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Transcript
Endocrine abnormalities PN4 Winter 2008 Common Key Features of Hormones • All hormones exert their effect at low blood concentrations • Receptors on or within target tissues are needed for all hormones to exert an effect • Most hormones (except for thyroid and adrenal medullary hormones) are not stored to any great extent and must be produced as needed • Hormones in the blood are bound to plasma proteins • Only free hormones can bind to their receptor sites Common Key Features of Hormones • Most hormones cause target tissues to increase or decrease their activity • The activity of hormones is of short duration • Continued hormone activity requires continued production and secretion • Clearance of secreted hormones occurs through cellular uptake, enzymatic breakdown, GI excretion or urinary excretion General Assessment Often present as problems associated with: • Nutrition-metabolic • Elimination • Sleep-rest • Sexuality-reproduction Review assessment questions from sem 2 and Iggy pg1452 Physical Assessment • • • • Inspection Palpation Auscultation Psycho-social Diagnostic Test • • • • • • Stimulation/suppression tests Assays Urine tests Test for glucose (look up Hgb A1C) CAT scan; MRI Needle biopsy Hypopituitarism • Deficiency in one or more hormone • Rarely all of the hormones • Results in metabolic abnormalities and sexual dysfunction • Deficiencies of ACTH and TSH are life threatening because they result in decrease of secretions from adrenal and thyroid glands Deficiencies of Gonadotropins • LH and FSH causes ????? • GH causes ????? Etiology • Benign or malignant pituitary tumor • Malnutrition or rapid loss of body fat, i.e. AN • Idiopathic cause • Postpartum hemorrhage • Infection • trauma Disorder of the Anterior Pituitary • Can be primary or secondary • One or more hormones are under or over secreted Treatment • • • • Testosterone Hormone therapy combinations e + p Clomid for pregnancy GH therapy Hyperpituitarism • Often caused by hormone secreting tumor • Causes gigantism or acromegaly Figure 63-1 The clinical features of GH excess Figure 63-2 The progression of acromegaly Pathophysiology • Often caused by a benign tumor • As tumor gets larger, in addition to extra hormone, client suffers from visual disturbances, headache, increased IP • Usually prolactin (PRL) and GH hypersecretion Nursing Diagnosis • Disturbed body image r/t altered physical appearance • Sexual dysfunction r/t actual limitation imposed by disease ( loss of libido, infertility, impotence) Addition ND • • • • • • Acute/chronic pain Fear Anxiety Activity intolerance Disturbed sensory perception Knowledge deficit Treatment • • • • Non-surgical Drugs Radiation Surgical Figure 63-3 The transsphenoidal surgical approach to the pituitary gland Disorders of the posterior pituitary gland • Also called neurohypophysis • Deficiency or excess of vasopressin (ADH) • Results in either diabetes insipidus or SIADH (syndrome of inappropriate antidiuretic hormone) Diabetes Insipidus • Disorder of water metabolism caused by a deficiency of ADH • Results in the excretion of large volumes of dilute urine. Kidneys do not concentrate • Polyuria • Dehydration causes thirst • Either insufficient production or kidneys inability to respond to ADH DI • Can be caused by Lithium or demeclocycline (Declomycin) • Key symptoms are excessive urination and thirst • Cardiovascular Sx • Renal/urinary Sx • Integumentary Sx • Neurologic Sx Treatment • Meds: Diabinese, Nova-Propamide which increase the action of existing ADH • Nrs Care: early detection, I = O, • Administer vasopressin transnasally • Medic alert SIADH • Increased ADH causes water retention resulting in dilution hyponatremia and fluid volume overload • Causes: malignancies, pulmonary causes, CNS disorders, medications • Diagnosis: blood and urine tests that relate to osmolarity and concentration Interventions • Fluid restriction • Drug therapy: diuretics, hypertonic IV, Adrenal Gland hypofunction • Acute adrenal insufficiency is called Addisonian Crisis and is life threatening • Affects electrolytes Na low, K+ high; and glucose levels • Tx: replacement therapy Adrenal hypersecretion • Cushings Syndrome (hyper cortisolism) • Increase in body fat, “buffalo hump”, “moon face”, decreased muscle mass, atrophic skin and bone density, hirsutism, oligomenorrhea Figure 63-6 Appearance of a client with Cushing’s disease or syndrome Endocrine System Problems: Thyroid and Para-thyroid PN 1V Overview • Hormones from the thyroid and para thyroid affect general metabolism, electrolyte balance and excitable membrane activity. • Disturbances usually have widespread clinical symptoms • Sometimes life threatening Hormonal Pathway Figure 62-6 Anatomic location of the thyroid gland Figure 62-9 Palpation of the thyroid gland Hyperthyroidism • • • • Called thyroidtoxicosis State of hypermetabolism Increased heart rate Elevated protein, carb and lipid metabolism • Glucose tolerance is decreased=hyperglyciemic • Fat metabolism increased = fat loss Hyperthyroidism • Over secretion of thyroid changes the secretions of hormones from the hypothalamus and anterior pituitary glands • Influence sex hormone production Etiology • Graves’ Disease or Goiter (auto immune) • Sx of GD: Exophthalmos, pretibial myxedema, • Can also be caused by overmedication of thyroid hormone • Thyroid Storm, Thyroid Crisis Figure 64-2 Exophthalmos Figure 64-3 Goiter Symptoms • • • • • • • Wt. loss Heat intolerance, diaphoresis Palpitations, chest pain, dyspnea Changes in vision, look of eyes Change of energy, weakness, insomnia, F Irritable or depressed Menstrual changes, increase libido Diagnostic and Lab findings • Elevated T3, T4, free T4, decreased TSH, positive RAI uptake scan and thyroid scan Interventions • • • • Monitor cardiovascular sytem Environmental Drugs: Tapazole, iodine, Atenolol Surgery: total or subtotal thyriodectomy – Pre op – Post op – Post discharge Hypothyroidism • Decreased metabolism due to low levels of the thyroid hormone • Can occur at any age/stage • Sx depend on length of time of disease Symptoms • Goiter • Lethargy, diminished reflexes, periorbital edema, bradycardia, dysrhythmia, hypotension, reproductive problems, coarse dry hair that falls out, coarse dry skin, signs of slowed metabolism, anemia, elevated serum lipids Symptoms • Assess for myxedema • Decreased T4 , free T4, normal T3, increased TSH • Managed by giving T4 replacement (Synthroid, Cytomel) Nsg Diagnosis • • • • • • • • Decreased cardiac output Constipation r/f impaired skin integrity R/f activity intolerance r/f sexual dysfunction Disturbed body image Hypothermia Knowledge deficit Nsg Interventions • Meds given in a.m. before or after meals (taken for life) Must use same brand • Adjust environment • Pace activities • Encourage fluid intake and fibre • Medic alert • What to report to MD? Thyroiditis • Inflammation of the thyroid gland • Acute, chronic, subacute • Chronic more common (Hasimotos’s disease) Thyroiditis Acute: bacterial, uncommon – Pain, neck tenderness, malaise, increase Temp; Sub acute: viral, sometimes follows URI - fever, chills, difficulty swallowing, muscle and joint pain, pain that radiates to jaw and ears - lymph nodes hard and enlarged - thyroid function is normal, but may go up or down TX: rest fluids ASA, sometimes c-steroids Thyroiditis Chronic: low thyroidism, males more than females, 30’s to 50’s Autoimmune • Thyroid gland is invaded with antibodies and lymphocytes and gland is destroyed • The more tissue destroyed the more hypo they become and the more TSH increases Chronic con’t • • • • DX: blood test Needle bx Scan RAIU • TX: thyroid hormone to decrease TSH which will decrease size of gland • Surgery • Life long meds Thyroid CA 4 types: • Papillary • Follidular • Medulllary • Anaplastic Types Papillary: most common, females under 40, slow growing, progresses for years before spreading to LN’s. Good cure if confined to gland Follicular: 25% over age 50yrs, invades blood vessels and spreads to bone and lung, rarely spreads to lymph G, prognosis fair Types Medullary: 5-10 % over age 50 yrs, mets via lymphatic Anaplastic: rapid, aggressive tumor invades, poor prognosis, die within 1 yr, surgery palliative Hyperparathyroidism • Occurs in older adults; 2x’s more common in women Etiology: – Primary: hyperplasia or tumor of one of the PT glands, increasing the absorption of calcium from GI tack – Secondary: enlargement d/t chronic hypocalcemia in the presence of elevated PTH – Tertiary; PT glands are enlarged and do not respond to changes in serum C+ usually associated with CRF Assessment findings • Polyuria and renal calculi, anorexia, constipation, nausea, vomiting, abdominal pain, generalized bone pain, pathologic fractures, muscle weakness and atrophy, CNS depression Diagnostic findings & Tx • Elevated serum levels of total calcium; increased PTH; decreased phosphate; possible bone changes on xray and CT • Treatment: decrease serum calcium with NS diuretics and phosphate replacement, surgery to remove involved PT glands Nsg Diagnosis • • • • • • Risk for injury Pain Impaired physical mobility r/f altered urinary elimination r/f constipation Knowledge deficit Nsg Interventions • • • • • Comfort and safety; pace activity etc Strain all urine 2 to 3 lts of fluid and fiber in diet Daily wt, nutrition, Chvostec and Trousseau signs, tetany (post surgery of aggressive tx) • Client education and assess their understanding Hypoparathyroidism • Low PTH levels causing hypocalcemia, usually caused by surgical removal of all or part of gland • Hypocalcemia raises the threshold for excitability in nerve and muscle fibers causing the fibers to be easily stimulated; could lead to life threatening tetany. Manifestations • GI symptoms (pain, n, v, d, anorexia) • Signs of hypocalcemia (anxiety, headache, paresthesia, neuromuscular irritability with tremors and muscle spasm) • Difficulty swallowing, (possibly laryngospasms!) hoarse voice, sensation of tightness in throat, dry hair, patch hair loss, ridged finger nails Diagnostic findings & Tx • Decreased PTH, total calcium, free calcium, increased serum phosphate • Tx: supplemental calcium and Vit D. Nursing education • Instruct ct. about diet high in calcium and Vit D, • identify minimum daily intake, • foods high in calcium such as cheese, milk, turnip greens, almonds, collard greens, beans, peanuts, frankfurters and bologna