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Transcript
Nursing of Adults with Medical & Surgical Conditions Endocrine Disorders 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 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 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 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 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 Giantism Signs & Symptoms – Great height – Increased muscle and visceral development – Increased weight – Normal body proportions – Weakness Giantism Treatment – Surgical removal of tumor – Irradiation of the anterior pituitary gland • Requires replacement of pituitary hormones Dwarfism Etiology/Pathophysiology – Deficiency in growth homone – Usually idiopathic Dwarfism Signs & Symptoms – Abnormally short height – Normal body proportion – Appear younger than age – Dental problems due to underdeveloped jaws – Delayed sexual development Dwarfism Treatment – Growth hormone injections – Removal of tumor if present 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 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 Diabetes Insipidus Treatment – ADH preparations • Vasopressin • IV, SQ, nasal spray – Limit caffeine due to diuretic properties 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 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 Graves’ Disease – Insomnia – Tachycardia – Hypertension – Warm, flushed skin – Fine hair – Amenorrhea – Elevated temperature – Diaphoresis – Hand tremors 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 – Post-Op • • • • • Graves’ Disease 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 – Chvostek’s Sign » Abnormal spasm of facial muscles elicited by light tap on the facial nerve – Trousseau’s Sign » Carpal spasm induced by inflation of B/P cuff on the upper arm for 3 minutes Chvostek’s Sign Trousseau’s Sign 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 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 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 Hypothyroidism – Decreased libido – Menstrual irregularities – Thin hair – Skin thick and dry – Enlarged facial appearance – Low hoarse voice – Bradycardia – Hypotension Hypothyroidism Treatment – Medications • • • • Synthroid Levothyroid Proloid Cytomel – Symptomatic treatment 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 Simple Goiter Signs & Symptoms – Enlargement of the thyroid gland – Dysphagia – Hoarseness – Dyspnea Simple Goiter Treatment – Potassium iodide – Diet high in iodine – Surgery • Thyroidectomy Cancer of the Thyroid Etiology/Pathophysiology – Malignancy of thyroid tissue – Very rare Cancer of the Thyroid Signs & Symptoms – Firm, fixed, small, rounded mass or nodule of thyroid Cancer of the Thyroid Treatment – Total thyroidectomy – Thyroid hormone replacement – If metastasis is present: • Radical neck dissection • Radiation therapy, chemotherapy, and radioactive iodine 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 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 Hyperparathyroidism Treatment – Removal of tumor – Removal of one or more parathyroid glands Hypoparthyroidism Etiology/Pathophysiology – Decreased parathyroid hormone – Decreased serum calcium levels – Inadvertent removal or destruction or one or more gland during thyroidectomy Hypoparthyroidism Signs & Symptoms – Neuromuscular hyperexcitability – Involuntary and uncontrollable muscle spasms – Tetany – Laryngeal spasms – Stridor – Cyanosis – Parkinson-like syndrome • Bizarre posturing • Spastic movements – Chvosteck’s sign &Trousseau’s sign 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 Adrenal Hyperfunction Cushing’s 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 Adrenal Hyperfunction Cushing’s Syndrome Signs & Symptoms – Moonface – Buffalo hump – Thin arms and legs – Hypokalemia – Proteinuria – Increased urinary calcium excretion – Susceptible to infections – Depression – Loss of libido Cushing’s Syndrome Adrenal Hyperfunction Cushing’s Syndrome – Ecchymoses and petechiae – Weight gain – Abdominal enlargement – Hirsutism in women • Exessive hair in a masculine distribution – Menstrual irregularities – Deepening of the voice Adrenal Hyperfunction Cushing’s 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 Adrenal Hypofunction Addison’s Disease Etiology/Pathophysiology – Adrenal glands do not secrete adequate amounts of glucocorticoids and mineralocorticoids – May result from • Adrenalectomy • Pituitary hypofunction • Long standing steroid therapy Adrenal Hypofunction Addison’s Disease Signs & Symptoms – Related to imbalances of hormones, nutrients, and electrolytes: – Nausea – Anorexia – Postural hypotension – Headache – Disorientation • Abdominal pain • Lower back pain Adrenal Hypofunction Addison’s Disease – Darkly pigmented skin and mucous membranes – Weight loss – Vomiting – Diarrhea – Hypoglycemia – Hyponatremia – Hyperkalemia Adrenal Hypofunction Addison’s Disease – Adrenal Crisis • • • • • Sudden, severe drop in B/P Nausea & vomiting Extremely high temperature Cyanosis Death Adrenal Hypofunction Addison’s 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 Diabetes Mellitus Type 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 Diabetes Mellitus Type 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 Diabetes Mellitus Type 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 Diabetes Mellitus Type 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 P’s” are usually mild Untreated may have skin infections & arteriosclerotic conditions Diabetes Mellitus Type 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 – 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 patient’s blood sugar levels were consistantly high for 6-8 weeks previously • Values – – – – Non-diabetic adult: Good diabetic control: Fair diabetic control: Poor diabetic control 2.2-4.8% 2.5-5.9% 6-8% above 8% 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 • Need 3 regular meals with snacks between meals and at bedtime to maintain constant glucose levels 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. These foods count as one (1) carbohydrate choice: 1 oz dinner roll 3 graham cracker squares 1 cup (8 oz) milk 1 cup berries 1/2 cup beans 1 - 6" tortilla 1 slice bread 1/2 cup sugar free pudding 1 cup (8 oz) soy milk 1/2 medium grapefruit 1/2 cup corn 1 - 4" waffle 1/2 cup cooked cereal 10-15 potato chips 8 oz yogurt (no added sugar) 3 prunes 1/2 cup green peas 3 cups popcorn 3/4 cup dry cereal (varies) 1/2 cup ice cream 1 taco 12-15 cherries or grapes 3 oz baked potato 4-5 crackers 2 - 4" pancakes 1 - 3" cookie 1 slice thin crust pizza 1 small apple or orange 1 cup winter squash 1 small muffin 1/2 cup pasta or potato salad 1 Tbsp syrup, honey, or sugar 1 cup bean or noodle soup 1 cup melon 1/2 cup canned fruit 15 pretzels 1/2 cup pasta 1/3-1/2 cup fruit juice 1 granola bar 2 Tbsp raisins 1/4 cup dried fruit 1/3 cup rice 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 – 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 • 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 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 • 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 Alternate Methods of Insulin Administration Insulin Pump Alternate Methods of Insulin Administration Alternate Methods of Insulin Administration Combined blood glucose monitoring and insulin dosing system – 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 – Tolinase – Diabinease short acting interm. acting long acting 6-12 hours 12-24 hours up to 60 hours – 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 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 – Signs and Symptoms • • • • • • • • • • • Trembling Perspiration Irrritability Dizziness Muscle weakness Headache Blurred vision Hunger Confusion Comatose Convulsions – Treatment • Increase blood glucose – High calorie drink » Orange juice » Cola – Concentrated sugar » Candy » Jelly – Then complex foods » Carbohydrates » Proteins – If unconsious » 50% dextrose IV Diabetic Acidosis/Ketoacidosis – Hyperglycemia – Usually occurs in Type I (IDDM) – Cause • Lack of insulin • Accumulation of glucose and wastes from fat and protein metabolism – Signs & Symptoms • • • • • • • • Polyuria Polydipsia Polyphagia Nausea & vomiting Weakness Headache Flushed face Late Symptoms – – – – Sweet fruity breath Hypotension Tachycardia Kussmaul’s Respirations » Loud, deep and rapid resp. followed by apnea – BS may be as high as 1000mg/dl – Treatment • Regular insulin IV • Fluids and electrolyte replacement • Find cause and educate patient 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 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 Patient Education – Diet – Exercise – Medications – Hygiene – Consider • • • • Intellect Motivation Physical ability (vision, etc) Social and personal resources – Success depends on ability and willingness