The endocrine system plays a key role in human growth, metabolism, and adaptation through the release of hormones. Nursing assessment of a patient with a potential endocrine disorder involves obtaining their health history, a review of symptoms, a physical exam including inspection, palpation, and auscultation of the endocrine glands, and relevant lab tests. Common endocrine disorders include diabetes, hyperlipidemia, osteoporosis, hypo- or hyperthyroidism, and metabolic syndrome. Addison's disease is an adrenal insufficiency caused by autoimmune destruction or other issues that results in impaired metabolism and electrolyte imbalances.
The endocrine system plays a key role in human growth, metabolism, and adaptation through the release of hormones. Nursing assessment of a patient with a potential endocrine disorder involves obtaining their health history, a review of symptoms, a physical exam including inspection, palpation, and auscultation of the endocrine glands, and relevant lab tests. Common endocrine disorders include diabetes, hyperlipidemia, osteoporosis, hypo- or hyperthyroidism, and metabolic syndrome. Addison's disease is an adrenal insufficiency caused by autoimmune destruction or other issues that results in impaired metabolism and electrolyte imbalances.
Original Description:
MEDICAL SURGICAL NURSING - ALTERED ENDOCRINE SYSTEM
The endocrine system plays a key role in human growth, metabolism, and adaptation through the release of hormones. Nursing assessment of a patient with a potential endocrine disorder involves obtaining their health history, a review of symptoms, a physical exam including inspection, palpation, and auscultation of the endocrine glands, and relevant lab tests. Common endocrine disorders include diabetes, hyperlipidemia, osteoporosis, hypo- or hyperthyroidism, and metabolic syndrome. Addison's disease is an adrenal insufficiency caused by autoimmune destruction or other issues that results in impaired metabolism and electrolyte imbalances.
The endocrine system plays a key role in human growth, metabolism, and adaptation through the release of hormones. Nursing assessment of a patient with a potential endocrine disorder involves obtaining their health history, a review of symptoms, a physical exam including inspection, palpation, and auscultation of the endocrine glands, and relevant lab tests. Common endocrine disorders include diabetes, hyperlipidemia, osteoporosis, hypo- or hyperthyroidism, and metabolic syndrome. Addison's disease is an adrenal insufficiency caused by autoimmune destruction or other issues that results in impaired metabolism and electrolyte imbalances.
Nutritional-Metabolic Patterns/Responses to Altered o about his cultural background and
Endocrine Function heredity
▪ The nurse obtains a social history The endocrine system plays a significant role in human o Ask about work, exercise, diet, use of growth, metabolism, and environmental adaptation recreational drugs, alcohol use, and Along with the nervous system, the endocrine system hobbies provides a communication system for the body o Also ask about stress, support systems, and coping mechanisms By releasing hormones from various ductless glands, the ▪ The nurse obtains a social history endocrine system carefully regulates many physiologic o Ask about work, exercise, diet, use of functions recreational drugs, alcohol use, and Nursing history hobbies o Also ask about stress, support systems, ▪ The nurse asks the patient about his chief and coping mechanisms complaint Physical assessment A patient with an endocrine disorder may report: ▪ The nurse begins with inspection o abnormalities of fatigue, mental status o Observe the patient’s general changes, polydipsia (extreme thirstiness), appearance and development, height, polyuria (excessive urination), weakness, weight, posture, body build, and weight changes proportionality of body parts, and o The patient with an endocrine disorder distribution of body fat and hair may also report problems of sexual o Note affect, speech, level of maturity and function consciousness, orientation, ▪ The nurse then questions the patient about his appropriateness of behavior, grooming present illness and dress, and activity level Ask the patient about his: o Assess overall skin color and, for areas of o symptom, including when it started, abnormal pigmentation, note any associated symptoms, location, radiation, bruising, lesions, petechiae, or striae intensity, duration, frequency, and o Assess the face for erythematous areas, precipitating and alleviating factors note facial expression, shape, and o the use of prescription and over-the- symmetry of the eyes; also note abnormal counter drugs, herbal remedies, and lid closure, eyeball protrusion, and vitamin and nutritional supplements periorbital edema, if present ▪ The nurse asks about medical history o Inspect the tongue for color, size, lesions, Question the patient about other endocrine tremor, and positioning disorders such as o Inspect the neck area for symmetry o diabetes mellitus, height and weight o Evaluate the overall size, shape, and problems, sexual problems, and thyroid symmetry of the chest, noting disease o any deformities, especially around the o about past reproductive problems and nipples use of oral contraceptives and hormones; o Check for truncal obesity, supraclavicular also ask whether she’s premenopausal or fat pads, and buffalo hump postmenopausal o Inspect the external genitalia for normal ▪ The nurse then assesses the family history development Ask about a family history of endocrine disorders: o Inspect the arms and legs for tremors, o such as diabetes mellitus and thyroid muscle development and strength, disorders symmetry, color, and hair distribution o Examine the feet, noting size, deformities, ✓ Kidney stones, pathological fractures, muscle lesions, marks from shoes and socks, weakness, memory loss. maceration, dryness, or fissures ✓ Polyuria, polydipsia, polyphagia (excessive eating ▪ Next, the nurse uses palpation and drinking, excessive urination). o Palpate the thyroid gland for size, ✓ Anorexia, weight gain or loss, constipation, symmetry, and shape; note any nodules dehydration. or irregularities ✓ Change in thought processes, restlessness, o Palpate the testes for size, symmetry, and agitation, confusion. shape; note any nodules or deformities Most common endocrine disorders include ▪ Then the nurse uses auscultation o Auscultate the thyroid gland to identify ✓ diabetes mellitus (DM) systolic bruits ✓ hyperlipidemia o Auscultate the heart, noting heart rhythm ✓ osteoporosis disturbances that may occur in endocrine ✓ hypo- or hyperthyroidism disorders ✓ metabolic syndrome Rapid Endocrine Assessment The endocrine glands produce many hormones, and many more are secreted by other organs. Major functions of the The endocrine system interacts with every cell in the body main glands and the major hormones of each are shown to maintain homeostasis. in the following table. It consists primarily of several glands that secrete ADDISON’S DISEASE hormones; however, many organs, such as the kidneys and liver, have secondary endocrine functions. is a chronic adrenocortical insufficiency most commonly caused by autoimmune destruction of the adrenal cortex The main glands of the endocrine system (excluding the ovaries and testes) include the ▪ Other causes of adrenal insufficiency include fungal infection and infectious disease such as ✓ Hypothalamus tuberculosis; hemorrhage; metastatic disease ✓ Pituitary. (rarely); therapy with drugs, such as ketoconazole, ✓ Thyroid and parathyroid glands. phenytoin, and rifampin; after sudden withdrawal ✓ Adrenals. of steroid therapy; and surgical removal of both ✓ Pancreas. adrenal glands Physical assessment of the endocrine system is difficult in ▪ Addison’s disease leads to impaired metabolism, that the thyroid is the only palpable gland and signs and inability to maintain a normal glucose level, and symptoms can be vague or attributable to other causes. fluid and electrolyte imbalances ▪ Primary insufficiency results from low levels of Laboratory and diagnostic tests consist of glucocorticoids and mineralocorticoids; secondary radioimmunoassay of insufficiency results from inadequate pituitary ✓ hormone levels, blood glucose levels, and other secretion of corticotropin laboratory tests ▪ Lack of cortisol (a glucocorticoid), aldosterone (a ✓ 24-hour urine studies; and radiological scans mineralocorticoid), and androgens diminish gluconeogenesis, decrease liver glycogen, and Some physical signs and symptoms that may result from increase the sensitivity of peripheral tissues to endocrine malfunction include: insulin ✓ Change in appearance of hair, nails, and skin. ▪ Because cortisol is required for a normal stress ✓ Increased or decreased energy, insomnia, fatigue. response, patients with cortisol insufficiency can’t ✓ Heat or cold intolerance, hypothermia, or fever. withstand surgical stress, trauma, or infection ✓ Tremors, tetany, muscle aches. ✓ Tachycardia, hypertension, or hypotension. Signs and symptoms ▪ Ensure strict adherence to the medication schedule to prevent crisis ▪ history of fatigue, muscle weakness, and weight ▪ Decrease environmental stressors as much as loss possible ▪ skin and mucous membranes may appear bronze ▪ Teach the patient and his family how to prevent (due to increased levels of melanocyte-stimulating complications of Addison’s disease by never hormone) omitting a dose of medication, notifying the ▪ GI effects: anorexia, nausea, vomiting, and practitioner if the patient can’t take the medication, diarrhea avoiding undue stress, and wearing a medical ▪ Other effects: dehydration, hyperkalemia, identification bracelet hypoglycemia, hyponatremia, hypotension, and ▪ Instruct the patient and his family to report any loss of axillary, extremity, and pubic hair symptoms of adrenal crisis to a practitioner Diagnosis CUSHING’S SYNDROME ▪ low levels of plasma and urine cortisol and is hyperfunction of the adrenal cortex caused by an elevated levels of plasma corticotropin, overabundance of cortisol hyperkalemia, hyponatremia, leukocytosis, and metabolic acidosis It’s classified as corticotropin-dependent or corticotropin- ▪ In a corticotropin stimulation test, plasma independent corticotropin levels may not increase o With corticotropin-dependent Cushing’s Treatment syndrome, cortical hyperfunction results from excessive corticotropin secretion by the pituitary ▪ replacing glucocorticoids and mineralocorticoids; gland; in 80% of cases, excessive corticotropin cortisone is given in two daily doses (usually on secretion is related to a pituitary adenoma arising and at 6 p.m.) to mimic the body’s diurnal o With corticotropin-independent Cushing’s variations; doses are increased during periods of syndrome, cortical hyperfunction is independent stress of corticotropin regulation; high levels of cortisol ▪ prevention of adrenal crisis, which may develop are caused by a neoplasm in the adrenal cortex, after trauma, infection, or GI upset; prevention or islet cell tumor requires consistent replacement therapy (without o Cushing’s syndrome may be caused by abnormal abrupt withdrawal); treatment of crisis requires cortisol production or excessive corticotropin immediate replacement of sodium, water, and stimulation (spontaneous disorder) or long-term cortisone glucocorticoid (such as prednisone) ▪ Adrenal hemorrhage after septicemia is a rare administration (iatrogenic disorder) complication of Addison’s disease; it’s treated with o For patients with this disorder, excessive cortisol aggressive antibiotic therapy, an I.V. vasopressor, leads to excessive glucose production and and massive doses of a steroid interferes with the cells’ ability to use insulin; Nursing interventions sodium retention, potassium excretion, and protein breakdown occur; body fat is redistributed ▪ Monitor the patient for signs and symptoms of from the arms and legs to the face, shoulders, adrenal crisis, such as fever, changes in GI trunk, and abdomen; and the immune system function (which may alter drug absorption), becomes less effective at preventing infection decreased sodium and cortisol levels with increased potassium levels (which may signal an impending crisis), dehydration, headache, hypotension, nausea, severe fatigue, tachycardia, and confusion Signs and symptoms maintaining a safe environment, teaching him how to use a walker or cane, encouraging the use of ▪ Muscle weakness and atrophy may be well-fitting shoes or slippers, and attending to accompanied by fat deposits on the trunk, complaints of lower back pain or joint pain abdomen, over the upper back (“buffalo hump”), ▪ Protect the patient from injury related to easy and face (“moon face”) bruising and protein wasting by avoiding ▪ Skin changes: acne, bruising, facial flushing, unnecessary venipunctures, using paper tape for hyperpigmentation, and striae dressing changes, avoiding over inflation of the ▪ Gynecomastia in men; clitoral enlargement and blood pressure cuff, keeping the skin clean and dry, menstrual irregularities in women and using a convoluted foam mattress, a water ▪ Other effects: Arrhythmias, edema, emotional mattress, or an air bed for a patient with skin lability, GI disturbances, headaches, hirsutism breakdown (fine, downy hair on face and upper body), ▪ Provide care related to limited mobility and muscle infection, vertebral fractures, & wt. changes weakness resulting from protein catabolism by Diagnosis and treatment planning rest periods, encouraging range-of-motion exercises or daily muscle-strengthening exercises, ▪ Dexamethasone suppression test and urine-free and referring the patient for physical therapy, if cortisol test needed ▪ Laboratory tests: coagulopathies, ▪ Protect the patient from infection related to hyperglycemia, hypokalemia, hypernatremia, decreased immune function by using strict aseptic increased aldosterone and cortisol levels, and technique (when appropriate) and discouraging ill suppressed plasma corticotropin levels; computed family members from visiting the patient tomography or magnetic resonance imaging may ▪ Provide postoperative care after adrenalectomy, show a tumor including monitoring vital signs frequently, ensuring The goal of treatment is normal cortisol activity adequate pain relief and fluid intake and output, and monitoring for complications of hypoglycemia Surgery: and signs of adrenal crisis ▪ Confirmed pituitary tumor ▪ Administer replacement medication as prescribed, - transsphenoidal resection; suspected pituitary and be familiar with its adverse effects tumor - cobalt irradiation of the pituitary gland ▪ Suggest that the patient wear a medical ▪ Confirmed adrenal cortex tumor identification bracelet - bilateral adrenalectomy; after surgery: lifelong ▪ Teach the patient and his family about the disease corticosteroid and mineralocorticoid and its treatment replacement DIABETES INSIPIDUS ▪ Drug therapy is (used if something else is causing corticotropin release): aminoglutethimide, is a deficiency of antidiuretic hormone (ADH), resulting in mitotane, and trilostane interfere with adrenal water imbalance; vasopressin is a natural ADH hormone synthesis or corticotropin production; Central diabetes insipidus results from the destruction of bromocriptine and cyproheptadine interfere with vasopressin producing cells; nephrogenic diabetes corticotropin secretion; and glucocorticoids (such insipidus results when the renal tubules don’t respond to as cortisone, dexamethasone, and prednisone) vasopressin treat congenital adrenal hyperplasia Syndrome of inappropriate antidiuretic hormone (SIADH) Nursing interventions causes the release of excessive ADH, resulting in water ▪ Encourage the patient to express concerns about retention (see Comparing diabetes insipidus and SIADH altered body image ▪ Protect the patient from injury related to loss of bone matrix and abnormal fat distribution by Nursing interventions ▪ Support the patient during the water deprivation test ▪ For diabetes insipidus: Treat altered fluid volume related to excessive urine output by maintaining fluid and electrolyte balance, administering replacement therapy as prescribed, and monitoring the patient for signs of therapy-related water intoxication, notifying the practitioner of significant changes in urine output and specific gravity, and observing patient for vital sign changes related to dehydration, such as increased heart rate and decreased blood pressure ▪ For SIADH: Treat altered fluid volume status related to water retention by weighing the patient at the same time daily, reporting weight gains or losses to the practitioner, so treatment with vasopressin or desmopressin can begin, and monitoring patient for signs of water retention, such as dyspnea, edema, hypertension, and tachycardia ▪ Provide oral and skin care, and reposition the patient frequently to prevent skin breakdown ▪ Conserve energy for a patient who is up often during the night to void or drink; encourage short naps to prevent sleep deprivation ▪ Protect the patient from injury related to fatigue, weakness, dehydration, or confusion by providing a safe environment, encouraging a weak patient to request assistance in walking to and from the bathroom, teaching a patient to sit up gradually to prevent dizziness resulting from orthostatic hypotension, and taking seizure precautions for a patient with a low serum sodium level ▪ Teach the patient and family to recognize the signs of diabetes insipidus and SIADH ▪ Teach the patient how to administer intranasal medications This chart summarizes the major characteristics of central and nephrogenic diabetes insipidus and syndrome of inappropriate antidiuretic hormone (SIADH). DIABETES MELLITUS Risk Factors/Causes is a chronic systemic disease that alters carbohydrate, fat, 1. Type 1 diabetes (5-10%) and protein metabolism. a. Usually <30 y/o it’s the most common endocrine disorder and the third b. Genetic leading cause of death in the United States. c. Immunologic (autoimmune) d. Environmental Factor 3rd leading cause of death 2. Type 2 (90-95%) General classifications: a. Usually over 30 y/o ▪ Prediabetes - can occur when the fasting blood b. Obesity (80%); Non-obese (20%) glucose is > 100 mg/dl and < 126 mg/dl or c. Heredity postprandial (kakatapos lang kumain) blood d. Gestational diabetes (hyperglycemia) glucose > 140 mg/dl and < 200 mg/dl ▪ Type 1 diabetes mellitus - is an absolute Clinical Manifestations deficiency of insulin secretion and may be 1. “Three Ps”: Polyuria; Polydipsia; Polyphagia hereditary; it’s associated with histocompatibility 2. Weight loss antigens, some viruses, abnormal antibodies that 3. Other symptoms: fatigue and weakness, sudden attack the islet of Langerhans cells, and toxic vision changes, tingling or numbness in hands or chemicals; it causes symptoms when 90% of the feet, dry skin, skin lesions or wounds that are slow pancreatic beta cells have been destroyed to heal, and recurrent infections (vaginal). ▪ Type 2 diabetes mellitus - may be hereditary, is associated with obesity, and results from different DKA: sudden weight loss, nausea, vomiting, abdominal causes than type 1 diabetes; it’s caused by pains, hyperventilation, and a fruity breath odor, defects in insulin secretion and decreased insulin effectiveness; it accounts for 90% of diabetic Assessment and Diagnostic Findings patients 1. Fasting Plasma glucose (FPG): fasting for at least 8 ▪ Gestational diabetes mellitus causes glucose hours intolerance during pregnancy; it usually o Normal: less than 100 mg/dL (< 5.6 mmol/L) disappears after delivery but may develop into o Prediabetes: 100 to 125 mg/dL (5.6 to 6.9 type 1 or type 2 diabetes mmol/L) Other: disorder & use of a drug or a chemical o Diabetes: 126 mg/dL or higher (7 mmol/L or higher) on two separate tests Notes: Other types of diabetes mellitus can be linked to 2. Random Plasma glucose: a blood sample for a either a disorder (such as an endocrinopathy, a genetic random plasma glucose test can be taken at any time. syndrome, an insulin receptor disorder, or a pancreatic o Normal: less than 200 mg/dL (<11.1 mmol/L) disease) or to the use of a drug or a chemical (such as a o Diabetes: 200 mg/dL or higher (11.1 mmol/L corticosteroid, epinephrine, furosemide, glucagon, lithium, or higher) or phenytoin) 3. 2-hour Postload Glucose o Normal: less than 140 mg/dL (< 7.8 mmol/L) Impaired glucose tolerance when glucose levels are o Prediabetes: 140 to 199 mg/dL (7.8 to 11.0 outside the normal range following a glucose tolerance test mmol/L) but the patient doesn’t meet the criteria for diabetes o Diabetes: 200 mg/dL or higher (11.1 mmol/L mellitus or higher) Signs and symptoms Notes: ▪ Polydipsia (excessive thirst) For people without diabetes, the normal range for the ▪ Polyphagia (eats excessive amt of food) hemoglobin A1c level is between 4% and 5.6%. ▪ Polyuria (excessive urine) Hemoglobin A1c levels between 5.7% and 6.4% mean you ▪ Weight loss have prediabetes and a higher chance of getting diabetes. ▪ Other: fatigue and somnolence Levels of 6.5% or higher mean you have diabetes. Diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic nonketotic syndrome (HHNS), both acute complications associated with diabetes, share some similarities, including changes in level of consciousness and extreme volume depletion, but they’re two distinct conditions. The following chart helps determine which condition your patient is experiencing. Treatment ▪ First/Primary goal of treatment: maintain a normal blood glucose level through oral antidiabetic or insulin therapy, diet control, and physical activity ▪ Second goal of treatment: prevent or delay the complications Notes: Criteria for the Diagnosis of Diabetes Mellitus Hypoglycemia (insulin shock) is a condition in which the 1. Random/Casual Plasma Glucose: Equal to or blood glucose level falls below the level required to sustain greater than 200 mg/dL (11.1 mmol/L or higher) homeostasis (usually under 60 mg/dl); it may result from too little food, too much insulin or oral antihypoglycemics, OR or too much exercise and can cause perma_x0002_nent 2. Fasting Plasma Glucose: Equal to or greater than neurologic damage or rebound hyperglycemia 126 mg/dL (7.0 mmol/L or higher) OR Onset occurs in minutes to hours, but most often before 3. Two-hour Postload Glucose: Equal to or greater meals, especially if meals are delayed or snacks omitted than 200 mg/dL (11.1 mmol/L or higher) during an Hypoglycemia is treated with: oral glucose tolerance test: using a glucose load containing 75 g anhydrous glucose dissolved in ✓ candy or orange juice if the patient’s awake, water. followed by a snack of protein and starch within 20 to 60 minutes Diagnosis ✓ I.V. bolus of 50% dextrose solution, if the patient ▪ plasma glucose level greater than 200 mg/dl, an is unconscious, 1 mg glucagon may be given I.V., 8-hour fasting plasma glucose level greater than I.M., or subcutaneously and, when awake, give a 126 mg/dl, or a 2-hour post load glucose level simple sugar followed by a snack greater than 200 mg/dl during an oral glucose tolerance test; testing must be confirmed on a subsequent day ▪ Hemoglobin A1C levels reflect the plasma glucose level during the past 2 to 3 months Medical Management (reduce vascular/idiopathic) 2. Patients Taking insulin: 1. Nutritional Therapy ✓ eat a 15-g carbohydrate snack (a fruit exchange) or a snack of complex carbohydrates with a For obese/type 2 DM: protein before engaging in moderate exercise. o 500 to 1000 calories are subtracted from the ✓ eat a snack at the end of the exercise daily total intake:1- to 2-pound weight loss per (strenuous/prolonged) and at bedtime and monitor week the blood glucose level more frequently. ✓ should test their blood glucose levels before, For type 1 DM: during, and after the exercise period. o diet with enough/high calories 3. Patients with type 2 diabetes who are not taking insulin o to regain weight loss or an oral agent may not need extra food before exercise. Caloric Distribution 1. Carbohydrates: 50% to 60% (whole grains); Fats: 20% General Precautions for exercise: to 30%; Protein: 10% to 20% (plant sources) ▪ Use proper footwear and, if appropriate, other 2. Fiber: Increase fiber in the diet (25 g daily) protective equipment. Soluble fiber - legumes, oats, and some fruits— ▪ Avoid exercise in extreme heat or cold. plays more of a role in lowering blood glucose and ▪ Inspect feet daily after exercise. ▪ Avoid exercise during periods of poor metabolic Insoluble fiber - whole-grain breads and cereals control. and in some vegetables. 3. Monitoring Glucose Levels and Ketones Other Dietary Concerns (cornerstone) 1. Alcohol Consumption A. Self-Monitoring of Blood Glucose - moderate amount only - May lead to excessive weight gain (kse Frequency of Self-Monitoring of Blood Glucose: mataas caloric content) 1. Patients with insulin: two to four times daily - Large fats lead to DKA - Hypoglycemia 2. Those not receiving insulin: at least two or - Low calorie/less sweet drinks + food intake three times per week, including a 2-hour 2. Sweeteners – Moderate amount; sorbitol/xylitol postprandial test. 3. Misleading Food Labels 3. For all patients: hypoglycemia or 2. Exercise (lowers blood glucose level, improve blood hyperglycemia is suspected circulation and muscle tone, reduce cardiovascular factors B. Testing for Glycated Hemoglobin (HgbA1C) and weight) - Blood test reflects average blood level Note: - Period of 2-3 months - Normal values: 4-6% (consistent near normal ✓ Exercise at the same time and each day blood glucose concentration); less than 7% ✓ Encourage walking as regular daily exercise C. Testing for Ketones Exercise Precautions - Byproducts of fat breakdown - Accumulated at blood/urine 1. Begin exercising until the urine test results are - Deficiency of insulin (most common in type 1 negative for ketones and the blood glucose level diabetes) is closer to normal. - Ketonuria (presence of ketones in urine) leads to Risk for DKA (type 1) Responding to Self-Monitoring of Blood Glucose Methods of Insulin Delivery Results: 1. Insulin Pens. 1. Patients are asked to keep a record or logbook of 2. Jet Injectors blood glucose levels 3. Insulin Pumps 2. When to test: B. Oral Antidiabetic Agents (for type 2 DM, nutrition - at the peak action time of the medication to + exercise) evaluate the need for dosage adjustments ▪ Sulfonylureas (stimulates beta cells in pancreas - before meals to evaluate basal insulin and to produce insulin) determine bolus insulin doses ▪ Non-Sulfonylurea Insulin Secretagogues - 2 hours after meals to evaluate bolus doses of (stimulates beta cells in pancreas to produce regular or rapid-acting insulin insulin BUT ONLY TAKEN AFTER MEALS) ▪ Biguanides (inhibits production of glucose in liver; - with type 2: daily before and 2 hours after the decrease cholesterol) largest meal of the day until stabilized ▪ Alpha-Glucosidase Inhibitors (helps delay - patients who take insulin at bedtime or who absorption of complex carbohydrates; TAKEN use an insulin infusion pump: test at 3 AM once WITH FIRST BITE OF FOOD) a week ▪ Thiazolidinediones or glitazones (stimulates insulin receptor sites to lower blood glucose; helps - if the patient is unwilling or cannot afford to improve action of insulin) test frequently: once or twice a day (before meal) Preparations: 4. Pharmacologic Therapy (Time Course; Agent; Onset; Peak; Duration) A. Insulin Therapy PAGKAKASUNOD SUNOD NYAN ETONG TIME - type 1 DM: needed insulin for life COURSE KINEME SA SS GAWAN MO TABLE - type 2 DM: maybe necessary to control glucose level Note: Insulin may be increased (depending on the doctors order) Complications of Insulin Therapy: 1. Local Allergic Reactions 2. Systemic Allergic Reactions (rare) 3. Insulin Lipodystrophy (lipodystrophy - loss of subcutaneous fat) 4. Resistance to Injected Insulin 5. Morning Hyperglycemia Notes: Notes: Rapid acting (EAT NO MORE THAN 5-15 MINS AFTER Lypoatrophy (small subcutaneous fats) INJECTION) Lypohypertrophy (fibro fatty mass because of r Short acting (regular insulin – clear solution FOR ONLY epeated injection of site) IV USE) Intermediate acting (NPH insulin – white, cloudy in color; TAKEN 30 MINS BEFORE MEALS) Nursing interventions Very long acting (peakless because it’s continuous; 1. Protect the patient from infection and injury related absorbs very slow, CAN BE GIVEN OD AT THE SAME to circulatory compromise and possible nerve TIME OF THE DAY OR HS) impairment Oral Antidiabetic Agents ▪ Report wounds to the practitioner for treatment Sulfonylureas ▪ Apply lanolin to the feet and ankles First-Generation Sulfonylureas ▪ Carefully dry the feet, especially between the toes ✓ Acetohexamide (Dymelor) ▪ Encourage the use of cotton socks to ✓ Chlorpropamide (Diabinese) reduce moisture, and wear well-fitting ✓ Tolazamide (Tolinase) shoes ✓ Tolbutamide (Orinase) ▪ Have toenails clipped by a podiatrist Second Generation Sulfonylureas (more potent) ▪ Teach the patient and family about good skin care ✓ Glipizide (Glucotrol) ▪ Tell the patient to avoid heating pads and ✓ Glyburide (Micronase, Glynase, Dia-beta) to exercise caution when near open fires ✓ Glimepiride (Amaryl) because burns are more difficult to treat in Side Effect: hypoglycemia; mild GI discomforts; weight diabetic patients gain; allergic reactions ▪ Treat fluid loss caused by hyperglycemia ▪ Rapidly infuse I.V. isotonic (normal) or Non-Sulfonylurea Insulin Secretagogues hypotonic (half-normal) saline solution ✓ Repaglinide (Prandin) ▪ When blood glucose level falls below 250 ✓ Nateglinide (Starlix) mg/dl, administer I.V. ▪ dextrose 5% in water to prevent SE: hypoglycemia hypoglycemia and cerebral edema Biguanides ▪ Check urine output and ketone levels hourly ✓ Metformin (Glucophage, Glucophage XL, ▪ Monitor potassium level, and replace Fortamet) potassium as needed ✓ Metformin (Glucovance) 2. Help the patient maintain good nutritional habits ▪ Obtain a diet history, and note the impact SE: hypoglycemia; lactic acidosis; GI disturbances of lifestyle and culture on food intake Alpha-Glucosidase Inhibitors ▪ Encourage the patient to follow the American Diabetes Association’s ✓ Acarbose (Precose) calculated diet plan; encourage the obese ✓ Miglitol (Glyset) patient to lose weight SE: hypoglycemia; GI discomforts (distention, ▪ Explain the importance of exercise and a diarrhea, flatulence) balanced diet 3. Teach the patient and his family about the Thiazolidinediones (or glitazones) disease, complications, and treatment • Pioglitazone (Actos) ▪ Discuss blood glucose self-testing, skin • Rosiglitazone (Avandia) care, and treatment of minor injuries; discuss which injuries should be reported SE: URTI; GI (diarrhea); headache; hypoglycemia to a practitioner ▪ Make sure the patient and his family know HYPERTHYROIDISM the signs of hyperglycemia and Excessive production of thyroid hormone resulting in a hypoglycemia hypermetabolic state ▪ Make sure the patient and family know how to adjust insulin doses for changes in Severe hyperthyroidism can precipitate a thyroid storm or diet, exercise, and stress level crisis, which is a life-threatening emergency; the crisis can ▪ Have the patient or a family member be triggered by minor trauma or stress demonstrate the technique for drawing up and administering insulin Hyperthyroidism can result from discontinuation or ▪ Teach the patient how to adjust doses if excessive use of antithyroid medication, tumors that an insulin-infusion pump is used stimulate thyroid secretion, or deterioration of preexisting ▪ Educate the patient and his family about hyperthyroid state due to DKA, infection, toxemia, trauma, care during illness; tell the patient to or excessive iodine intake monitor blood glucose levels more Types: frequently, to increase fluid intake, and not to stop taking his antidiabetic without ▪ Graves’ disease consulting with the practitioner ▪ Toxic nodular goiter 4. Provide care for a diabetic patient with peripheral neuropathy ▪ Discuss causes of aching or burning sensation in legs ▪ Provide foot cradles to prevent contact with bed linens for a patient in severe pain ▪ Encourage exercise as tolerated, which may help to relieve pain 5. Provide care for a diabetic patient with altered bowel and bladder elimination related to neuropathy by providing psychological support, administering prescribed drugs such as metoclopramide hydrochloride, and discussing the signs of bladder infection with the patient and family Diagnosis 6. Provide care for a diabetic patient with retinopathy by encouraging independence, providing a safe ▪ Increased levels of thyroid hormones environment, and eliciting the support of (triiodothyronine [T3] and thyroxine [T4]) community agencies ▪ Decreased thyroid-stimulating hormone (TSH) 7. Provide care for a patient with diabetes who has a level sexual dysfunction related to neuropathy by ▪ Increased blood glucose level resulting from impaired insulin secretion encouraging expression of feelings; exploring ▪ Electrocardiography shows atrial fibrillation, P- options such as a penile prosthesis; and and T-wave alterations, and tachycardia recommending professional counseling as ▪ thyroid scan shows increased uptake of needed radioactive iodine Treatment room cool, establishing a calm environment, using relaxation techniques, administering drugs as ▪ To reduce thyroid hormone levels (The principal prescribed, identifying and treating precipitating goal of treatment) factors, and teaching the patient and family how to o Antithyroid medications are generally used prevent thyroid storm for pretreating patients who are elderly or who ▪ If the patient has exophthalmos, administer have cardiac disease before starting eyedrops or ointment, and encourage the use of radioactive iodine; methimazole and sunglasses for comfort and to protect his eyes propylthiouracil are slow-acting drugs that ▪ If the patient has diaphoresis block thyroid synthesis and typically produce o keep his skin dry with powders that contain improvement after 2 to 4 weeks of therapy; A cornstarch, and frequently change his bed beta-adrenergic blocker such as propranolol linens may be used as an adjunct to control activity ▪ If the patient underwent a thyroidectomy of the sympathetic nervous system o keep him in Fowler’s position to promote o Surgery (subtotal thyroidectomy) is reserved venous return from the head for patients with a very large gland, or who o assess for signs of respiratory distress and can’t undergo other treatments, or who have vocal changes thyroid cancer; before surgery, the patient o keep a tracheotomy tray at the bedside; receives antithyroid medication to reduce monitor him for signs of hemorrhage; hormone levels and saturated solution of assess for hypocalcemia (such as tingling potassium iodide to decrease surgical and numbness of the extremities, muscle complications twitching, laryngeal spasm, and positive o Radioactive iodine therapy also is the Chvostek’s and Trousseau’s signs), which standard for treating hyper thyroidism; dosing may occur if parathyroid glands are is based on the patient’s symptoms; it’s damaged contraindicated during pregnancy or o assess for signs of thyroid storm (such as breastfeeding, and many patients who receive tachycardia, hyperkinesis, fever, vomiting, radioactive iodine become euthyroid or and hypertension) hypothyroid, requiring levothyroxine treatment o and keep calcium gluconate available for ▪ Prevent thyroid storm (The second goal of emergency I.V. administration treatment) o Antipyretic (only as prescribed and to seek HYPOTHYROIDISM care for infection) ▪ Hypothyroidism is the diminished production of o Fluids replacement (Fluids are replaced as thyroid hormone, leading to thyroid insufficiency needed to prevent the condition from ▪ Primary hypothyroidism is caused by thyroid worsening) gland dysfunction Nursing interventions ▪ Secondary hypothyroidism, from insufficient secretion of TSH by the pituitary gland ▪ Maintain normal fluid and electrolyte balance to ▪ Hypothyroidism occurs as myxedema in adults, as prevent arrhythmias juvenile hypothyroidism in young children, or as ▪ Tell the patient to avoid caffeine, which can stimulate congenital hypothyroidism the sympathetic nervous system ▪ Thyroid insufficiency causes decreased ▪ Provide a high-calorie, high-protein diet through consciousness, hypometabolism, hypothermia, several small, well-balanced meals and hypoventilation ▪ Ensure adequate hydration ▪ Unrecognized and untreated congenital ▪ Conserve the patient’s energy to help decrease hypothyroidism — cretinism — can result in metabolism needs mental and physical retardation ▪ Prevent thyroid crisis by using a cooling mat to achieve normal temperature, keeping the patient’s ▪ Hypothyroidism may be caused by worsening of a ▪ Monitor fluid intake and output, and weigh the preexisting hypothyroid condition; insufficient patient daily to check for fluid retention thyroid hormone replacement therapy for ▪ If the patient has hypothermia, increase body hyperthyroidism; pituitary gland dysfunction due to temperature gradually by using warm blankets or infection, surgery, trauma, or tumor; autoimmune increasing the room temperature disease; iodine deficiency; and drugs (such as ▪ Encourage coughing and deep breathing, and lithium and amiodarone) administer oxygen as prescribed ▪ Ask the patient and his family to demonstrate their Signs and symptoms understanding of the medication schedule ▪ VS: bradycardia, decreased respiratory rate with ▪ Give the patient and his family opportunities to ask shallow inspirations, hypotension, and about the disease and its treatment hypothermia ▪ Provide supportive care for a patient in myxedema ▪ Hoarseness, impaired hearing, myxedema coma; maintain a patent airway, monitor vital signs (nonpitting edema), and a puffy face, hands, and closely, and administer oxygen and I.V. fluid tongue may result from swelling replacement until the patient begins to recover ▪ Crackles may stem from pleural effusion from the coma ▪ Other: intolerance to cold; dry, coarse skin; lethargy, stupor, coma; menstrual irregularities; fatigue; alopecia; and brittle nails Diagnosis ▪ serum TSH, T3 , and T4 , and free T4 levels; T3 resin uptake test; and radioisotope thyroid uptake test ▪ blood glucose level, plasma osmolality, a decreased TSH level (with a pituitary or hypothalamic defect) or an increased TSH level (with a thyroid defect), and hyponatremia Treatment ▪ primary treatment: lifelong replacement of the deficient hormone; synthetic levothyroxine sodium is the preferred thyroid hormone replacement and typically relieves symptoms in 2 to 3 days ▪ myxedema coma: immediate I.V. administration of a corticosteroid, glucose, and levothyroxine sodium can reverse this life-threatening condition Nursing interventions ▪ Administer replacement therapy as prescribed ▪ Avoid sedating the patient, which may further decrease respirations ▪ Recognize that slower metabolism may slow drug absorption and excretion ▪ Provide frequent skin care to prevent breakdown and decrease the risk of infection ▪ Administer fluids as prescribed; correct imbalances without causing fluid overload