Chap 19 Endocrine System
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Transcript of Chap 19 Endocrine System
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The Endocrine System
Normal Changes of Aging
Decreased secretion of insulin
Potential for thyroid function problems with systemicsymptoms that may be attributed to normal aging
Decreased sensitivity to insulin resulting in variation of
blood glucose levels Peripheral tissues may become insulin resistant,
especially with obesity
Review of Thyroid
Hormoneso Thyroxine (T4)o Triiodothyronine (T3)
o Thyrotropin-releasing hormone (TRH) producing ofthyroid-stimulating hormone (TSH) [T4 + T3]production + increased carbohydrate, protein, and
lipid metabolism negative feedback decreasedTSH + TRH
Altered Thyroid Function with Agingo Gland atrophyo Nodularity of thyroid gland, especially areas with
low iodine levelso Elevated thyroid antibody levelso Decreased T4 production but serum T4 unchanged
because of diminished use
Decline in lean body masso Decreasing T3 levelso Elevated TSH levels
Impact of age-related changes on endocrine function.
Diabetes Mellitus (DM)
Statistics for older adultso Highest prevalence ages 65 to 74o Second highest, > 75 yearso Thirteen times > than in persons < 45 years oldo Ethnic groups
Higher for African Americans and Hispanicso African American women < 75 years of age
at highest prevalence, except Hispanicmales after age 75
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More likely to develop microvascularcomplications
More lower limb amputations than Caucasians
Statistics for Older Adultso Higher death rates from other illnesses
Pneumonia
Influenza
Heart diseaseo Greater functional disabilityo More coexisting illnesso Greater risk
Depression
Cognitive impairment
Urinary incontinence
Falls
Persistent pain
Pathophysiologyo Defective insulin secretion and/or defective
utilization of insulin abnormally high bloodglucose damage to multiple organs + bloodvessels + nervous system
Type 1
o -cell destruction lack of or underproduction ofinsulin
o Cause Autoimmune disease
Idiopathico Insulin dependento At risk for ketoacidosis
Type 2o Most prevalent in all age groupso Decreased insulin ability to stimulate glucose
uptake by skeletal muscle + failure to inhibit
hepatic glucose production Insulin resistance +insulin secretory defect rising glucose levels +more insulin production
o Symptoms
Visceral/abdominal obesity
Hypertension
Hyperlipidemia
Coronary artery disease
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Others
Rare ketoacidosis
Complications of DM
o Eye disease loss of vision or even blindnesso Kidney failureo Heart disease
o Nerve damage loss of feeling or pain in thehands, feet, legs, or other parts of the body(peripheral neuropathies)
o Strokeo Poor wound healing
Impaired immune response
Poor tissue perfusion in peripheral vasculardisease
Blood Glucose Elevations withoutDMo
Glucocorticoidso Some diureticso Peritoneal dialysiso Infectiono Acute event, such as myocardial infarction
Diagnostics for DMo Physical examination
Especially sites at high risk for micro- andmacrovascular disease
o
Nutritional assessment including weighto Eye examinationo Electrocardiogram if patient has not had one within
10 years
Diagnostics for DM
Laboratory testso Thyroid function tests (TSH)o Urinalysis to test for albuminuria, and serum
creatinine for renal functiono
Fasting lipid profile to assess cardiovascular risko Glycosylated hemoglobin (HbA1c)
Medication review
Psychosocial assessment
Gait and balance evaluationNKHHC
Symptomatic hyperglycemia + inadequate fluid intakeNKHHC
Complication of type 2 DM with high mortality rate
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o Widespread thrombosiso DIC
Symptoms of hyperglycemiao Dry moutho Extreme thirsto Excessive urinationo Fatigueo Blurred visiono Weight losso Nausea and vomitingo Abdominal pain
Laboratory values for NKHHCo Hyperglycemia (> 500 mg/dl)o Hyperosmolarityo Metabolic acidosiso Serum Na and K levels, usually normalo Increased blood urea nitrogen (BUN) and serum
creatinine levels
Prevalence of Thyroid Disease in Older Persons
Hypothyroidismo Women > men of all ageso Higher in institutionalized elderly than in older
community-residing elderly
Hyperthyroidismo Similar general population rates
Hypothyroidism Symptoms
Hypothyroidismnot the classic symptomso Fatigueo Increased need for sleepo Muscle acheso Dry skino Bradycardia, decreased contractility and stroke
volumeo Increased cholesterol levels (elevations in LDL)o Ataxia and balance difficultieso Hearing loss
Hypothyroidismo Depressiono Cold intoleranceo Hair loss
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o Voice changeso Hypothermiao Periorbital swellingo Decreased appetite and weight loss
Other symptomso Neurological
Headache Vertigo
Relaxation of DTRs
Psychiatric disorders
Cognitive deficits
Visual disturbanceso Sensory
Numbness, tingle, and paresthesias
Other symptomso Musculoskeletal
Muscle fatigue
Cramps and myalgias
Joint effusions
Osteoporosis
Pseudogouto GI
Constipation and gaseous distention
o Achlorhydria and pernicious anemia Note: Older patients may have fewer symptoms than
younger patients.Hypothyroidism Diagnosis
Thyroid function testingo Free T4 and TSH
TSH gold standard
Serum T4
High sensitivity for elderlyo T3
Low in only 50% of hypothyroid elders
Nutritional deficiencies can slow peripheralconversion
Thyroid Function Testingo Other tests
T3-resin uptake
Assesses thyroxine and Triiodothyronine
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Thyroglubulin levels
Marker for thyroid cancer
Thyroid antibody levels
Hashimotos thyroiditis
I 131 uptake
Graves disease
Physical examination
Comprehensive health assessment
Hyperthyroidism
Graves disease
Toxic nodular goiters
Medicationo Amiodaroneo Levothyroxine
Hyperthyroidism Signs and Symptoms
Exhibit fewer and different in elderly than in youngeradults
Most common in older adulto Tachycardia, > 90 beats/minute in older adults
Atrial fibrillationo Weight losso Fatigueo
Weakness or apathy
Hyperthyroidism Diagnosis
Comprehensive health history
Physical examinationo Emphasize
Cardiovascular assessment
BP, pulse rate, and rhythm
Thyroid palpation
Neuromuscular examination Eye exam with vision assessment
Laboratory testso TSH levelo Serum T3, T4, and thyroglobulin levels are lower in
elders with hyperthyroidism
Ultrasound
Fine-needle aspiration
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Risk factors to health for the older person with an endocrineproblem
Risk Factors for Diabetes Mellitus
Genetics
Environmental factorsType 2 DM
Overweight (BMI > 25) with higher percentages of bodyfat
Weight may be normal with upper-body obesity increased waist-to-hip ratio (> 1)
Age over 45 risk increases with age African American, Hispanic/Latino American, Asian
American or Pacific Islander, or Native American ethnicgroups
Parent, brother, or sister with DM
Blood pressure above 140/90 Low levels of HDL (< 40 for men and < 50 for women)
(good cholesterol) and high levels of triglycerides (> 250mg/dL).
Gestational diabetes while pregnant or giving birth to alarge baby (more than 9 pounds)
Sedentary lifestyleexercising less than three times perweek
Impaired glucose tolerance
Random blood glucose levels > 160 mg/dL(NDEP, 2003)
Risk Factors for Developing Hypothyroidism
Older age
Female gender
History or diagnosis of thyroid diseaseo Goitero Thyroid noduleso Thyroiditiso Hyperthyroidism
Treatment of head or neck cancero External radiationo Iodine131
Risk Factors for Developing Hypothyroidism
Family history
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Medicationso Lithiumo Amiodaroneo Sulfonylureaso Salicylateso Furosemideo Phenytoino Rifampino Radioactive contrast dyes
Unique presentation of diabetes and thyroid problems in theolder person.
Symptoms of DM in Older Persons
Anorexia
Incontinence
Falls Pain intolerance
Cognitive or behavioral changes
Symptoms of hyperglycemia (usually > 200 mg/dl)o Polydipsia (excessive thirst)o Weight losso Polyuria (excessive urination)o Polyphagia (excessive hunger)o Blurred visiono Fatigueo Nauseao Fungal and bacterial infections
Older womeno Perineal itching as a result of vaginal candidiasiso Frequent urinary tract infections (UTIs)
Type 1 DM in the Elderly
Slower onset of hyperglycemia symptoms Absence of ketoacidosis
Note: Pancreatic cancer should be considered in olderadults with rapid onset weight loss, polyuria, polydypsia,and polyphagia with elevated blood glucose.
Complications of DM are accelerated in the elderly.
Blood glucose levels before breakfast are exaggerated inolder patients with DM.
Euthyroid sick syndrome
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o Body compensates for decreased metabolic rates decreased TSH levels + low T4 levels
Nursing interventions directed toward assisting older adultswith endocrine problems to develop self-care abilities.
High-Risk Diabetic Foot Exam Presence of protective sensation
Vascular status
Skin integrity
Foot structure
Saving the Diabetic Foot
Identification of feet at risk
Prevention of foot ulcers
Treatment of foot ulcers Prevention of recurrence of foot ulcers
Hygieneo Lubricate dry areaso Dry between toes
Protectiono Mirror on or near the flooro Have podiatrist cut toenails
Management Goals of DM in the Older Person
Control of hyperglycemia and its symptoms
Prevention, evaluation, and treatment of macrovascularand microvascular complications
Self-management through education
Maintenance or improvement of general health status
Individualized Goals of DM
Highly functional older persono A fasting blood glucose level between 100 and 120
mg/dLo A postprandial glucose level of less than 180 mg/dLo An HbA1c under 8%
Older person with advanced microvascular complicationso A fasting glucose level of less than 140 mg/dL
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o A postprandial glucose level of less than 200 to 220mg/dL
o An HbA1c under 10%
Controlling DM in the Older Person
Weight managemento Address elevated lipidso Maintain protein and calcium requirementso Maintain sodium restrictionso Control carbohydrate and fat intake at mealtimeso Eat a high-fiber dieto Snack during peak insulin or oral hypoglycemia
actiono Avoid alcohol
Physical exerciseo Avoid strenuous activities because of risk for retinal
detachmento Exercise carefully with peripheral neuropathieso Check blood glucose prior to exercise if taking
insulin
If < 100 mg/dL, eat additional carbohydrateso Avoid exercise if fasting glucose > 250 mg/dLo Obtain medical assessment prior to implementation
of program
Graded exercise test Radionuclide stress test
Physical exerciseo Benefits of walking
Getting more energy
Reducing stress
Improving sleep
Toning muscles
Controlling appetite
Increasing the number of calories burned bybody daily
Preventing complications of diabetes
Appropriate Use of Medications
Monotherapy or combinationo Combinations
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Simplify dosing
May be less expensive
Antihyperglycemic drugs
Biguanides enhanced glucose uptake + muscleutilization increased insulin sensitivity
Metformino Weight losso Improved lipid profileo Rare hypoglycemiao Do not use if > 80 years or renal failure if serum
creatinine > 1.5 for men or > 1.4 for women
-glucosidase inhibitors slow digestion + delayedabsorption of carbohydrates decreased postprandialhypoglycemia
o Good for normal baseline blood glucose buthyperglycemic after eating a meal
o GI with flatulence and bloating
Thiazolidinediones activate intracellular receptors +repress hepatic glucose production enhanced insulinsensitivity
o Contraindicated
Acute liver disease
ALT > 2.5 times upper limit
CHF
AHA class III or IV
Oral Hypoglycemic Drugs
Sulfonylureas
o Second-generation stimulates beta cells increased insulin
hypoglycemia
Glyburide
If low blood sugar, monitor in hospital for 2to 3 days
Weight gain
Check sulfa allergy
Meglitinide stimulates insulin release in response tomeal
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o Rapid onset with short durationo Do not take with a meal
Insulin
Used primarily with type 1
Long actingo Control blood glucose levelso Provide insulin after meal is digested
Short actingo Provide insulin after meal or snacks
Prevention of Complications
Acute illnesso Vaccinations
Annual influenza
Pneumococcal at age 65
Revaccinate if > 5 years and under 65years at initial vaccination
Hypoglycemiao Symptoms
Feeling nervous or shaky
Sweaty
Onset of excessive fatigue
Check blood twice, including after a snack
Hyperglycemiao Tendency for blood glucose level to rise before
breakfast is exaggerated in older patients with DM
Lipidso LDL < 100 mg/dLo HDL
> 45 mg/dL for men
> 55 mg/dL for women
Educate Regarding Acute Illness Acute illness can cause hyperglycemia
Call healthcare provider ifo Unable to keep food or liquids down or eat normally
for more than 6 hourso Occurrence of severe diarrheao Unintentional weight loss of 5 poundso Oral temperature higher than 101 F
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o Blood glucose levels lower than 60 mg/dL or morethan 300 mg/dL
o Presence of large amounts of ketones in the urineo Difficulty breathingo Feeling sleepy or unable to think clearly
Nursing interventions
Six Geriatric Syndromes Associated with DM RequiringCareful Management
Polypharmacy
Depression
Cognitive impairment
Urinary incontinence
Injurious falls
Pain
The Goals of Therapy for Hypothyroidism Relieve symptoms
Provide sufficient thyroid hormone to decrease raisedserum TSH levels to the normal range
o If history of heart disease cardiac stress testingand complete cardiovascular risk assessment beforeinitiating treatment
Tailored to meet the needs of the individual patiento T4 replacement = Levothyroxine sodium
> 65 years 0.075 to 0.1 mg/day
CAD then begin 0.0125 to 0.025 mg/day
Increase gradually (0.025 mg) for 4 weekintervals
o TSH below normal
Decrease dose of levothyroxineo TSH above normal
Slowly increase dose of levothyroxine
Monitor Medications with Levothyroxine Interfere
o Aluminum hydroxideo Calcium preparationso Cholestyramineo Colestipolo Iron preparationso Sucralfate
Accelerate metabolism
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o Rifampino Anticonvulsants
Monitoring Older Persons Receiving Treatment forHyperthyroidism
I131
o Treatment of choice for older adults
Other antithyroid drugso Prophylthiouracilo Methimazoleo Side effects of both drugs dose related
Skin rash, nausea, hepatitis, and arthritis
Careful monitoring for granulocytopenia
Watch for signs and symptoms of illness
Surgery
Beta-blockers for Hashimotos diseaseo Monitor cardiac status
Nursing Diagnoses for Older Patients with EndocrineDisorders
Type 2 DM and obesityo Imbalanced nutrition: more than body requirementso Risk for infectiono Risk for sensory/perceptual alterations: tactile
Thyroid disorderso Sleep deprivationo Fatigueo Risk for activity intoleranceo Ineffective thermoregulationo Risk for imbalanced body temperature