Endo-Gastro-7-13.pdf

Before the surgery EUTHYROID- normal thyroid (46weeks) (+) Chvosteck’s Sign – abnormal spasm of the facial muscle evaluate V/S “Normalize first T3 T4 then supply” that elicited fby light tapping the pts facial Obstruction...

Before the surgery EUTHYROID- normal thyroid (46weeks) (+) Chvosteck’s Sign – abnormal spasm of the facial muscle evaluate V/S “Normalize first T3 T4 then supply” that elicited fby light tapping the pts facial Obstruction nerve near the lower jaw –HYPOCALCEMIA ❖ Care with the client undergoing Thyroidectomy accumulation of bronchotracheal secretion Preoperative Intervention (+) Trousseau's Sign secondary to bleeding instruct client on how to perform DBCT exercise ad Mgt: Calcium Preparation – Calcium spasm and laryngo edema how to support the neck in the post-operative Gluconate Management: Emergency Tracheostomy period when coughing and moving Administer following meds to prevent thyroid LARYNGEAL NERVE INJURY Thyroid Crisis/ Thyroid Crisis storm: Hoarseness Aphonia ➔ Is an extreme and life threatening form of Na Iodide Sol’n ( Lugol’s Sol’n ) thyrotoxicosis, it is rarely seen today because of Mgt: assess client talking ability Inderal (Propanolol) improved diagnosis and treatment methods Bleeding – Glucocorticoids ➔ When it does occur, if is seen most in undx case or ➔ failure to administer LUGOLS or KISS Check Electrocardiogram (ECG) in person w/ hyperthyroidism who have not been Post-Operative Care ➔ Failure surgeon to tie bleeders adequately treated. Establishment of patent airway: Px: Semifowlers ➔ Continuous oozing of blood ➔ It is often is precipitate by stress such as infection Tracheostomy set at bedside ➔ Cots causes respiratory obstruction (usually respiratory, by DKA, by physical and Render steam inhalation Frequent swallowing indicate BLEEDING. emotional trauma, or by manipulation of a hyperactive thyroid gland during thyroidectomy. Provide adequate nutrition and fluid and electrolyte Assessment ➔ Thyroid storm is manifested by a very high fever, Observe Complication check dressing extreme cardiovascular effects (ex tachycardia, CHF, angina and severe effecte ex agitation, TETANY – accidental removal of parathyroid gland slip hand under the head/neck and check for restlessness and delirium) the mortality rate is dampness high. Nursing Care PARATHYROID GLANDS Excess parathormones can result in markedly 1. Peripheral cooling is initiated w/ cold packs a normally four in number, are situated in the neck, embedded elevated levels of serum calcium, a potentially life- cooling mattress in the post aspect of the thyroid gland. threatening situation. 2. Replace fluids, glucose and electrolyte are essential Function: Parathormone – the protein hormone from the HYPERPARATHYROIDISM hypermetabolic state parathyroid glands. -cause by overproduction of PTH by parathyroid gland is 3. B-adrenergic blocking agent. 1. Regulate calcium and phosphorus metabolism - Increase characterized by bone decalcification and development of 4. Propylthriouracil or methimazole may be given to secretion of PTH result in increased calcium absorption renal stones containing calcium. Cause: Adenoma, block thyroid synthesis from the kidney, the intestine, and bones, thereby raising Hypertrophy, Hyperplasia 5. Aspirin increase the level of free thyroid hormone the blood calcium level – some actions of the hormones by displacing the hormones from their protein are increased by the presence of Vit D. cause and shout not be used during thyroid storm. 2. PTH also tends to lower the blood phosphorus level. 3. Regulate cardiac rythmicity 4. Blood Coagulation  Diagnostic Exam: Medical Management 1. Persistent elevation of serum calcium & elevation I. Hydration therapy – because kidney involvement is level of parathormone possible pt w/ hypeparathyroidism are risk for renal 2. Radioimmune Essay calculi. 3. Double antibody PTH test Nursing Care: 4. Ultrasound 1. Encourage intake of 2,000 ml or more encouraged 5. MRI 2. Cranberry juice is suggested 6. Thallium scan 3. Pt is instructed to report other manifestation of 7. Fine-needle biopsy 8. X-ray- bones appears porous. renal calculi such as abdominal pain & hematuria. 9. SALKOWITCH TEST- test for calcium in urine. 4. Monitor K level Complication of HYPERPARATHYROIDISM 5. Thiazide is avoided Nursing Dx - Acute hypercalcemia crisis can occur in Risk for Injury hyperparathyroidism this occur w/ extreme elevation of II. Mobility Pain serum calcium level. Serum calcium levels higher than 15 - walking or use of rocking chair, is encouraged as much as Altered Elimination ( Constipation ) mg/dl result in neurologic, cardiovascular, renal symptoms possible because bones subjected to normal stress give up that can be lifethreatening. less calcium. - oral phosphate lower serum calcium level in Altered Cardiac Output some pt but long term use is not recommended because of Nutrition: Less than body requirements Treatment risk for ectopic deposits in soft tissues. S/S: 1. Rehydration w/ large volumes of intravenous fluid Body System 2. Diuretics agents to promote renal excretion of III. Diet & Medication Apathy - HPN excess calcium. a. pt is advised to avoid a diet w/ restricted or excess Fatigue - Cardiac dysrhthmias calcium (Low calcium diet - eliminate MILK) Furosemide ( Lasix ) Muscular weakness b. If the pt has co-existing peptic ulcer, specifically Thiazide diuretics should not be administered to prescribed antacids & protein feeding are N/V pt w/ hyperparathyroidism, since they decrease necessary. Phychological the renal excretion of calcium, thereby causing Avoid meds containing calcium hypercalcemia, or calcium reabsorption in the disk ➔ Irritability & necrosis to psychosis is cause by the convulated tubule of the kidney. c. Because anorexia is common – effort are made to direct effect of calcium on the brain improve the pt appetite. & NS Phosphate therapy-control hypercalcemia( ex. Biphosphanates) control hypercalcemia (ex. d. Prune juice, stool softeners & physical activity, ➔ An increase in Ca produce a decrease in excitation Biphosphonate) along w/ increased OFI, help to offset constipation potential of nerve & muscle Cytotoxic Agents (Mithramycin) Surgery Parathyroidectomy tissue A combination of calcitonin & corticosteriods has HYPOPARATHYROIDISM been administered en emergencies – to reduces The incidence of PEPTIC ULCER & PANCREATITIS is increased the serum calcium level by increasing calcium - the most common cause of hypopara is hyperparathyroidism & may responsible for many of GI inadequate secretion of PTH after of the blood supply or deposition in bone. symptom that occur. surgical removal of parathyroid gland tissue during irritability (Tetany) thyroidectomy, parathyroidectomy or radical neck Nursing Diagnosis: 2. Tracheostomy or mechanical ventilator may dissection Risk for Injury become necessary along w/ bronchodilator Knowledge deficit for diet & medications medications 3. Diet: increase calcium, decrease phosphorus Assessment 4. Oral tablets of calcium salts, such as calcium Diagnostic Findings Gluconate may supplement diet Latent tetany is suggested by 5. Aluminum hydroxide gel or alumunum carbonate positive (Gelusil, Amphogel). Is administered after meals to bind phosphate and promote its excretion through the GIT. 1. TROUSSEAU’s Sign – positive when carpopedal 6. Variable dosages of vitamin D preparation ex. spasam is induced by occluding the blood flow to Dihydrotachysterol ( AT10 or Hytakerol) the arm for 3 mins with use of a BP cuff. Ergocalciferol ( Vit D2) 2. CHVOSTEK’s Sign – is positive when a sharp tapping Cholecalciferol ( Vit D3) over the facial nerve just infront of the parotid gland & anterior to the ear causes spasm or 7. If the patient has cardiac problems, is subject to dysrythmias or is receiving digitalis, calcium twitching of mouth, nose & eye. gluconate is administered slowly and cautiously- Laboratory Test: continous cardiac monitoring and carefull Serum Ca – 5 to 6 mg/dl (1.2 to assessment. 1.5mmol/l) ADRENAL GLANDS Serum Phosphate – Increased - two adrenal glands in human, each attached to X-ray of bone show increase in density the upper portion of the kidney. - each adrenal gland is, in reality, two endocrine glands with separate independent Medical Management functions. The goal of therapy is to raise the serum calcium level to 9- 10mg/dl (2.2-2.5 mmol/l) ADRENAL MEDULLA : Hormones 1. When Hypocalcemia & tetany occur after a 1.) Epinephrine – effects of sympatho-adreno- dullary thyroidectomy, the immediate tx is to administer response, stimulations on body organs are as follow Calcium Gluconate IV (Concept “ Every function is high and fast, except G.I and G.U”) 2. If this does not decrease neuromuscular irritability & seizure activity immediately SEDATIVES, such as Brain : increase alertness, restlessness PHENOBARBITAL may be administered. Eyes : dilation of pupils, relaxation of ciliary bodys Heart : increase heart rate, increase contractility, Nursing Care increase stroke volume, coronary vasodilation. 1. Provide an environment that free of noise, sudden Lungs : relaxation of bronchial muscles ( drafts, bright light or sudden movement – because bronchodilation), increase RR. of neuromuscular  Peripheral blood vessels: vasoconstriction, increase  vertigo, blurring of vision, tinnitus, air hunger and BP dyspnea. Factors that may elevate catecholamine levels must be Mouth : decrease salivary glands secretion, dry controlled to obtain valid results: mouth and thrist. Assessment and Diagnostic Findings: - 1. consumption of coffee or tea. Pheochromocytoma is suspected if signs of 2. Skin: Pilomotor muscle contraction, localized use of tobacco. symphathetic nervous system overactivity. -These sweating, cold clammy skin. 3. emotional and physical stress ( bending, lifting, Valsalva signs can be associated with the 5 H’s” G.I : deceased production of GI secretions, 1. Hypertention manuever, can be ppted) decreased motility. 4. over- the- counter medications ( e.g amphitamines, 2. Headache Kidney : increased renin secretion nosedrops or sprays, decongestants and 3. Hyperhidrosis ( excessive sweating) brochodilators. Urinary bladder: relaxation of detrusor muscles and contraction of sphincter. 4. Hypermetabolism 5. Hyperglycemia Normal Value: Catecholamine level Liver : Glycogenolysis, gluconeogenesis, increase -Blood pressure with client in upright and horizontal Blood/ plasma: 0.2- 0.9mg% serum glucose. positions’ Urine: 0.2- 7 mg/24 hours Pancreas : decreased secretion of Islets cells, decreased insulin secretion, increased glucose TEST: Medical Management: Gallbladder- relaxation of the gallbladder -Measurement of urine and plasma levels of catecholamine - During an episode or attack of hypertention, tachycardia, Fat cells – Lipolysis are the most direct and conclusive test for overactivity of anxiety, and the other syptoms of pheochromocytoma, the adrenal medulla. - Measures of urinary catecholamine patient is placed on bed rest with the head of the bed Disorders: metabolites: elevated to promote an orthostatic decreased in blood 1. ) PHEOCHROMOCYTOMA 1. MN ( metanephrines) pressure. - is the tumor that is usually benign and originate from the 2. VMA ( Vanillylmandelic acid) Pharmacologic Therapy: chromaffin cells of the adrenal medulla, the tumor arises in the medulla 1) Alpha adrenergenic blocking agents( ex Phentolamine( Food to avoid/ medications ( 3 days before the test): Regitine) or smooth muscle relaxants( Nipride)- to lower the - it may occur at any age, but its peak incidence is between -coffee, tea, banana, chocolates, vanilla, beer, wine, citrus blood pressure. 2) Beta- adrenergic blocking agents, such as ages 20 to 50 years, it occurs both men and women fruits, aspirin ( may alter the results of propranolol ( Inderal)- maybe used in patients with cardiac equally. these tests, therefore carefull instructions) dysrhytmias/ tachycardia. - Clinical Manifestation: 3.) Phenoxybenzamine (Dibenzyline)- long acting alpha-  typical Triad symptoms includes A 24 hour urine specimen is collected- How? - Total blocker.  headache plasma catecholamine( blood) can also be measured:  diaphoresis 1. Position patient in supine position and rest Surgical Management: for 30 minutes. -The definitive treatment of pheochromocytoma is surgical  palpitations 2. To prevent elevation of catecholamine removal of the tumor, usually with  hypertention and other cardiovascular disturbance are level by stress of venipuncture, a butterfly needle, ADRENALECTOMY. Bilateral adrenalectomy maybe necessary common. scalp vein needle, venous catheter maybe inserted if tumors of both adrenal glands are present.  other symptoms : tremor, headache, flushing, anxiety. 30 minutes before the blood specimen is obtained.  Hyperglycemia- may result from conversion of liver and ADRENAL CORTEX muscle glycogen to glucose by epinephrine secretion. HYPERTENSIVE CRISIS -complication 3 kinds of steroid hormone produced by the adrenal cortex: 1.) Glucocorticoids or Hydrocortisone - It is primarily secreted in response to the presence 2.) Mineralocorticoids or Aldosterone 3.) Sex Hormone( of angiotensin II in the bloodstream - Angiotensin II is a mainly Androgens- male sex substance the elevates the blood pressure by constricting hormones) arteriols. Its concentration is increased when renin is released. 2. Glucocorticoids 3. ) Adrenal Sex Hormone ( Androgens) - synthesized - are synthesized in zona fasciculata and zona reticularis. primarily by the zona reticularis and zona fascicullata of - are given their name because they have an important the cortex. -the third major type of steroid hormones influence on glucose metabolism. - Glucocorticoids are produced by adrenal cortex. secreted from the adrenal cortex in response to release of - the adrenal gland may also secrete small amount of ACTH from the anterior PG. some estrogens/or female sex hormone - secretion of - helps to protect the body during long- term stressful adrenal androgens is controlled by ACTH. situations such as extended illness and surgery. - When secreted in normal amounts, the adrenal - Stimulates gluconeogenesis ( increase blood glucose), androgens probably have a little effect but when secreted in lipolysis, decrease protein synthesis, suppress the excess in certain inborn enzymes deficiencies , inflammatory response, promote sodium retention and MASCULINIZATION may result- this termed the potassium loss. adrenogenital syndrome ( Virilism, - Glucocorticoids Musculination, hirsutism) - Glucocorticoids ( in the form of corticosteroids) are frequently administered to inhibit the inflammatory DISORDERS: response to tissue injury and suppress allergic 1.) Cushing’s Syndrome/ Disease - result from manifestations. - Their side effects include development of excessive rather than deficient adreno- cortical activity. DM, osteophorosis, peptic ulcer, increase protein - the syndrome may result from excessive breakdown resulting in muscle wasting, poor wound administration of corticosteroids or ACTH, or healing, redistribution of body fat. -If exogenous hyperplasia of the adrenal cortex glucocorticoid administration is suddenly discontinued, ADRENAL INSUFFICIENCY result because of the inability of the atropied cortex respond adequately. 2) Mineralocorticoids - produce in zona glomerulosa. - play an essential role in regulating potassium and sodium levels and water balance. - exert their major effects on electrolyte metabolism, they act principally on renal Nursing diagnosis for Cushing: tubular and gastrointestinal epithelium to cause increase sodium ion absorption in exchange for excretion of 1. Riskfor Injury related to weakness potassium or hydrogen ions. - Aldosterone secretion is only 2. Body Image disturbance minimally influenced by ACTH. 3. Fluid Volume Excess Indicators of Cushing’s Syndrome includes: pt. with Cushing’s Syndrome is monitored closely for 1. serum sodium hypotension , rapid, weak pulse 2. blood glucose levels Rapid resp. rate, pallor and extreme weakness. 3. decrease serum concentration potassium - The patient with Cushing’s Syndrome who experiences highly stressful events, such as trauma or emergency Diagnostic Test: surgery, is at increased risk for Addisonian crisis because of 1). Low Dose Dexamothasone Suppression Test – long term suppresion of the adrenal cortex. Dexamethazone( 1mg) is administered orally at 11pm, and plasma cortisol level is obtained at 8am the next morning ADVERSE EFFECTS OF ADRENOCORTICAL ACTIVITY Result: increase cortisol balance. - Fluid and electrolyte status is assessed by monitoring 2.) 24- hour urinary free cortisol level and high dose or low laboratory values and the patients daily weight. dose dexamethasone test. - Because of the increased risk of glucose intolerance and hyperglycemia. Blood glucose monitoring is initiated, and Surgical Management: elevated blood glucose levels are reported to the  ADRENALECTOMY- removal of adrenal gland. physician. CUSHING’S- have extra” cushion of hormone”  TRANSSPHENOIDAL HYPOPHYSECTOMY- surgical removal of the tumor of pituitary gland. ADDISON’S DISEASE - Hyposecretion of adrenal hormnes( mineralocorticoids, glucocorticoids, NURSING CARE: androgens) 1. Decreasing Risk for Injury- a protective environment is establish to prevent falls, fractures and other injuries to Pathophysiology: bones and soft tissues. Diagnostic Findings: - decrease Na dehydration Blood Studies: - decrease glucose 2. Diet: High protein, high calcium, low carbohydrates, - decrease blood volume + shock high potassium, low sodium, low calorie diet - decrease Na - increase K metabolic acidosis+ arrythmias 3. Decreasing Risk for Infection- unnecessary exposure to - increase Potassium - decrease blood sugar+ insulin shock others is avoided. The patient is assessed frequently for - decrease fasting plasma cortisol signs of infections because the anti inflammatory - decrease aldosterone effects of corticosteroids. Urine studies - 17- hydroxycorticosteroids 4. Preparing the patient for Surgery - 17- ketogenic steroid 5. Encouraging Rest and Activity 6. Promoting Skin Integrity 7. Potential Complication of Medical Management: Cushing: 1. Immediate treatment is directed toward combating shock, restoring blood circulation. ADDISONIAN CRISIS- the patient with Cushing’s syndrome - Administering fluids and corticosteroids. whose symptoms are treated by withdrawing corticostiroids - Monitoring vital signs or by adrenalectomy or removing a pituitary tumor is at risk for adrenal hypofunction or Addisonian crisis, therefore the - Hydrocortisone ( Solu- Cortef) is administered followed by -series of blood specimen is collected after administration 5% dextrose in normal saline. - Vasopressor amines maybe HYPERALDOSTERONISM (CONN’S SYNDROME) of glucose ( 30 mins, 1 hour, 2 hours, if required 3 hours , 4 required if hypotention persist. ASSIGNMENT hours, and 5 hours after) - Antibiotics maybe administered if infection has -If glucose level peak at higher than normal at 1 to 2 hours precipitated. DIABETES MELLITUS after ingestion or injection of glucose and slower than - Oral intake maybe initiated as soon as tolerated by the - is a chronic disorder of carbohydrates, fats, protein normal to return to fasting levels, the DM is confirmed. patient. metabolism. -Done when results of FBS and 2 PPBS are borderlined ( high normal) - If the adrenal gland does not regain function, the patient - It is due to inadequate insulin production or increased needs LIFELONG replacement of corticosteroids and resistance to insulin. mineralocorticoids- to prevent recurrence of adrenal - The cause of DM is unknown. 4. HGT- No NPO ( Blood) Hemoglucotest/ Capillary insufficiency and prevent Addisonian crisis in times of Blood Glucose Test stress and illness. The predisposing factors of DM are as follows: a. Stress 5. Glycosylated Hemoglobin ( HbA1c) b. Heredity Pharmacologic Management of Addison: - most accurate indicator of DM ( Diabetes Mellitus) c. Obesity - Prednisone - Decadrone - reflects serum glucose levels for past 3 to 4 mos d. Viral infections - Dexamethasone - Solu- Cortef - evaluate amount of glucose attached to the hemoglobin e. Autoimmune disorders of your blood for previous 120 days, - Hydrocortisone - Decelon forte f. Women, who are multigravida with large babies - NV: 4% to 6% ( up to 7%) for non diabetics - Betametasone -the goal for client with DM is 7.5% or less DIAGNOSTIC TEST: Nursing Responsibility if the patient is taking STEROIDS: 1. Fasting Blood Sugar( FBS) 6.Acetest- evualate Ketunuria : fats 1. Given with meal and full stomach. Normal: 70- 110mg/dl - Get acetest tablet( offwhite, creamy, white color) 2. Monitor blood sugar level. DM : Increase 140mg/dl for 2 readings 3. MIO - 1-2 drops of urine. 4. Limit fluid and NaCl intake - if color is LAVANDER (+) Ketonuria 2. 2hours Post Prandial Blood Sugar(2PPBS) - initial blood specimen is withdrawn - No change (-) Nursing Management of Addison: - 100g of carbohydrates in diet is taken by the client 1) Diet: High protein, high carbohydrates, high sodium, -2 hours after meal, blood specimen is withdrawn 7. Clinitest ( Glycosuria) low potassium. blood sugar returns to normal level. - 2nd voided/double voieded Procedure: - Clinitest 2) Monitor blood pressure and pulse rate as the patient tablet- Do not hold with barehand, its corrosive. moves from lying to standing position. 3. OGTT/GTT ( Oral Glucose Tolerance Test) - Test tube- 10 gtts water, 5gtts of urine, put tablet and - Take high carbohydrate diet (200 to 300g) for 3 days SIZZLE sound is present. 3) Weight the patient- Best indicator for hypovolemia/ -Avoid alcohol, coffee, and smoking for 36 hours before the dehydration. - Result: test. 0- 0% - blue 4) Monitor for Addisonian Crisis- s/s shock, hypotension, - NPO for 10 to 16 hours trace- ¼ %- blue geen rapid resp. rate, pallor, and extreme weakness - Initial blood and urine specimen are collected + - ½% - green Management: - Immediate treatment with intravenous -150 to 300g of glucose per orem or IV is given ++ - 3/4% - yellow green administration of fluid, glucose, electrolytes esp. sodium, +++ - 1% - yellow green replacement of missing corticosteroids.