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Chapter 11
Care of the Patient with
an Endocrine Disorder
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Overview of Anatomy and
Physiology
• Endocrine glands and hormones
 The endocrine system is composed of a series of
ductless glands
 It communicates through the use of hormones
• Hormones are chemical messengers that travel though
the bloodstream to their target organ
*Exocrine=glands that secrete through ducts
(sebaceous, sudoriferous)
*Endocrine= ductless glands; release secretions
directly into bloodstream
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 2
Overview of Anatomy and Physiology
•
•
•
•
Works closely with nervous system
Both control homeostasis
Small amount of hormone is very powerful
Too much or too little of one hormone can affect
other hormones (interrelated)
• Controlled by negative feedback system
• Information continually exchanged between target
organ and pituitary gland
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Slide 3
Overview of Anatomy and
Physiology
• Pituitary gland—“master gland”; works closely with
hypothalamus
 Anterior pituitary gland (6 hormones)
• TSH (growth and secretion of thyroid)
• FSH (growth of ovarian follicle, production of estrogen in females,
and production of sperm in males)
• GH (also called somatropic hormone; accelerates the growth of the
body)
• ACTH (growth and secretion of adrenal cortex)
• LH (stimulates ovulation and formation of corpus luteum in
menstruation cycle)
• PROLACTIN (secretion of milk and influences maternal behavior)
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Slide 4
Posterior Pituitary
 Posterior pituitary gland (2 hormones)
• Oxytocin (maintains water balance by increasing the reabsorption
of water by the kidneys)
• ADH (vasopressin) maintains water balance by increasing the
reabsorption of water by the kidneys.
•
•
•
Categorized Based on Function:
TROPIC- target other endocrine structures to increase
their growth and secretions
SEX- influence reproductive changes
ANABOLIC- stimulate the process of building tissues.
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Slide 5
Overview of Anatomy and
Physiology
• Thyroid gland




Butterfly shaped
Thyroxine (T4), Triiodothronine (T3), Calcitonin
Requires iodine for function
Control metabolism, growth and development,
nervous system activity
 Controlled by TSH released by pituitary gland
• Parathyroid gland
 4 glands in posterior surface of thyroid
 PTH; regulates Ca and Phosphorus
Calcium: > levels=impaired heart fx, cardiac arrest
<levels=excitability of nerve cells; increased
muscle stimulation; tetany
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Slide 6
Overview of Anatomy and Physiology
• Adrenal gland
 Adrenal cortex; outer section
• 3 layers; each secrete hormone (steroid)

Mineralocorticoids, glucocorticoids, sex hormones
 Adrenal medulla; inner section
• Epinephrine (adrenaline), norepinephrine
• Pancreas
 Exocrine and endocrine functions
 Insulin and glucagon
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Slide 7
Figure 11-2
(From Thibodeau, G.A., Patton, K.T. [2008]. Structure and function of the body. [13th ed.]. St. Louis: Mosby.)
Pituitary hormones.
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Slide 8
Overview of Anatomy and
Physiology
• Female sex glands
 Ovaries; estrogen & progesterone
 Placenta; releases estrogen & progesterone during
pregnancy
• Male sex glands
 Testes; testosterone
• Thymus gland
 Thymosin; assists with immunity during infancy
• Pineal gland
 Melatonin; biological clock & inhibits gonadotropic
activity
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Slide 9
Disorders of the Pituitary Gland
• Acromegaly
 Etiology/pathophysiology
• Overproduction of growth hormone in the adult
• Causes


Idiopathic hyperplasia of the anterior pituitary gland
Tumor growth in the anterior pituitary gland
• Changes are irreversible
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Slide 10
Disorders of the Pituitary Gland
• Acromegaly (continued)
 Clinical manifestations/assessment
•
•
•
•
•
•
•
•
Enlargement of the cranium and lower jaw
Separation and malocclusion of the teeth
Bulging forehead
Bulbous nose
Thick lips; enlarged tongue; hypertrophy of vocal cords
Generalized coarsening of the facial features
Enlarged hands and feet
Enlarged heart, liver, and spleen
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Slide 11
Disorders of the Pituitary Gland
• Acromegaly (continued)
 Clinical manifestations/assessment (continued)
•
•
•
•
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 common
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Slide 12
Figure 11-6
(Courtesy of the Group for Research in Pathology Education.)
Right: Coarse facial features typical of acromegaly. Left: Patient’s
face several years before she developed the pituitary tumor.
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Slide 13
Acromegaly
• Assessment
 Subjective; pain, visual disturbances, emotional
reactions
 Objective data; monitor bone enlargement, joint
involvement, vital signs, s/s heart failure
• Diagnosis
 CT, MRI, cranial radiographic evaluation
 Complete ophthalmic exam to determine damage to
optic nerve,
 Lab tests: serum GH level, oral GTT (GH usually falls
during challenge but not in acromegaly)
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Slide 14
Disorders of the Pituitary Gland
• Acromegaly (continued)
 Medical management/nursing interventions
• Pharmacological management
• Given to suppress GH release



•
•
•
•
•
Parlodel
Sandostatin
Analgesics
Cryosurgery (application of extreme cold)
Transsphenoidal removal of tissue
Proton beam therapy (radiation)
Soft, easy-to-chew diet
Prognosis: changes irreversible; prone to complications
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Slide 15
Disorders of the Pituitary Gland
• Gigantism
 Etiology/pathophysiology
•
•
•
•
Overproduction of growth hormone
Caused by hyperplasia of the anterior pituitary gland
Occurs in a child before closure of the epiphyses
Results in overgrowth of long bones
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Slide 16
Disorders of the Pituitary Gland
• Gigantism (continued)
 Clinical manifestations/assessment
•
•
•
•
•
Great height
Increased muscle and visceral development
Increased weight
Normal body proportions
Weakness
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Slide 17
Gigantism
 Assessment
• Subjective; patient’s understanding of disease
process/ability to verbalize emotional responses
• Objective; frequent height measurement, use of
adaptive coping mechanisms/family interactions
 Diagnosis
• GH suppression test (glucose loading test); baseline
GH levels high
 Medical management/nursing interventions
• Surgical removal of tumor
• Irradiation of the anterior pituitary gland
Prognosis: shorter than average life span
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Slide 18
Disorders of the Pituitary Gland
• Dwarfism
 Etiology/pathophysiology
• Deficiency in growth hormone; usually idiopathic
• Some cases attributed to autosomal recessive trait
 Clinical manifestations/assessment
•
•
•
•
•
Abnormally short height
Normal body proportion
Appear younger than age
Dental problems due to underdeveloped jaws
Delayed sexual development`
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Slide 19
Disorders of the Pituitary Gland
• Assessment
 Subjective; pt’s understanding of disease process; emotional
response
 Objective; regular ht/wt measurement
• Diagnostic tests
 Radiographic evaluation of wrist for bone age & MRI/CT scan to
r/o pituitary tumor
 Plasma GH levels (will be decreased)
• Medical management/nursing interventions
•
•
•
•
Growth hormone injections
Removal of tumor, if present
Major issues with self-esteem
Prognosis: normal life span; prone to
musculoskeletal/cardiovascular problems
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Slide 20
Disorders of the Pituitary Gland
• Diabetes insipidus
 Etiology/pathophysiology
• Transient or permanent metabolic disorder of the
posterior pituitary
• Deficiency of antidiuretic hormone (ADH)
• Primary or secondary
• Significant electrolyte and fluid imbalances
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Slide 21
Disorders of the Pituitary Gland
• Diabetes insipidus
 Clinical manifestations/assessment
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•
•
•
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Polyuria; polydipsia
May become severely dehydrated
Lethargic
Dry skin; poor skin turgor
Constipation
 Assessment
• Subjective; embarrassment, not restricting fluids
• Objective; skin turgor, I&O, urine color, daily weight
 Diagnosis
• Urine ADH measurement, urine specific gravity, urine
output, serum Na levels
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Slide 22
Diabetes Insipidus
 Medical management/nursing interventions
• ADH preparations
• Limit caffeine due to diuretic properties
• Prognosis: dependant on etiology, usually dependant
on medication for life, constant medical monitoring
since condition may worsen with time
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Slide 23
Posterior Pituitary Hormones




ADH
Vasopressin may cause abdominal cramps,
anaphylaxis, bronchial constriction, circumoral
pallor, diarrhea, flatus, intestinal hyperactivity,
headache, sweating, tremors, urticaria, uterine
cramps, vertigo, vomiting; large doses may
produce death
Oxytocin
ACTH
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24
Disorders of the Thyroid and
Parathyroid Glands
• Hyperthyroidism
 Etiology/pathophysiology
• Also called Graves’ disease, exophthalmic goiter, and
thyrotoxicosis
• Overproduction of the thyroid hormones
• Exaggeration of metabolic processes
• Exact cause unknown
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Slide 25
Disorders of the Thyroid and
Parathyroid Glands
• Hyperthyroidism (continued)
 Clinical manifestations/assessment
•
•
•
•
•
•
•
•
Edema of the anterior portion of the neck
Exophthalmos
Inability to concentrate; memory loss
Dysphagia
Hoarseness
Increased appetite
Weight loss
Nervousness
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Slide 26
Disorders of the Thyroid and
Parathyroid Glands
• Hyperthyroidism (continued)
 Clinical manifestations/assessment (continued)
•
•
•
•
•
•
•
•
Insomnia
Tachycardia; hypertension
Warm, flushed skin
Fine hair
Amenorrhea
Elevated temperature
Diaphoresis
Hand tremors
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Slide 27
Hyperthyroidism
• Assessment
 Subjective: inability to concentrate, memory loss,
feelings of nervousness, jittery, insomnia
 Objective: rapid pulse, high BP, skin warm/flushed,
amenorrhea, hyperactivity, clumsiness, weight loss
• Diagnosis
 Decrease in TSH levels & elevated T3, T4
 Elevated iodine uptake test
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Slide 28
Disorders of the Thyroid and
Parathyroid Glands
• Hyperthyroidism (continued)
 Medical management/nursing interventions
• Pharmacological management



Propylthiouracil (PTU)
Methimazole (Tapazole)
Block production of thyroid hormones
• Radioactive iodine (ablation therapy)
• Subtotal thyroidectomy
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Slide 29
Antithyroid Products
Action

Stop the production of thyroid hormones
Uses

Treatment of hyperthyroidism; to improve
hyperthyroidism in preparation for surgery or
radioactive iodine therapy
Adverse Reactions
Drug Interactions
Nursing Implications and Patient Teaching
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30
Disorders of the Thyroid and
Parathyroid Glands
• Hyperthyroidism (continued)
 Medical management/nursing interventions
(continued)
• Postoperative







Voice rest; voice checks
Avoid hyperextension of the neck
Tracheotomy tray at bedside
Assess for signs and symptoms of internal and external
bleeding
Assess for tetany
o Chvostek’s and Trousseau’s signs
Assess for thyroid crisis
Prognosis: normal life expectancy; may develop
hypothyroidism due to treatment
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Slide 31
Disorders of the Thyroid and
Parathyroid Glands
• Hypothyroidism
 Etiology/pathophysiology
• Insufficient secretion of thyroid hormones
• Slowing of all metabolic processes
• Failure of thyroid or insufficient secretion of thyroidstimulating hormone from pituitary gland
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Slide 32
Disorders of the Thyroid and
Parathyroid Glands
• Hypothyroidism (continued)
 Clinical manifestations/assessment
•
•
•
•
•
•
•
Hypothermia; intolerance to cold
Weight gain
Depression
Impaired memory; slow thought process
Lethargic
Anorexia
Constipation
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Slide 33
Disorders of the Thyroid and
Parathyroid Glands
• Hypothyroidism (continued)
 Clinical manifestations/assessment
•
•
•
•
•
•
•
•
Decreased libido
Menstrual irregularities
Thin hair
Skin thick and dry
Enlarged facial appearance
Low, hoarse voice
Bradycardia
Hypotension
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Slide 34
Hypothyroidism
• Assessment
 Subjective: depression, paranoia, impaired memory,
irritability, coping mechanisms
 Objective: skin, hair, facial features, voice,
bradycardia, decreased BP, weakness, menorrhagia
• Diagnosis
 Physical exam
 Lab tests: TSH, T3, T4,
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Slide 35
Disorders of the Thyroid and
Parathyroid Glands
• Hypothyroidism (continued)
 Medical management/nursing interventions
• Pharmacological management




Synthroid
Levothyroid
Proloid
Cytomel
• Symptomatic treatment
• Prognosis: require medication for life
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Slide 36
Thyroid Hormones
Thyroid Supplements or Replacements
Action

Increase metabolic rate: increase tissue oxygen
consumption, body temperature, heart and respiratory
rate, cardiac output, and carbohydrate, lipid, and protein
metabolism; influence the development of the skeletal
system
Uses

Replacement therapy for several conditions
Table 21-12
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37
Thyroid Hormones (cont.)
Adverse Reactions
 Dysrhythmias, hypertension, tachycardia,
hand tremors, headache, insomnia,
nervousness, diarrhea, vomiting, weight loss,
menstrual irregularities, rash, glycosuria,
hyperglycemia, increase prothrombin time,
and increase serum cholesterol levels
Drug Interactions
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.
38
Thyroid Hormones (cont.)
Nursing Implications and Patient Teaching
 Assessment, diagnosis, planning,
implementation, evaluation
 Administration
 Drug action/expected outcomes
 Drug interactions: diabetes; anticoagulants;
checking with health care provider
 Signs/symptoms of hyperthyroidism and
hypothyroidism
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39
Disorders of the Thyroid and
Parathyroid Glands
• Simple goiter
 Etiology/pathophysiology
• Enlarged thyroid due to low iodine levels
• Enlargement is caused by the accumulation of colloid in
the thyroid follicles
• Usually caused by insufficient dietary intake of iodine
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Slide 40
Disorders of the Thyroid and
Parathyroid Glands
• Simple goiter (continued)
 Clinical manifestations/assessment
•
•
•
•
Enlargement of the thyroid gland
Dysphagia
Hoarseness
Dyspnea
 Assessment
 Medical management/nursing interventions
• Pharmacological management

Potassium iodide
• Diet high in iodine
• Surgery—thyroidectomy
• Prognosis: normal life expectancy
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Slide 41
Figure 11-10
(Courtesy of L. V. Bergman & Associates, Inc., Cold Springs, New York.)
Simple goiter.
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Slide 42
Disorders of the Thyroid and
Parathyroid Glands
• Cancer of the thyroid
 Etiology/pathophysiology
• Malignancy of thyroid tissue; very rare
 Clinical manifestations/assessment
• Firm, fixed, small, rounded mass or nodule on thyroid
 Assessment - What would Claudette’s symptom’s be
with thyroid cancer? What is her treatment?
 Diagnosis; thyroid needle biopsy
 Medical management/nursing interventions
• Total thyroidectomy
• Thyroid hormone replacement
• If metastasis is present: radical neck dissection; radiation,
chemotherapy, and radioactive iodine
• Prognosis: dependent on tumor type
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Slide 43
Disorders of the Thyroid and
Parathyroid Glands
• Hyperparathyroidism
 Etiology/pathophysiology
• Overactivity of the parathyroid, with increased
production of parathyroid hormone
• Hypertrophy of one or more of the parathyroid glands
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Slide 44
Disorders of the Thyroid and
Parathyroid Glands
• Hyperparathyroidism (continued)
 Clinical manifestations/assessment
•
•
•
•
•
•
•
•
Hypercalcemia
Skeletal pain; pain on weight-bearing
Pathological fractures
Kidney stones
Fatigue
Drowsiness
Nausea
Anorexia
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Slide 45
Disorders of the Thyroid and
Parathyroid Glands
• Hyperparathyroidism (continued)
 Assessment
 Diagnosis
• X-ray-skeletal decalcification; PTH increased, serum
phosphorus low, calcium high
 Medical management/nursing interventions
• Removal of tumor
• Removal of one or more parathyroid glands
• Prognosis: good with proper treatment unless due to
carcinoma
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Slide 46
Disorders of the Thyroid and
Parathyroid Glands
• Hypoparathyroidism
 Etiology/pathophysiology
• Decreased parathyroid hormone
• Decreased serum calcium levels
• Inadvertent removal or destruction of one or more
parathyroid glands during thyroidectomy
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Slide 47
Disorders of the Thyroid and
Parathyroid Glands
• Hypoparathyroidism (continued)
 Clinical manifestations/assessment
•
•
•
•
•
•
•
•
Neuromuscular hyperexcitability
Involuntary and uncontrollable muscle spasms
Tetany
Laryngeal spasms
Stridor
Cyanosis
Parkinson-like syndrome
Chvostek’s and Trousseau’s signs
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Slide 48
Disorders of the Thyroid and
Parathyroid Glands
• Hypoparathyroidism (continued)
 Assessment
 Diagnosis
• Decreased serum calcium and PTH, increased serum
phosphorus
 Medical management/nursing interventions
• Pharmacological management

Calcium gluconate or intravenous calcium chloride
• Vitamin D
• Prognosis: fairly normal lifestyle and expectancy
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Slide 49
Disorders of the Adrenal Glands
• 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
• Adrenocorticotropic hormone (ACTH) secreting tumor
outside the pituitary
• Overuse of corticosteroid drugs
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Slide 50
Disorders of the Adrenal Glands
• Adrenal hyperfunction (Cushing’s syndrome)
(continued)
 Clinical manifestations/assessment
•
•
•
•
•
•
•
•
Moonface
Buffalo hump
Thin arms and legs
Hypokalemia; proteinuria
Increased urinary calcium excretion
Susceptible to infections
Depression
Loss of libido
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Slide 51
Disorders of the Adrenal Glands
• Adrenal hyperfunction (Cushing’s syndrome)
(continued)
 Clinical manifestations/assessment
•
•
•
•
•
•
Ecchymoses and petechiae
Weight gain
Abdominal enlargement
Hirsutism in women
Menstrual irregularities
Deepening of the voice
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Slide 52
Disorders of the Adrenal Glands
• Adrenal hyperfunction (Cushing’s syndrome)
(continued)
 Assessment – How would Bartolome adjust to this
diagnosis?
 Diagnosis
• Clinical appearance and lab tests; high cortisol levels,
CT/ultrasound to r/o adrenal/pituitary tumor
 Medical management/nursing interventions
• Treat causative factor


Adrenalectomy for adrenal tumor
Radiation or surgical removal for pituitary tumors
• Lysodren
• Dietary recommendations: Low-sodium, High- K+
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Slide 53
Disorders of the Adrenal Glands
• 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
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Slide 54
Disorders of the Adrenal Glands
• Adrenal hypofunction (Addison’s disease)
(continued)
 Clinical manifestations/assessment
• Usually not detected until 90% adrenal cortex destroyed
• Related to imbalances of hormones, nutrients, and
electrolytes
• Nausea; anorexia
• Postural hypotension
• Headache
• Disorientation
• Abdominal pain; lower back pain
• Anxiety
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Slide 55
Disorders of the Adrenal Glands
• Adrenal hypofunction (Addison’s disease)
(continued)
 Clinical manifestations/assessment
•
•
•
•
•
•
•
•
Darkly pigmented skin and mucous membranes
Weight loss
Vomiting
Diarrhea
Hypoglycemia
Hyponatremia
Hyperkalemia
Assess for adrenal crisis
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Slide 56
Disorders of the Adrenal Glands
• Adrenal hypofunction (Addison’s disease)
(continued)
 Assessment
 Diagnosis
• Decreased serum Na, increased K+, decreased
glucose, cortisol/aldosterone levels low
 Treatment
•
•
•
•
Restore fluid and electrolyte balance
Replacement of adrenal hormones
Diet high in sodium and low in potassium
Adrenal crisis


IV corticosteroids in a solution of saline and glucose
Prognosis: fair with proper treatment
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Slide 57
Adrenocortical Hormones
Actions
 Manufactures glucocorticoids,
mineralocorticoids, and small amounts of sex
hormones
Uses
 Adrenal insufficiency (Addison disease)
 Reduce inflammation in allergic or
immunologic responses; treat hematologic
and malignant diseases
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58
Adrenocortical Hormones (cont.)
Nursing Implications and Patient Teaching

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





Frequent medical monitoring
Avoid smoking
Alcohol use: ulcer development
Risk for infection
Increase dose during times of stress
Signs and symptoms of adrenal insufficiency
Do not stop drug abruptly
MedicAlert bracelet
Immunization considerations
Diet
Storage of drug
Drug interactions
Dosage schedule, missed dosage
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Sex Hormones



Production influenced by the anterior pituitary
Male: testosterone; androgens
Female: estrogen; progesterone
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60
Androgens
Actions

Development of secondary sex characteristics; tissue
building
Uses

Hypogonadism, hypopituitarism, dwarfism, eunuchism,
cryptorchidism, oligospermia, and male androgen
deficiency
Adverse Reactions

Edema due to sodium retention, acne, hirsutism, male
pattern baldness, cholestatic hepatitis with jaundice,
buccal irritation, nausea and vomiting, diarrhea
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61
Androgens (cont.)
Drug Interactions



Increased effects – anticoagulants, antidiabetic agents,
and other drugs
Decreased effects – barbiturates
Concurrent use with corticosteroids increase edema
Nursing Implications

Assessment, diagnosis, planning, implementation, and
evaluation
Drug Table 21-9
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62
Estrogens
Action and Uses

Used for hormone replacement therapy in menopause
and other conditions (ovarian failure); infertility workups; palliative breast cancer treatment
Adverse Reactions
Drug Interactions
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63
Progestins
Action
Uses

Contraception, control excessive uterine bleeding,
treatment of secondary amenorrhea, dysmenorrhea,
premenstrual tension, and control of pain in
endometriosis
Drug Interactions
Nursing Implications and Patient Teaching
Copyright © 2013, 2010, 2006, 2003, 2000, 1995, 1991 by Mosby, an imprint of Elsevier Inc.
64
Disorders of the Adrenal Glands
• Pheochromocytoma
 Etiology/pathophysiology
• Chromaffin cell tumor; usually found in the adrenal
medulla
• Causes excessive secretion of epinephrine and
norepinephrine
 Clinical manifestations/assessment
• Hypertension
 Diagnosis: urinary metanephrines (catecholamine
metabolites) elevated
 Medical management/nursing interventions
• Surgical removal of tumor
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 65
Disorders of the Pancreas
• Diabetes mellitus
 Etiology/pathophysiology
• A systemic metabolic disorder that involves improper
metabolism of carbohydrates, fats, and proteins
• Insulin deficiency
• Risk factors




Heredity – Bartolome had DM 2, who else might?
Environment and lifestyle
Viruses
Malignancy or surgery of pancreas
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 66
Nature of Diabetes

Defining factor




Glucose is primary source of energy for the body
Insulin is needed to be taken out of blood and
transferred into cells
People with diabetes either do not produce insulin
or cannot effectively use insulin produced
Diabetes: group of metabolic diseases
characterized by hyperglycemia
Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
67
Disorders of the Pancreas
• Diabetes mellitus (continued)
 Types of diabetes mellitus
• Type I—insulin dependent (IDDM)
• Type II—non-insulin dependent (NIDDM)
 Clinical manifestations/assessment
• Type I and type II

“3 Poly’s”
o Polyuria
o Polydipsia
o Polyphagia
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 68
Disorders of the Pancreas
• Diabetes mellitus (continued)
 Clinical manifestations/assessment (continued)
• Type I




Sudden onset
Weight loss
Hyperglycemia
Under 40 years old
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 69
Disorders of the Pancreas
• Diabetes mellitus (continued)
 Clinical manifestations/assessment (continued)
• Type II




Slow onset
May go undetected for years
“3 Ps” are usually mild
If untreated, may have skin infections and arteriosclerotic
conditions
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 70
Disorders of the Pancreas
• Diabetes mellitus (continued)
 Diagnostic tests
•
•
•
•
•
•
Fasting blood glucose (FBG)
Oral glucose tolerance test (OGTT)
2-hour postprandial blood sugar
Patient self-monitoring of blood glucose (SMBG)
Glycosylated hemoglobin (HbA1c)
C-peptide test
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 71
Impaired Glucose Tolerance



Above normal fasting blood glucose but not high
enough to be diabetes
A risk factor for type 2 diabetes
Underlying conditions often present
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72
Disorders of the Pancreas
• Diabetes mellitus (continued)
 Medical management/nursing interventions
• Diet




A goal of nutritional therapy is to achieve a blood glucose
level of <126 mg/dL
Balanced diet should include proteins, carbohydrates,
and fats
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
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 73
Disorders of the Pancreas
• Diabetes mellitus
• Medical management/nursing interventions
(continued)
• Diet (continued)


American Diabetes Association (ADA) diet
o Seven exchanges
o Quantitative diet
Need three regular meals with snacks between meals
and at bedtime to maintain constant glucose levels
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 74
Disorders of the Pancreas
• Diabetes mellitus
• Medical management/nursing interventions
(continued)
• Exercise



Promotes movement of glucose into the cell
Lowers blood glucose
Lowers insulin needs
• Stress of acute illness and surgery



Extra insulin may be required
Increased risk of ketoacidosis (hyperglycemia)
Glucose must be monitored closely
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 75
Disorders of the Pancreas
• Diabetes mellitus (continued)
 Medical management/nursing interventions
(continued)
• Medications

Insulin
o Classified by action: Regular; Lente and NPH;
Classified by type: Humulin/Novolin; Humulog,
Lantus
o Injection sites should be rotated to prevent scar
tissue formation
o Understand onset, peak and duration of insulin effect
o Sliding scale
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 76
Disorders of the Pancreas
• Diabetes mellitus (continued)
 Medical management/nursing interventions
(continued)
• Medications



A. Decrease glucose absorption in the intestine
B. Increase receptor activity
C. Oral hypoglycemic agents
o Stimulate islet cells to secrete more insulin
o Only for type II diabetes mellitus
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 77
Oral Hypoglycemics
Action

Stimulate insulin release from pancreatic beta cells;
decrease insulin resistance
Uses


Monotherapy versus combination therapy
Six classes






Sulfonylureas, 1st and 2nd generation
Biguanides
Alpha-glucosidase inhibitors
Meglitinides
Thiazolidinediones
Incretins
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78
Oral Hypoglycemics (cont.)
Adverse Reactions
 Hypoglycemia; allergic reactions
Drug Interactions
 Displacement; potentiation
Thiazide diuretics oppose the secretion of insulin from
beta cells and decrease the effectiveness of
sulfonylureas
Nursing Implications
 Assessment: health history; renal and liver function;
sulfa allergies
Patient Teaching
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79
Disorders of the Pancreas
• Diabetes mellitus (continued)
 Medical management/nursing interventions
(continued)
• Patient teaching




Good skin care
Report any skin abnormalities to physician
Special foot care is crucial
o Do not trim toenails—go to podiatrist
o No hot water bottles or heating pads
Assess for symptoms of hypoglycemia
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 80
Disorders of the Pancreas
• Diabetes mellitus (continued)
 Medical management/nursing interventions
(continued)
• Acute complications


Coma – compare and contrast the 3 below:
o Diabetic ketoacidosis
o Hyperglycemic hyperosmolar nonketotic
o Hypoglycemic reaction
Infection
o Raises metabolic needs resulting in increased insulin
requirements
o Wounds are harder to heal with increase BS levels
o Wounds are harder to heal with decreased circulation
issues
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Slide 81
Disorders of the Pancreas
• Diabetes mellitus (continued)
 Medical management/nursing interventions
(continued)
• Long-term complications -3 “pathy’s”



Diabetic retinopathy
Cardiovascular problems (neuropathy)
Renal failure (nephropathy)
Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.
Slide 82
Question 1
A lack of insulin can increase the production
of free fatty acids. There may be an increase
in glucagon and other hormones and a
decrease in pH. This is called:
1.
2.
3.
4.
Lipodystrophy.
Ketoacidosis.
Hyperglycemia.
Hypoglycemia.
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83
Type 2 Diabetes Mellitus








Accounts for 90% to 95% of cases
Previously called adult-onset or non–insulindependent diabetes
Initial onset usually after age 40 years
Strong genetic link
Prevalent in older, obese people
Caused by insulin resistance or defect
Usually treated with diet, exercise
Now being diagnosed in children due to obesity
issues
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84
Other Types of Diabetes (p. 404)

Causes




Genetic defect
Pancreatic conditions or disease
Endocrinopathies: imbalance with other hormones
in the body
Drug/toxin induced or chemical induced
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85
Symptoms of Diabetes

Laboratory test results




Glycosuria (sugar in urine)
Hyperglycemia (elevated blood sugar)
Abnormal glucose tolerance tests
Progressive results



Water, electrolyte imbalance
Ketoacidosis
Coma
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86
The Metabolic Pattern of
Diabetes

Sources of blood glucose



Dietary intake
Glycogen from liver and muscles
Uses of blood glucose



For immediate energy needs: glycolysis
Change to glycogen for storage: glycogenesis
Convert to fat for longer-term storage: lipogenesis
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87
Pancreatic Hormone Control
(p. 405)

Islets of Langerhans produce:



Insulin
Glucagon
Somatostatin
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88
Insulin

Controls blood sugar






Helps transport glucose into cells
Helps change glucose to glycogen and store it in
liver, muscles
Stimulates changes of glucose to fat for storage as
body fat
Inhibits breakdown of tissue fat and protein
Promotes uptake of amino acids by skeletal
muscles
Influences burning of glucose for energy
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89
Glucagon



Acts in a manner opposite to insulin
Breaks down stored glycogen and fat
Raises blood glucose as needed to protect brain
during sleep or fasting
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90
Somatostatin



A “referee” for several other hormones
Inhibits secretion of insulin, glucagon, and other GI
hormones
Also produced in other parts of the body (e.g.,
hypothalamus)
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91
Long-Term Complications
(p. 408)




Retinopathy: leading cause of new cases of
blindness age 20 to 74
Nephropathy: leading cause of end-stage
renal disease
Neuropathy: nervous system damage in legs
and feet
Heart disease


Dyslipidemia: Elevated triglyceride, decreased
high-density lipoprotein cholesterol
Hypertension: A major comorbid condition
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92
General Management of
Diabetes (p. 409)




Early detection
Prevention of complications
Glucose tolerance test
Goals of care



Maintaining optimal nutrition
Avoiding symptoms
Preventing complications
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General Management of
Diabetes (cont’d) (p. 411)

Self-care skills


People with diabetes must treat themselves
Basic elements of diabetes management



Healthy diet
Physical activity
Ensure adequate insulin
Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
Medical Nutrition Therapy for Individuals
with Diabetes

Individuals with diabetes

Blood glucose levels remain as safe as possible
 Lipid and lipoprotein profile
 Blood pressure levels
 Prevent, or at least slow, the rate of chronic
complications
 Address individual nutrition needs
 Maintain the pleasure of eating
Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
Case Study

Mr. Jones is a 45-year-old black male. He is 25 lbs
overweight. He also has a family history of diabetes.
His most recent lab work reveals an elevated fasting
blood sugar, elevated total cholesterol, and low HDL
level.
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96
Diet Management

Carbohydrate counting



Count carbohydrates for a meal
Inject appropriate amount of insulin to process
glucose
Food exchange system

Organizes food into groups
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Special Concerns (p. 416)







Special diet food items: usually not needed
Alcohol: occasional cautious use allowed
Hypoglycemia: prepare for possibility
Illness: adjust food and insulin accordingly
Travel: consult with dietitian first
Eating out: plan ahead and choose restaurants wisely
Stress: antagonistic to insulin
Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
Diabetes Education Program

Goal: person-centered self-care



Patients taking more active role in their care
Diabetes requires daily survival skills
Diabetes Self-Management Education
(DSME)

Support informed decision-making
 Self-care behaviors
 Problem-solving
 Active collaboration with health care team
Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.
Necessary Skills




Healthy eating
Being active
Monitoring
Medications





Insulin
Oral hypoglycemic agents
Problem-solving
Health coping
Reducing risk
Copyright © 2013 Mosby, Inc., an imprint of Elsevier Inc. All rights reserved.