self blood-glucose monitoringIII. dietary exchange system or refer to appropriate resourcesIV. about medications and side effectsV. foot care

VI. early reporting of complications ofI. ketoacidosisII. insulin shock

III. long term issuesVII. about insulin administrationVIII. about the need to:

I. eat more before strenuous exerciseII. carry extra rapid-absorbing carbohydrate on person at all

timesIII. wear medical-alert jewelryIV. have regular eye examsV. consider emergency care for insulin shock

Points to Remember

About Insulin

In the pancreas's islets of Langerhans, beta cells secrete insulin-the islet-cell hormone ofmajor physiological importance;

Without sufficient insulin, the body develops diabetes mellitus. Exploration of a number of new delivery systems for insulin is ongoing. Implanted insulin delivery systems, in combination with a glucose sensor may create an

"artificial pancreas." Exercise increases the body's metabolic rate to result in a decrease in blood sugar and an

increase in insulin sensitivity. Signs of hypoglycemia often occur. Illness can disrupt metabolic control and raise blood sugar, which results in an increased need

for insulin. Insulin-dependent clients should be well controlled for at least one week prior to any surgery. Special care for any client with either type of diabetes mellitus should be taken to monitor

blood glucose during and after surgery and adjust insulin accordingly.

About the Thyroid

Following neck surgery, potentially life-threatening complications such as laryngeal edema andtracheal obstruction can occur. Monitor for respiratory distress.

FOOT CARE

1. Wash feet daily with mild soap with tepid water.2. Do not soak feet.3. Pat dry thoroughly especially in between toes; do not rub.4. Observe feet every day, in bright light, for dryness, redness, swelling, sores.5. Check for ingrown toenails, calluses, and corns. If one appears, consult a foot health

care provider.6. Never cut corns or calluses.7. Use lotion to prevent dryness but do not use lotion in between toes.8. Wear cotton socks and change them several times each day if feet perspire.9. Trim toenails only after bathing, when they are soft and pliable.

10. Cut toenails straight across.11. Never go barefoot.12. Do not wear circular garters or anything that constricts blood flow to feet.13. Avoid shoes that fit poorly.14. Treat cuts and scratches right away with antiseptic and topical antibiotic.15. Call health care provider for any sign of infection, blisters, or sores on feet.
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Following thyroid surgery, many clients suffer transient hypocalcemia from hyporfunction orremoval of the parathyroids. Monitor for signs of tetany for up to three days after surgery.

About the Parathyroid

Positive Chvostek's sign: contraction of facial muscle near mouth occurs when light tap isgiven over facial nerve in front of ear.

Positive Trousseau's sign: carpopedal spasm results during the deflation of a blood pressurecuff that has been inflated for at least one minute.

8F Endocrine Finalwithdx

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