Nursing of Adults with Medical

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Nursing of Adults withMedical Surgical
Conditions

• Endocrine
• Disorders

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Acromegaly

• Etiology/Pathophysiology
• Overproduction of growth hormone in the adult
• Idiopathic hyperplasia of the anterior pituitary
  gland
• No known cause
• Tumor growth in the anterior pituitary gland
• Changes are irreversible

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Acromegaly

• Signs Symptoms
• Enlargement of the cranium and lower jaw
• Separation and malocclusion of the teeth
• Bulging forehead
• Bulbous nose
• Thick lips
• Enlarged tongue
• Generalized coarsening of the facial features
• Enlarged hands and feet
• Enlarged heart, liver, and spleen

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Acromegaly

• Muscle weakness
• Hypertrophy of the joints with pain and stiffness
• Males impotence
• Females deepened voice, increased facial hair,
  amenorrhea
• Partial or complete blindness with pressure on
  the optic nerve due to tumor
• Severe headaches

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Acromegaly

• Treatment
• Medications
• Parlodel
• Sandostatin
• Inhibit production of growth hormone
• Cryosurgery
• Destroy tissue by freezing
• Transphenoidal removal of tissue
• Proton beam therapy
• Low doses of radiation
• Soft easy to chew diet
• Analgesics

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Giantism

• Etiology/Pathophysiology
• Overproduction of growth hormone
• Caused by hyperplasia of the anterior pituitary
  gland
• Occurs in a child before closure of the epiphyses
• Other causes
• Genetic disorders
• Disturbances in sex hormone production

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Giantism

• Signs Symptoms
• Great height
• Increased muscle and visceral development
• Increased weight
• Normal body proportions
• Weakness

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Giantism

• Treatment
• Surgical removal of tumor
• Irradiation of the anterior pituitary gland
• Requires replacement of pituitary hormones

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Dwarfism

• Etiology/Pathophysiology
• Deficiency in growth homone
• Usually idiopathic

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Dwarfism

• Signs Symptoms
• Abnormally short height
• Normal body proportion
• Appear younger than age
• Dental problems due to underdeveloped jaws
• Delayed sexual development

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Dwarfism

• Treatment
• Growth hormone injections
• Removal of tumor if present

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Diabetes Insipidus

• Etiology/Pathophysiology
• Transient or permanent metabolic disorder of the
  posterior pituitary
• Deficiency of antidiuretic hormone
• Primary
• Secondary
• Head injury intracranial tumor, aneurysm, or
  infarct encephalitis or meningitis

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Diabetes Insipidus

• Signs Symptoms
• Polyuria
• Urine very dilute
• May exceed 10 L in 24 hours
• Polydipsia
• Craves cold water
• Up to 40 L of fluid daily
• May become severly dehydrated
• Lethergic
• Dry skin
• Poor skin tugor
• Constipation

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Diabetes Insipidus

• Treatment
• ADH preparations
• Vasopressin
• IV, SQ, nasal spray
• Limit caffeine due to diuretic properties

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Graves Disease

• Etiology/Pathophysiology
• Overproduction of the thyroid hormones
• Exaggeration of metabolic processes
• Exact cause unknown
• Risk factors
• Physical or emotional stress
• Pregnancy
• Adolescence
• Infection
• Genetic
• Autoimmune

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Graves Disease

• Signs Symptoms
• Edema of the anterior portion of the neck
• Enlargement of the thyroid
• Exphtalmos
• Bulging of the eyeballs due to periorbital edema
• Inablility to concentrate
• Memory loss
• Dysphagia
• Hoarsness
• Increased appetite
• Weight loss
• Nervousness

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Graves Disease

• Insomnia
• Tachycardia
• Hypertension
• Warm, flushed skin
• Fine hair
• Amenorrhea
• Elevated temperature
• Diaphoresis
• Hand tremors

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Graves Disease

• Treatment
• Medications
• Propylthiouracil
• Methimazole
• Block production of thyroid hormones
• Radioactive iodine
• Destroys part of thyroid tissue
• Subtotal thyroidectomy
• Part of thyroid is removed

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Graves Disease

• Post-Op
• Voice rest
• Voice checks
• Avoid hyperextention of neck
• Tracheotomy tray at bedside
• Assess for s/s of internal and external bleeding
• High risk of hemorrhage
• Assess for tetany
• May occur due to accidental removal of
  parathyroid glands
• Decreases serum calcium levels
• Chvosteks Sign
• Abnormal spasm of facial muscles elicited by
  light tap on the facial nerve
• Trousseaus Sign
• Carpal spasm induced by inflation of B/P cuff on
  the upper arm for 3 minutes

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Chvosteks Sign
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Trousseaus Sign
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Graves Disease

• Thyroid Crisis
• Caused by manipulation of thyroid
• Releases large amounts of thyroid hormones
• Usually occurs within first 12 hrs
• Exaggerated symptoms of hyperthyroidism
• Can be fatal if untreated

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Hypothyroidism

• Etiology/Pathophysiology
• Insufficient secretion of thyroid hormones
• Slowing of all metabolic processes
• Failure of thyroid or insufficient secretion of
  TSH from pituitary gland
• Myxedema
• Adults
• Cretinism
• Newborns congenital

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Hypothyroidism

• Signs Symptoms
• Depends on degree of thyroid hormone deficiency
• Hypothermia
• Intolerance to cold
• Weight gain
• Depression
• Impaired memory
• Slow thought process
• Lethargic
• Anorexia
• Constipation

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Hypothyroidism

• Decreased libido
• Menstrual irregularities
• Thin hair
• Skin thick and dry
• Enlarged facial appearance
• Low hoarse voice
• Bradycardia
• Hypotension

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Hypothyroidism

• Treatment
• Medications
• Synthroid
• Levothyroid
• Proloid
• Cytomel
• Symptomatic treatment

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Simple Goiter

• Etiology/Pathophysiology
• Enlarged thyroid due to low iodine levels
• Enlargement is caused by the accumulation of
  colloid in the thyroid follicles
• Usually cause by insufficient dietary intake of
  iodine

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Simple Goiter

• Signs Symptoms
• Enlargement of the thyroid gland
• Dysphagia
• Hoarseness
• Dyspnea

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Simple Goiter

• Treatment
• Potassium iodide
• Diet high in iodine
• Surgery
• Thyroidectomy

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Cancer of the Thyroid

• Etiology/Pathophysiology
• Malignancy of thyroid tissue
• Very rare

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Cancer of the Thyroid

• Signs Symptoms
• Firm, fixed, small, rounded mass or nodule of
  thyroid

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Cancer of the Thyroid

• Treatment
• Total thyroidectomy
• Thyroid hormone replacement
• If metastasis is present
• Radical neck dissection
• Radiation therapy, chemotherapy, and radioactive
  iodine

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Hyperparathyroidism

• Etiology/Pathophysiology
• Overactivity of the parathyroid, with increased
  production of parthormone
• Hypertrophy of one or more of the parathyroid
  glands
• Usually due to an adenoma

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Hyperparathyroidism

• Signs Symptoms
• Hypercalcemia
• Calcium leaves the bones and enters the
  bloodstream
• Skeletal pain
• Pain on weight bearing
• Pathological fractures
• Kidney stones
• Fatigue
• Drowsiness
• Nausea
• Anorexia

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Hyperparathyroidism

• Treatment
• Removal of tumor
• Removal of one or more parathyroid glands

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Hypoparthyroidism

• Etiology/Pathophysiology
• Decreased parathyroid hormone
• Decreased serum calcium levels
• Inadvertent removal or destruction or one or more
  gland during thyroidectomy

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Hypoparthyroidism

• Signs Symptoms
• Neuromuscular hyperexcitability
• Involuntary and uncontrollable muscle spasms
• Tetany
• Laryngeal spasms
• Stridor
• Cyanosis
• Parkinson-like syndrome
• Bizarre posturing
• Spastic movements
• Chvostecks sign Trousseaus sign

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Hypoparthyroidism

• Treatment
• Calcium gluconate or calcium chloride IV
• Must be given very slowly due to irritation of
  vessel
• Rate should not exceed 1 ml/min
• Can precipitate cardiac arrest
• Vitamin D
• Increases absorption of calcium

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Adrenal HyperfunctionCushings Syndrome

• Etiology/Pathophysiology
• Plasma levels of adrenocortical hormones are
  increased
• Hyperplasia of adrenal tissue due to
  overstimulation by the pituitary gland
• Tumor of the adrenal cortex
• ACTH secreting tumor outside the pituitary
• Overuse of corticosteriod drugs

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Adrenal HyperfunctionCushings Syndrome

• Signs Symptoms
• Moonface
• Buffalo hump
• Thin arms and legs
• Hypokalemia
• Proteinuria
• Increased urinary calcium excretion
• Susceptible to infections
• Depression
• Loss of libido

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Cushings Syndrome
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Adrenal HyperfunctionCushings Syndrome

• Ecchymoses and petechiae
• Weight gain
• Abdominal enlargement
• Hirsutism in women
• Exessive hair in a masculine distribution
• Menstrual irregularities
• Deepening of the voice

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Adrenal HyperfunctionCushings Syndrome

• Treatment
• Treat causative factor
• Adrenalectomy for adrenal tumor
• Radiation or surgical removal for pituitary
  tumors
• Lysodren
• Cytotoxic agent to decrease production of adrenal
  steroids
• Low sodium, high potassium diet

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Adrenal HypofunctionAddisons Disease

• Etiology/Pathophysiology
• Adrenal glands do not secrete adequate amounts of
  glucocorticoids and mineralocorticoids
• May result from
• Adrenalectomy
• Pituitary hypofunction
• Long standing steroid therapy

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Adrenal HypofunctionAddisons Disease

• Signs Symptoms
• Related to imbalances of hormones, nutrients, and
  electrolytes
• Nausea
• Anorexia
• Postural hypotension
• Headache
• Disorientation
• Abdominal pain
• Lower back pain
• Anxiety

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Adrenal HypofunctionAddisons Disease

• Darkly pigmented skin and mucous membranes
• Weight loss
• Vomiting
• Diarrhea
• Hypoglycemia
• Hyponatremia
• Hyperkalemia

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Adrenal HypofunctionAddisons Disease

• Adrenal Crisis
• Sudden, severe drop in B/P
• Nausea vomiting
• Extremely high temperature
• Cyanosis
• Death

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Adrenal HypofunctionAddisons Disease

• Treatment
• Restore fluid and electrolyte balance
• Replacement of adrenal hormones
• Florinef
• Diet high in sodium and low in potassium
• Adrenal Crisis
• IV corticosteroids in a solution of saline and
  glucose

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Diabetes MellitusType I and Type II

• Etiology/Pathophysiology
• Unknown
• Risk Factors
• Heredity
• Blood relatives of people who have DM (esp Type
  II) are more likely to develop DM
• Environment and lifestyle
• Overweight, sedentary lifestyle are more prone to
  Type I DM
• Viruses
• Chickenpox-type viruses have been associated with
  the development of Type I DM
• Malignancy or Surgery of Pancreas
• Decreased functioning ability

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Diabetes MellitusType I and Type II

• Pathophysiology
• Insulin deficiency
• May be decreased or none
• Insulin is secreted by the beta cells in the
  islets of Langerhans
• Insulin is necessary for the cells to combine O2
  and glucose to produce energy
• If insulin is not present or is reduced, glucose
  accumulates in the blood and is excreted in the
  urine
• The body then uses proteins and fat for energy
  which can cause acidosis

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Diabetes MellitusType I and Type II

• Classifications
• Type I
• Insulin Dependent (IDDM)
• Type II
• Non-insulin Dependent (NIDDM)
• Signs Symptoms
• Type I Type II
• Polyuria
• Polydypsia
• Polyphagia

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Diabetes MellitusType I and Type II

• Type I
• Sudden onset
• Weight loss
• Hyperglycemia
• Under 40 years old
• Type II
• Slow onset
• May go undetected for years
• 3 Ps are usually mild
• Untreated may have skin infections
  arteriosclerotic conditions

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Diabetes MellitusType I and Type II

• Diagnostic Tests
• Urine glucose and acetone
• Neither are normally in urine
• Glucose in urine means the blood glucose has
  exceeded the renal threshold
• Blood glucose
• Venipuncture or capillary
• Glucose is always present in the blood
• Amount can fluctuate according to how much and
  what type of foods have been eaten
• Normal values
• 70-110 mg/dl

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• Oral glucose tolerance test
• Fasting (NPO for at least 8 hours)
• Fasting blood sugar is drawn
• Glucose drink administered
• Blood drawn at 1 hr, 2 hrs, and 3 hrs after drink
• 1hr elevated
• 2hr essentially normal
• 3hr within normal limits
• 2 hour post-parandial blood sugar
• Blood sugar drawn 2 hours after a normal meal
• Values should be within normal limits
• Glycohemoglobin
• Glucose in hemoglobin
• Elevation means that the patients blood sugar
  levels were consistantly high for 6-8 weeks
  previously
• Values
• Non-diabetic adult 2.2-4.8
• Good diabetic control 2.5-5.9
• Fair diabetic control 6-8
• Poor diabetic control above 8

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• Treatment
• Diet
• The cornerstone of treatment
• Usually based on caloric needs (pt. size,
  activity, etc)
• Type II may be controlled by diet alone
• Type I diet is calculated and then the amount of
  insulin required to metabolize it is established
• ADA diet (American Diabetes Association)
• 7 Exchanges
• Free calories
• Vegetables
• Fruits
• Bread
• Meat
• Fats
• Milk
• Quantitative Diet
• Carbohydrates 45-50 of calories
• Proteins 10-20 of calories
• Fats no more than 30 of calories

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Carbohydrate Counting

• Adults with Type 2 diabetes generally need to
  limit carbohydrates to no more than 45-60 grams
  per meal and 15-30 grams for a snack.
• Eat three meals a day with one to three snacks. 
  Try to eat around the same times every day.
• Avoid skipping meals.
• Follow the food guide pyramid.  Pay attention to
  carbohydrate choices.  Stay within your
  recommended serving ranges.
• Limit foods that are high in added sugars and
  fats.  If you do consume foods with added sugar,
  be sure to count them into your carbohydrate
  choices.
• Avoid drinking high sugar beverages such as
  regular sodas, fruit juices, lemonade and punch. 
  All of these can be substituted with diet, low
  calorie, low sugar or light alternatives.

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These foods count as one (1) carbohydrate
choice 1 oz dinner roll 1 cup (8 oz) milk  1/2
cup beans 1 slice bread 1 cup (8 oz) soy
milk  1/2 cup corn  1/2 cup cooked cereal 8 oz
yogurt (no added sugar) 1/2 cup green peas  3/4
cup dry cereal (varies)  1 taco  3 oz baked
potato  2 - 4" pancakes 1 slice thin crust
pizza  1 cup winter squash 1/2 cup pasta or
potato salad 1 cup bean or noodle soup 1/2 cup
canned fruit   1/2 cup pasta 1 granola bar 1/4
cup dried fruit 1/3 cup rice
3 graham cracker squares 1 cup berries 1 - 6"
tortilla 1/2 cup sugar free pudding  1/2 medium
grapefruit  1 - 4" waffle 10-15 potato chips  3
prunes  3 cups popcorn 1/2 cup ice cream 12-15
cherries or grapes 4-5 crackers  1 - 3" cookie 1
small apple or orange 1 small muffin 1 Tbsp
syrup, honey, or sugar 1 cup melon 15
pretzels 1/3-1/2 cup fruit juice 2 Tbsp raisins
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These foods count as two (2) carbohydrate
choices 1 - 8 to 11 oz frozen dinner 1 hamburger
with bun 1 - 2-oz English muffin 1 cup lasagna
(3" x 4" piece) 1 - 2-oz hamburger or hotdog
bun 1 cup macaroni and cheese 1 cup sweetened
yogurt  1 slice thick crust pizza 1 - 7" meat
burrito 1/2 large bag light popcorn 1 medium
banana or pear 1 small bagel 1 cup chili 1 cup
casserole
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• Insulin
• Classified by Action
• Regular
• Fast acting
• Peek action 2-4 hours
• Duration 5-8 hours
• Lente NPH
• Intermediate acting
• Peek action 4-12 hours
• Duration 18-24 hours
• Ultralente
• Long acting
• Peek action 12-18 hours
• Duration 28-36 hours
• Classified by Type
• Beef/Pork
• derived from the pancreas of a pig or cow
• Humulin/Novolin
• synthetic human insulin

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• Regular Insulin is the ONLY form that can be
  given IV!
• Should be administered at room temperature
• Should be discarded after open for 3 months
• Standardized Dose
• 100 units/ml (U100)
• Use ONLY insulin syringes
• Administer subcutaneous

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Insulin Injection Sites

• Injection Sites
• Should be rotated to prevent scar tissue
  formation
• Insulin is not well absorbed in scar tissue
• Sites
• Lateral surface of the upper arms
• Abdomen just below the rib cage
• Buttocks
• Anterior surface of thighs

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• Sliding Scale
• Insulin is given according to blood glucose
  levels
• Regular insulin is only type that should be given
  to scale
• Scales will vary on different patients,
  physicians, etc.
• Sample Scale
• Blood Sugar Insulin
• 200-225 2 units
• 226-250 3 units
• 251-275 4 units
• 276-300 5 units
• above 300 Call MD

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Alternate Methods of Insulin Administration
Insulin Pump
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Alternate Methods of Insulin Administration
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Alternate Methods of Insulin Administration
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Combined blood glucose monitoring and insulin
dosing system
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• Oral hypoglycemic agents
• Stimulate islet cells to secrete more insulin
• Must have some production of insulin by pancreas
• Only for Type II DM
• NOT insulin
• Side Effects
• hypoglycemia
• Types
• Orinase short acting 6-12 hours
• Tolinase interm. acting 12-24 hours
• Diabinease long acting up to 60 hours

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• Hygiene
• Prevention more than treatment
• Decreased resistance to infection
• Wounds heal more slowly
• Proper care of feet
• Clean
• Nail care
• Proper fitting shoes
• No heating pads
• Do NOT trim nails - MD only
• Exercise
• Promotes movement of glucose into the cell by
  changing the cell permeability
• Lowers blood glucose
• Lowers insulin needs

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• Insulin Reaction
• Hypoglycemia
• May be due to a sudden drop to below normal or
  may be due to a sudden drop from extremely high
  to normal
• Pathophysiology
• Too little circulating glucose
• Cause
• Too much insulin OR not enough food

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• Signs and Symptoms
• Trembling
• Perspiration
• Irrritability
• Dizziness
• Muscle weakness
• Headache
• Blurred vision
• Hunger
• Confusion
• Comatose
• Convulsions

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• Treatment
• Increase blood glucose
• High calorie drink
• Orange juice
• Cola
• Concentrated sugar
• Candy
• Jelly
• Then complex foods
• Carbohydrates
• Proteins
• If unconsious
• 50 dextrose IV

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• Diabetic Acidosis/Ketoacidosis
• Hyperglycemia
• Usually occurs in Type I (IDDM)
• Cause
• Lack of insulin
• Accumulation of glucose and wastes from fat and
  protein metabolism

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• Signs Symptoms
• Polyuria
• Polydipsia
• Polyphagia
• Nausea vomiting
• Weakness
• Headache
• Flushed face
• Late Symptoms
• Sweet fruity breath
• Hypotension
• Tachycardia
• Kussmauls Respirations
• Loud, deep and rapid resp. followed by apnea
• BS may be as high as 1000mg/dl

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• Treatment
• Regular insulin IV
• Fluids and electrolyte replacement
• Find cause and educate patient

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• Chronic Complications
• Macrovascular changes
• Caused by atherosclerosis
• Intermittent claudication
• Stroke
• Gangrene
• Coronary artery disease
• Microvascular changes
• Caused by changes in the capillaries
• Eyes
• diabetic retinopathy
• cateracts
• Kidneys
• nephropathy
• Infection
• High BS levels cause poor circulation and
  decreased sensation
• CNS disturbances
• Metabolic imbalances affects the sensory and
  motor fibers

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• Other Complications
• Surgery
• Stresses the body
• Pts. who required no insulin, may now require
  insulin
• Pts. who were on insulin, will probably require
  increased doses
• Tests
• NPO
• Need to consider how long they will be NPO and
  what type insulin they are taking
• Sick Days
• Increased risk of ketoacidosis (hyperglycemia)
• Glucose must be monitored closely

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• Patient Education
• Diet
• Exercise
• Medications
• Hygiene
• Consider
• Intellect
• Motivation
• Physical ability (vision, etc)
• Social and personal resources
• Success depends on ability and willingness