MED SURG II CHAPTER 56

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MED SURG IICHAPTER 56

• CARING FOR CLIENTS WITH DISORDERS OF THE
  ENDOCRINE SYSTEM

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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

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SIMMONDS 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

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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

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Sydrome of Inappropriate ADH Secretion (SIADH)

• Characterized by renal reabsorption of water
  instead of its 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 IO, v/s, assessment of LOC,

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HYPERTHYROIDISM

• Allso known as Graves disease, Basedows
  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

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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

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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

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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

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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

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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

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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

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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

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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 Chvosteks or
  Trousseaus 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

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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

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DISORDERS OF THE ADRENAL GLANDS

• Adrenal Insufficiency or Addisons 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

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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

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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

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CUSHINGS 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.

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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, IO, wt, assess for edema

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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

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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 Addisons 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

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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.

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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 its initiated slowly
  increased cautiously.