Management of Patients with Endocrine Disorders 2 PDF

MANAGEMENT OF PATIENTS WITH ENDOCRINE DISORDERS 2 Presented by:Keron Jones-Fraser; RN, BScN, Cert. Nsg. Ed. MScN OBJECTIVES  By the end of the three hours session students should be able to:  Give a review of two organs the of endocrine system (Pituitary gland and th...

MANAGEMENT OF PATIENTS WITH ENDOCRINE DISORDERS 2 Presented by:Keron Jones-Fraser; RN, BScN, Cert. Nsg. Ed. MScN OBJECTIVES  By the end of the three hours session students should be able to:  Give a review of two organs the of endocrine system (Pituitary gland and the Pancreas)  Explain the major conditions of the pituitary gland  Overview of information can be garnered from a health history and assessment of the various conditions with 95% accuracy  Discuss the nursing care of clients with conditions of the pituitary gland OBJECTIVES  Define the term Diabetes Mellitus  List the functions of Insulin  Outline the classification of Diabetes Mellitus  List the risk factors of Type 1 and Type 11 Diabetes Mellitus.  State the clinical manifestations of Diabetes Mellitus  Describe the management of the client with Hypoglycemia.  Describe the management of the client with Diabetic Ketoacidosis. OBJECTIVES  List the long term complications associated with Diabetes Mellitus.  Describe the nursing care management of a client with Diabetes Mellitus. OVERVIEW OF THE PITUITARY GLAND  Hypothalamus: Control the release of pituitary hormones  Pituitary Gland : Master Gland  Anterior  Follicle stimulating hormone(FSH ) Luteinizing hormone (LH) - gonadotrophic cells  Thyroid Stimulating hormone – thyrotrophic cells  Adrenocorticotrophic stimulating -  Growth harmone - somatotrophic cells  Prolactin: Lactotrophic cells OVERVIEW OF THE PITUITARY GLAND  Posterior : (Nerve tissue)  Store and release Antidiuretic hormone (Vasopressin) –decrease urine production  Oxytocin  induce contraction in the smoothe muscles in the reproductive organs and milk ejection Pituitary Gland and Its Hormones Overview of Endocrine System Overview of Endocrine System Pancreas –Regulates Carbohydrates Metabolism  Exocrine  Endocrine  Islets of Langerhans  Alpha cells - Glucogon  Beta cells -Insulin  Delta - Inhibits the functions of Alpha and Beta cells  F cells – Inhibits exocrine function Endocrine disorders: Anterior Pituitary Gland  These conditions are characterized by excessive or under production and secretion of one or more of the trophic hormones  Hypersecretion  Giantism : occurs when there is a hyper secretion of the growth hormone (GH) before puberty. Resulting in the closure of the epiphyseal plates and person become abnormally tall exceeding 7 feet  Acromegally : (Enlarge extremities) hypersecretions begins during adulthood. Endocrine disorders: Anterior Pituitary Gland Giantism Cause  Pituitary tumours  Pituitary hyperplasia Endocrine disorders: Anterior Pituitary Gland Acromegally Cause  Pituitary tumours  Pituitary hyperplasia Endocrine disorders: Anterior Pituitary Gland  Hyposecretion  Causes  Pituitary Tumours  Removal of the gland  Radiation  Pituitary infarction  Infection  trauma Endocrine disorders: Posterior Pituitary Gland  Conditions resulting from a hyper or hyposecretion of antidiuretic hormone (ADH) (Vasopressin)  Conditions includes  Syndrome of inappropriate ADH secretion (SIADH)  High levels of ADH  Cause from ectopic production of ADH eg (oat cell carcinoma of the lung, pancreatic carcinoma, leukemia, Hodgkin’s diseases or from head injury, and certain medications eg barbiturates, anesthetics, and diuretics ) Endocrine disorders: Posterior Pituitary Gland SIADH  Manifestations  serum hypo-osmolarity, water retention, hyponatremia, increase blood volume plasma is diluted shifting of fluid from intravascular to interstitial space and cells resulting in decrease U/O concentrated urine  Treatment  Fluid restriction 1L /day  Flurosemide ½ strength saline decrease fluid volume nd prevent sodium loss.  Declomycin (tetracycline antibiotics) unique property of increase urine flow Endocrine disorders: Posterior Pituitary Gland Diabetes Insipidus Result from ADH insufficiency Types Neurogenic : Disruption of hypothalamus or pituitary gland Nephrogenic : renal tubules not sensitive to ADH Manifestations Large amount of diluted urine , low specific gravity; Excessive thirst, dehydration and hypernatremia Endocrine disorders: Comparison of Posterior Pituitary Gland Disorders SIADH Diabetes Insipidus  Excessive ADH  Deficient ADH  Fluid Volume Excess  Fluid volume deficit  Restrict fluid intake  Encourage fluid intake  Demeclocycline (caused  Desmopressin DDAVP) excessive urination nasal spray causes increase water reabsorption Care of the Clients with Diabetes Mellitus : DEFINITION  Diabetes Mellitus is a group of metabolic diseases characterized by increased levels of glucose in the blood resulting from defects in insulin secretion, insulin action, or both. Care of the Clients with Diabetes Mellitus :Functions of Insulin  Transports and metabolizes glucose for energy  Stimulates storage of glucose in the liver and muscle as glycogen  Signals the liver to stop the release of glucose Care of the Clients with Diabetes Mellitus :Functions of Insulin  Enhances the storage of dietary fat in adipose tissue.  Accelerates transport of amino acids into cells.  Inhibits the breakdown of stored glucose, protein, and fat. Care of the Clients with Diabetes Classifications of Diabetes  Type 1 diabetes (also known as Juvenile & Insulin Dependent Diabetes)  Type 2 diabetes  Gestational diabetes  Diabetes mellitus associated with other conditions or syndromes Type 1 Diabetes  Insulin producing beta cells in the pancreas are destroyed by an autoimmune process  Requires insulin, as little or no insulin is produced  Onset is acute and usually before 30 years of age  5–10% of persons with diabetes Pathogenesis of Type 1 Diabetes Type 2 Diabetes ❖ Decreased sensitivity to insulin (insulin resistance) and impaired beta cell function results in decreased insulin production  More common in persons over age 30 and in the obese.  Slow, progressive glucose intolerance  Treated initially with diet and exercise  Oral hypoglycemic agents and insulin may be used Pathogenesis of Type 2 Diabetes Risk Factors  Type 1: A family history: Anyone with a parent or sibling with type 1 diabetes has a slightly increased risk of developing the condition.  Genetics: The presence of certain genes indicates an increased risk of developing type 1 diabetes.  Type 2: family history of diabetes, obesity, race/ethnicity, age greater than 45 years, previous identified impaired fasting glucose or impaired glucose tolerance, hypertension ≥ 140/90, history of gestational diabetes or babies over 9 pounds  Clinical Manifestations  “Three Ps”  Fatigue, weakness, vision  Polyuria changes, tingling or numbness in hands or feet, dry skin, skin  Polydypsia lesions or wounds that are slow  Polyphagia to heal, recurrent infections  Type 1 may have sudden weight loss, nausea, vomiting, and abdominal pain if DKA has developed Diagnostic Findings  Fasting blood glucose 126  Fasting: 5.6 mmol/L mg/dL or more  2 hours postprandial: 7.8  Random glucose exceeding mmol/L 200 mg/dL  Random: 4.4-6.6 mmol/L  Gerontologic considerations: age-related elevation of blood glucose  Insulin Therapy  Blood glucose monitoring  Categories of insulin Rapid-acting – Lispro (Humalog) Onset 10- 15min Short-acting – Regular Humalog R, Novolin R Onset 30 min – 60 min Insulin Therapy  Intermediate-acting Humulin N Onset 3 – 4 hours  Very long-acting Glargine (Lantus) Onset 1 hour Oral Antidiabetic Agents  Used for patients with type 2 diabetes who cannot be treated with diet and exercise alone.  Combinations of oral drugs may be used  Major side effect: hypoglycemia  Nursing interventions: monitor blood glucose, and for hypoglycemia and other potential side effects  Patient teaching Hypoglycemia  Abnormally low blood glucose level (below 50–60 mg/dL) or (2.8-3.3mmol/L)  Causes include too much insulin or oral hypoglycemic agents, too little food, and excessive physical activity Hypoglycemia  Manifestations  Central nervous system symptoms:  inability to concentrate  headache  confusion  memory lapses  slurred speech  numbness of lips and tongue  irrational or combative behavior , drowsiness  double vision Hypoglycemia  Adrenergic symptoms: sweating, tremors, tachycardia, palpitations, nervousness, hunger  Severe hypoglycemia may cause disorientation, seizures, and loss of consciousness Management of Hypoglycemia  Treatment must be immediate  4–6 ounces of juice or regular soda (not diet soda)  6–10 hard candies  2–3 teaspoons of honey Management of Hypoglycemia  Retest blood glucose in 15 minutes, retreat if >70 mg/dL or 3.8mmol/L or if symptoms persist more than 10–15 minutes and testing is not possible.  Provide a snack with protein and carbohydrate unless the patient plans to eat a meal within 30– 60 minutes. Emergency Measures  If the patient cannot swallow or is unconscious:  Subcutaneous or intramuscular glucagon 1 mg  25–50 mL 50% dextrose solution IV Diabetic Ketoacidosis (DKA)  Caused by an absence of or inadequate amount of insulin resulting in abnormal metabolism of carbohydrate, protein, and fat.  Clinical features  Hyperglycemia  Dehydration  Acidosis  Fruity Breath  Ketones (Urinalysis) Diabetic Ketoacidosis (DKA)  Manifestations include polyuria, polydipsia, blurred vision, weakness, headache, anorexia, abdominal pain, nausea vomiting, acetone breath, hyperventilation with Kussmaul respirations, and mental status changes Assessment of DKA  Blood glucose levels vary from 300–800 mg/dL  Severity of DKA is not related to blood glucose level  Ketoacidosis is reflected in low serum bicarbonate and low pH; low PCO2 reflects respiratory compensation  Ketone bodies in blood and urine.  Electrolytes vary according to water loss and level of hydration. Treatment of DKA  Rehydration with IV fluid  IV continuous infusion of regular insulin  Reverse acidosis and restore electrolyte balance  Note: rehydration leads to increased plasma volume and decreased K+, insulin enhances the movement of K+ from extracellular fluid into the cells Treatment of DKA  Monitor  Blood glucose and renal function/UO  EKG and electrolyte levels—Potassium  lung assessments, signs of fluid overload Hyperglycemic Hyperosmolar Nonketotic Syndrome  Hyperosmolality and hyperglycemia occur due to lack of effective insulin. Ketosis is minimal or absent.  Hyperglycemia causes osmotic diuresis with loss of water and electrolytes; hypernatremia, and increased osmolality occur.  Manifestations include hypotension, profound dehydration, tachycardia, and variable neurologic signs due to cerebral dehydration.  High mortality. Long-Term Complications of Diabetes  Macrovascular complications  Accelerated atherosclerotic changes  Coronary artery disease, cerebrovascular disease, and peripheral vascular disease  Microvascular complications  Diabetic retinopathy,  Nephropathy  Neuropathy Long-Term Complications of Diabetes  Neuropathic changes  Peripheral neuropathy, autonomic neuropathies, hypoglycemic unawareness, neuropathy, sexual dysfunction Nursing Process: The Care of the Patient with Diabetes—Assessment  Obtain a history of current problems, family history, and general health history.  Has the patient experienced polyuria, polydipsia, polyphagia, and any other symptoms?  Number of years since diagnosis of diabetes  Family members diagnosed with diabetes, their subsequent treatment, and complications  Skin: skin lesions, infections, dehydration, evidence of poor wound healing  Eyes: changes in vision “floaters, halos, blurred vision, dry or burning eyes, cataracts, glaucoma” Nursing Process: The Care of the Patient with Diabetes—Assessment  Perform a review of systems and physical examination to assess for signs and symptoms of diabetes, general health of patient, and presence of complications.  General: recent weight loss or gain, increased fatigue, tiredness, anxiety Nursing Process: The Care of the Patient with Diabetes—Assessment  Mouth: gingivitis, periodontal disease  Cardiovascular: orthostatic hypotension, cold extremities, weak pedal pulses,  GI: diarrhea, constipation, early satiety, bloating, increased flatulence, hunger or thirst Nursing Process: The Care of the Patient with Diabetes—Assessment  Genitourinary (GU): increased urination, nocturia, impotence, vaginal discharge  Neurologic: numbness and tingling of the extremities, decreased pain and temperature perception, changes in gait and balance Nursing Process: The Care of the Patient with Diabetes— Diagnosis  Risk for Activity Intolerance related to poor glucose control Nursing Interventions  Advise patient to assess blood glucose level before and after strenuous exercise.  Instruct patient to plan exercises on a regular basis each day.  Encourage patient to eat a carbohydrate snack before exercising to avoid hypoglycemia. Nursing Interventions  Advise patient that prolonged strenuous exercise may require increased food at bedtime to avoid nocturnal hypoglycemia.  Instruct patient to avoid exercise whenever blood glucose levels exceed 250 mg/day and urine ketones are present. Patient should contact health care provider if levels remain elevated. Nursing Diagnosis  Risk for Impaired Skin Integrity related to decreased sensation and circulation to lower extremities Nursing Interventions  Assess feet and legs for skin temperature, sensation, soft tissue injuries, corns, calluses, dryness, bunion deformation, hair distribution, pulses, deep tendon reflexes. Nursing Interventions  Maintain skin integrity by protecting feet from breakdown.  Use heel protectors, special mattresses, foot cradles for patients on bed rest.  Avoid applying drying agents to skin (eg, alcohol).  Apply skin moisturizers to maintain suppleness and prevent cracking and fissures. Nursing Interventions  Advise the patient who smokes to stop smoking or reduce if possible, to reduce vasoconstriction and enhance peripheral blood flow. Help patient to establish behavior modification techniques to eliminate smoking in the hospital and to continue them at home for smoking-cessation program. Nursing Interventions  Counsel patient to inject insulin into the abdominal site on days when arms or legs are exercised.  Instruct patient in foot care guidelines  Care of your feet is very important. In diabetics, the nerves to the feet often becomes less sensitive so you may not be aware of any cut, burn, blister or infection. Nursing Interventions – Foot Care Guidelines  Wash your feet every day.  Dry your feet gently and carefully especially between the toes.  Check your feet daily especially between your toes. Use a mirror if needed. Nursing Interventions – Foot Care Guidelines  Cut toenails after a bath or shower as the nails are softer.  Always cut toe nails straight across.  Make sure that the corners of the nails are gently rounded by using a nail file. Nursing Interventions – Foot Care Guidelines  Wear shoes or slippers at all times.  Make sure your shoes fit you correctly that is they do not rub.  Check the inside of your shoes for foreign objects such as pins, and nails, before putting them on. Nursing Interventions – Foot Care Guidelines DO NOT  Walk barefooted.  Wear tight or worn shoes.  Wear open toe sandals.  Wear slip on type foot wear Nursing Interventions – Foot Care Guidelines  Do not attempt to cut your nails if you cannot see them clearly.  Do not cut the sides of your nails.  Never put your feet directly on to hot water bag as this can cause serious burns Nursing Interventions – Foot Care Guidelines WHEN YOU CHECK YOUR FEET LOOK FOR…  Any change in the colour of your feet and toes.  A change in temperature, as hot feet may indicate infection and cold feet could be a problem with your circulation.  Unusual dampness in socks or stocking could be due to a break in the skin, blisters or infection.  Any change of feeling in the feet example burning pains and needles, sharp pain, or cramps Nursing Diagnosis  Risk for Deficient Knowledge related to use of oral hypoglycemic agents and exercise for promoting normoglycemia. Nursing Interventions  Assess patient’s health care literacy (language, reading, comprehension). To ensure that information is presented in a manner that is educationally appropriate.  Teach patient to check expiry date on medication.  Explain to the client the importance of following the diet outlined by the nutritionist. Nursing Interventions  Teach clients to be alert for signs of hypoglycemia such as: sweating, slurred speech, weight loss, staggering gait etc  Teach patient about signs of hyperglycemia such as : polydispia, polyuria, polyphagia, fruity – smelling breath and fatigue. Exercise Precautions  Exercise with elevated blood sugar levels (above 250 mg/dL) and ketones in urine should be avoided  Insulin normally decreases with exercise; patients on insulin should eat a 15g carbohydrate snack before moderate exercise to prevent hypoglycemia  If exercising to control or reduce weight, insulin must be adjusted  Potential post-exercise hypoglycemia  Encourage client to monitor blood glucose levels Exercise Recommendations  Modify exercise regimen to patient needs and presence of diabetic complications or potential cardiovascular problems  Exercise stress test for patients older than age 30 who have 2 or more risk factors is recommended Teaching Patients Self-Care  Assess knowledge and adherence to plan of care.  Provide basic information about diabetes, its cause and symptoms, and acute and chronic complications and their treatment.  Include family in plan of care. Teach self-care activities to prevent long-term complications including foot care, eye care, and risk-factor management. Provide information, encourage health promotion activities, and recommended health screenings.  Question Is the following statement True or False? Type 1 diabetes mellitus is treated initially with diet and exercise. Answer False Type 2 diabetes mellitus, NOT type 1 diabetes mellitus, is treated initially with diet and exercise. Question What category of insulin is rapid acting? A. Humalog B. Humalog R C. Humulin N D. Glargine (Lantus) Answer A Humalog is a rapid-acting insulin. Humalog R is a short-acting insulin. Humulin N is an intermediate-acting insulin. Glargine (Lantus) is a very long-acting insulin. Individual Activity Mr. T, a 36 year old Insurance agent, is admitted to a Medical ward with a history of having an ulcer to his foot that has not healed for weeks, passing his urine frequently and having tingling sensations and numbness to his hands and feet. He was diagnosed with Diabetes Mellitus 3 months ago. Individual Activity ❖ Describe nursing intervention measures, which will assist Mr. T in meeting the following needs during the first 48 hours of admission to the male surgical ward. A. Safety and Security B. Love and Belonging ❖ Explain the following component of a discharge plan for Mr. T: a. Foot care b. Diet References Brunner & Suddarth’s Medical surgical Nursing (12th ed.) (2010). Philladelphia: Lippincott, Williams & Wilkins. CDC. National Diabetes Fact Sheet. United States. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2003.pdf. Lemone, P., Burke, K. M., & Bauldoff, G. (2014). Medical- Surgical Nursing Critical Thinking in Patient Care (5th ed., pp. 769-881). Edinburgh Harlow: Pearson Education Limited. Siebenhofer A, Plank J, Berghold A, et al. Short acting insulin analogues versus regular human insulin in patients withdiabetes mellitus. Cochrane Database Syst Rev. 2004;CD003287. [Medline]. Swearingen P. L., (2008) All-in –One Care Planning Resource 2nd ed Mosby :Elsevier