Endocrine & Musculoskeletal Bullets

8/3/2019 Endocrine & Musculoskeletal Bullets

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ENDOCRINE DISORDERS

Prepared by : LORI R.LARA, R.N.

ABNORMAL PITUARY FUNCTIONS

Hyper and Hyposecretion of Growth Hormone Growth hormone (Somatotropin) a protein hormone that increases protein

synthesis the breakdown of fatty acids in adipose tissue and increases the glucose level inthe blood.

Insufficient secretion during childhood results in generalized limited growth and

dwarfism.

Hypersecretion would result in Cushings syndrome or acromegaly.

Panhypopituarism (Simmonds Disease)

Extreme weight loss Emaciation

Hair loss

Impotence

Atrophy of all endocrine glands and organs

Amenorrhea

Hypometabolism

Hypoglycemia

Pituitary Tumor

Usually occurs in the anterior lobe of the pituitary and characterized as benign,small and encapsulated

Medical and Surgical Management

Transphenoidal Hypophysectomy

Stereotactic radiation therapy, bromocriptine and octreotide

Nursing Management for Patient who has Undergone Transphenoidal Hypophysectomy:

Asses for any signs of increasing ICP and CSF leaks. Elevate the head to 20

degrees and notify physician in case CSF leaks. Monitor for seizure and stress ulcer

Apply cool, moist packs over the eyes for ecchymosis and periorbital edema.

Administer artificial tears or ointment as prescribe

Use sterile technique for all dressing changes to prevent meningitis.

Do not suction through the nose if the nasal membrane is torn, CSF may leak and

infection may occur. Do suction by other routs minimally, suctioning increases ICP.


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Types of Hypophysectomy and the Nursing Consideration

Supratentorial Surgery: Elevate head of the bed to 30 degrees.

Infrantentorial Surgery : Keep client flat on the bed to prevent pressure on the

brainstem. Turn every 2 hrs. but never onto the back

Posterior Fossa Surgery : Position on either side but never on the back. A pillow

may be placed under the head for support. Monitor for changes in vital signs because the

surgery site is close to vital brain stem functions. Monitor for cardiac arrythmias and air

embolism..

Bony Flap : Place the client only on the unoperated side or back.

Diabetes Insipidus

A condition charecterized by a deficiency of antidiuretic hormone (ADH)

Results in water imbalance characterized by polydipsia and a large amount of

dilute urine

Signs and Symptoms

Polyuria

Polydypsia

Excretion of urine with abnormally low specific gravity

Medical and/or Surgical Management

Vasopressin (e.g. Desmopressin or DDAVP) and lypressin (e.d Diapid) may be

given nasally.

Benzothiadiazine diuretics, clofibrate and chlorpropamide may be given as

antidiuretics.

If it is secondary to tumor, excision of the tumor may be curative.

ABNORMAL THYROID FUNCTION

Diagnostic Evaluation

Serum Immunoassay for Thyroid Stimulating Hormone the single best

screening test of thyroid function because of its high sensitivity.

Serum Immunoassay for Free Thyroxine (FT4) test to confirm an abnormal

thyroid-stimulating hormone


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Hypothyroidism

Deficiency of thyroid hormones thyoxine (T4) and triodothyronine (T3) resulting

in slowed body metabolism and pronounced personality changes

Signs and Symptoms

Decreased heart rate, stroke volume and cardiac output

Hyperlipidemia, hypercholesterolemia

Anemia, easy bruising

Dyspnea, fatigue, lethargy

Fluid retention, and possible weight gain

Anorexia and constipation

Sensitivity to cold, decreased ability to sweat

Slowed physical and mental reactions

Dry, course skin and hair, brittle nails, alopecia

Normal to enlarge thyroid gland

Expressionless face

Periorbital edema

Slow deliberate speech

Myxedema, myxedema coma

Medical and/or surgical Management

Thyroid hormone preparation (synthetic levothyroxine, desiccated thyroid)

Iodine preparations and Iodine enriched diet

Surgery is done if the goiter is very large and not responding to therapy.

Nursing Management

Monitor for angina and dysrhythmias

Assess symptoms of thyrotoxicosis: (tachycardia, diarrhea, sweating, agitation,

tremors, and shortness of breath)

Instruct patient to avoid extreme cold until stable

Avoid using heating pads or electric blankets because of potential vasodilation,

loss of heat and vascular collapse

Administer narcotics and sedatives judiciously due to decreased metabolic rate.


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Educate the client about the drug-drug interactions:

- Thyroid hormones increase blood glucose levels

- Phenytoin and tricyclic antidepressants increase the effect of thyroid hormone

- Thyroid hormones increase the effect of digitals, anticoagulants and indomethacin

Hyperthyroidism

Excessive seretion of thyroid hormones due to over functioning of the thyroid

gland

Most common form : Graves disease

Thyroid enlargement due to hyperplasia

exophthalmos

Signs and Symptoms

Tachycardia, palpitations, and elevated blood pressure

Increased respiratory rate and depth

Weight loss despite ravenous appetite

Diarrhea

Heat intolerance, profuse diaphoresis

Hand tremors at rest

Flushed, warm skin

Fine, soft hair

Mood swings ranging from mild euphoria to delirium

Agitation, restlessness and irritability

Enlarge thyroid gland

Exophthalmos

Fatigue and muscle weakness

Thyroid Storm (Thyrotoxic Crisis)

Medical emergency characterized by high fever, severe tachycardia, delirium anddehydration, and extreme irritability

Precipitated stress, infection, insulin reaction, diabetic acidosis, pregnancy,

digitals toxicity, withdrawal to antithyroid drugs or vigorous palpation of thyroid


Antithyroid Hormone Medications:

Propylthiouracil (e.g. Propacil, PTU)

Ethimazole (Tapazole)

Radioiodine Therapy

Thyroidectomy


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Iodine and iodide compounds (e.g. potassium iodide, Lugols solution, SSKI)

Beta-adrenergic blockers

Nursing Management Provide high calorie, high protein diet.

For exopthalmos, provide eye moisturizers and eye patches as needed to prevent

irritation.

Instruct patient to avoid taking over the counter medications with iodine, cough

medications, expectorants, bronchodilators and salt substitutes if the patient is receiving

iodine or iodide compounds.

Decrease strain on suture line by:

Placing the patient in Semi-flowers position

Supporting the head and neck with pillows and sand bags

Instructing the client not to extend the neck.

ABNORMAL PARATHYROID FUNCTION

Hypoparathyroidism

Results when insufficient amount of PTH are secreted, or when the hormone fails

to act the tissue level

Characterized by decreased serum calcium level

Signs and Symptoms

Hypocalcemia, hyperphosphatemia

Latent tetany:Numbness, tingling, crams, stiffness of hands and feet

Overt tetany:

bronchospasm, laryngospasm, photophobia, dysrrhythmias, seizures

Anxiety, irritability, depression, delirium

Positive Chvosteks and Trousseaus signs

Thin, patchy hair, brittle nails, dry, scaly skin

Cataract formation


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Elevate the serum calcium level to 9-10 mg/dL

Calcium gluconate IV in hypoparathyroidism and hypocalcemia

Parental parathormone, bronchodilators and phenobarbital

Tracheostomy or mechanical ventillation

High calcium, low phosphorous diet

Oral calcium salts, aluminum hydroxide gel or aluminum carbonate may be given

Vitamin D

Hyperparathyroidism

Overactivity of one or more of the parathyroid glans

Regulates serum calcium level

Excess in circulating PTH leads to bone damage, hypercalcemia, renal failure, and

decreased phosphate levels

Signs and Symptoms Back ache, joint pain

Pathologic fractures of the spine, ribs, and long bones

Polyuria, polydypsia

Kidney stones

Nausea, anorexia, contipation, abdominal pain

Restlesness, depression, emotional irritability neurosis, psychosis


Hydration therapy

Loop diuretics, furosemide (lasix) to promote renal calcium secretion Avoid thiazide diuretics because they increase calcium levels

Medications that inhibit bone resorption: Mithramycin (mitracin), Gallium nitrate

(ganite), Phosphates and calcitonin

Parathyroidectomy

Nursing Management

Encourage fluid intake up to 3000 ml/day unless contraindicated. Cranberry juice,prune juice and ginger ale make the urine more acidic and help prevent stone formation.

Encourage low calcium, low vitamin D diet.

ABNORMAL ADRENAL FUNCTIONSPheochromocytoma

Catecholamine-secreting tumor of the adrenal medulla

Excessive secretion of epinephrine and norepinephrine

Signs and Symptoms

5 Hs Hypermetabolism, Hypertension, Hyperhidrosis, Hyperglycemia and

Headache


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Acute attack: profuse diaphoresis, dilated pupils, and cold extremities, extreme

anxiety and weak, headache, vertigo, blurring of vision, tinnitus, air hunger, dyspnea,feeling of impending doom, palpitations, tachycardia

Clonidine suppression test reveals no change in cathecholamine levels


Alpha-adrenergic blockers (e.g. phentolamine) smooth muscle relaxants (e.g.

Nitroprusside) are given for hypertensive crises.

Phenoxybenzamine, beta-adrenergic blockers, metyrosine and corticosteriods

therapy.

Unilateral or bilateral adrenalectomy

Primary Adrenocortical Insufficiency

Addisons Disease

Insufficient secretion of adrenocortical hormones by the adrenal cortex as a result

of a disorder within the adrenal gland

Decreased levels of mineralcorticoids, glucocorticoids and androgens

Signs and Symptoms

Muscle weakness, fatigue

Anorexia, loss, emaciation

Postural hypotension

Bronzed skin discoloration (knuckles, knees, elbows, mucous membranes) Emotional disturbances ranging from mild neurotic symptoms to severs

depression

Decreased resistance to emotional or physical stress

Depleted sodium and water, chronic dehydration

Addisonians Crisis:

Shock, rapid, weak pulse, tachypnea, pallor, weakness, sudden profound weakness,severe abdominal, back and leg pain, hyperpyrexia followed by hypothermia, peripheral

vascular collapse, coma, renal shutdown

Hypoglycemia, hyponatremia, hyperkalemia, leukocytosis


Corticosteroid replacement therapy

Restore blood circulation and prevent shock

Vasopressors and antibiotics may be given


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Nursing Management

Instruct the patient to report increased thirst

Provide sodium and high-carbohydrate and high protein diet

Educate about the lifelong adrenal cortex hormone replacement

Prohibit beverages or food with caffeine

Instruct the patient to avoid strenuous activity in hot and humid weather

Cushings Syndrome

Hypersecretion of glucocorticoids and androgens due to over activity of the

adrenal gland

Most common cause:Pituitary tumors

Signs and Symptoms

Muscle wasting, osteoporosis, kyphosis, backache, fractures

Hypokalemia , metabolic alkalosis Hypertension, CHF

Abnormal fat distribution: Moon-shaped face, dorsocervical fat pad (buffalo

hump), truncal obesity with slender limbs

Skin oiliness, acne

Increased susceptibility to infection, decreased resistance to stress

Poor wound healing

Virility in women, menstrual irregularities

Loss of libido


Radiation therapy for pituitary tumors and adenomas

Cytoxic anti-hormonal agents

Hydorcortisone therapy

Lifetime replacement of adrenal cortex hormones

Adrenal enzyme inhibitors

Transphenoidal hypophysectomy

Adrenalectomy

Nursing Management

Provide high protein, calcium and Vit. D and low sodium, carbohydrates and

calories diet

Promote rest and activity

Post-transphenoidal hypophysectomy

Assess for signs of cerebral edema and rising intracranial pressure

Assess for signs of meningitis


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Observe client for rhinorrhea after nasal packing removed.

ABNORMAL PANCREATIC FUNCTIONS

Acute Pancreatitis

Inflammation of the pancreas characterized by hemmorage, necrosis and

suppuration of pancreatic parenchyma.

Major causes: Alcoholism and cholelithiasis

Alcohol associated pancreatitis: Pain begins 12-48 hrs. after an episode of inebriationGallstone related pancreatitis: Pain begins after a large meal

DIABETES MELLITUS

Nature of Diabetes Mellitus

Group of metabolic diseases characterized by elevated levels of glucose in the

blood resulting from defects in insulin secretion.

Metabolic disorder characterized by glucose intolerance

Systemic disease caused by an imbalance between insulin supply and insulin

demand of the cell

2 types of Diabetes Mellitus Type 1 (IDDM)

Insulin Dependent Diabetes Mellitus

Insulin-producing pancreatic beta cells are destroyed by autoimmune process

Usually occurs before 30yrs of age

Insulin injection is required

Type 2 (NIDDM)

Non-Insulin Dependent Diabetes Mellitus

Sensitivity to insulin (insulin resistance) or decrease amt. of insulin produced

Also called adult onset and mild diabetes Occurs in clients over 35yrs of age but can also occur in children

Only 20-30% of clients require injection

Metabolic effects of Diabetes


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Decreased utilization of glucose

Increased fat metabolism

Increased protein utilization

Complications of Diabetes Neuropathy, retinopathy, nephropathy

Cataracts, glaucoma, pyelonephritis and infections

Peripheral vascular lesions, coronary artery disease (CAD)

Stroke, hypertension

Signs and Symptoms

Polyuria

Polydypsia

Polyphagia

Weight loss

Vision changes

Tingling, numbness in hands or feet

Slow healing sores

Fasting plasma glucose(FPG)>126mg/dL

Random plasma glucose levels>200mg/dL


5 components in diabetes management

Nutrition or diet management Exercise

Monitoring

Pharmacologic therapy

Education

Insulin therapy

Pancreas transplant

MUSCULOSKELETAL DISORDERS

CastPurpose of cast

Immobilization of the reduced fracture

Correction of deformity

Support and stabilization of weakened structures


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Types of Cast

Arm Cast

Leg Cast

Walking Cast

Body or Spica Cast

Cast Syndrome

Acute anxiety reaction characterized by behavioral changes and sympathetic

autonomic responses

Physiologic GI motility, intestinal gas accumulation, abdominal distention,

nausea, and vomiting

Treatment: Decompression and intravenous fluid therapy until GI motility is restored

Nursing Management for Potential Complications from Cast

Compartment Syndrome

Condition of compromised circulation related to progressively increased pressure

in a confined space.

Caused by factors that decrease the compartment size such as external

compression, bleeding or edema

Nursing Management

Assist in bivalving & fasciotomy

Elevate extremity no higher tha heart level

Record neurovascular responses and report any changes to the physician

Pressure Ulcers

Any lesion on the skin caused by unrelieved pressure resulting to damage

underlying tissues

Immobility is the major risk factor

Classification of ulcers

Stage I: Non-blanching erythema of intact skin

Stage II: Partial-thickness skin loss involving epiderms and/or dermis; superficial

ulcer which appear as abrasion, blister, or shallow crater

Stage III: Full-thickness skin loss involving damage or necrosis of subcutaneouslayer; ulcer presents as deep crater

Stage IV: Full-Thickness skin loss with extensive destruction, tissue necrosis, or

damage to muscle, bone or supporting tissues

Nursing Management

Elevate the heels using pillows or pressure reduction boots

Remove devitalized tissue from ulcer

Monitor for possible infection

Position the client off the ulcers


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Disuse Syndrome

Muscle weakness due to immobilization, which occurs as early as 1wk after

immobilization

Decreased bone mass; increases risk for developing heterotopic ossification

Nursing Management

Ask the patient to push down or make a fist (isometrics), to help reduce

muscle atropy and maintain muscle strenght.

Portable electrical stimulators may be attached over large muscles of afected area

prior to cast application

Documents

Endocrine & Musculoskeletal Bullets