Management of Patients With Endocrine Disorders PDF

Prepared by/ As.prof.Dr: Heba Ahmed Presented by/ 2021 - 2022 Outlines  Introduction  Anatomy and physiology of endocrine system  Diagnostic tests for endocrine system  Common endocrine disorder :  Hyperthyroidism  Hypothyroidism  Parathyroid glands’ disorders  Nursing car...

Prepared by/ As.prof.Dr: Heba Ahmed Presented by/ 2021 - 2022 Outlines  Introduction  Anatomy and physiology of endocrine system  Diagnostic tests for endocrine system  Common endocrine disorder :  Hyperthyroidism  Hypothyroidism  Parathyroid glands’ disorders  Nursing care with patient in endocrine disorder  Introduction  The nervous system and endocrine system are interconnected to control body systems.  Disorders of the endocrine system are common and have the potential to affect the function of every organ system in the body.  Endocrine glands (Ductless) secrete their products directly into the bloodstream.  Exocrine glands :Which secrete their products through ducts e.g. products of gastrointestinal tract (salivary glands, pancreas, and liver ). Sweat glands, its product (sweats) presence onto epithelial surfaces. The endocrine system links with the nervous system The nervous system : The hypothalamus is the link between the endocrine and nervous systems. The hypothalamus produces releasing and inhibiting hormones, which stop and start the production of other hormones of endocrine system throughout the body.  The endocrine system secrete hormones affect the nervous system for example the adrenal medulla : norepinephrine and epinephrine that act as neurotransmitters.  The endocrine system links with the nervous system and the immune system.  The immune system interacts with the endocrine system.  It responds to the introduction of foreign agents by chemicals (eg, interleukins, interferons) and is regulated by hormones secreted by the adrenal cortex.  The glands of the endocrine system are anatomically separated in the body.Theses glands secrete hormones Hormones are important in regulation of the internal environment of the body and affect every aspect of life. Cardiac hormones Atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) (ANP and BNP) are synthesized and secreted by cardiac muscle cells in the walls of the atria in the heart. These cells contain volume receptors which respond to increased stretching of the atrial wall due to increased atrial blood volume.  Hormone concentration in the bloodstream is maintained at a relatively constant level.  When the hormone concentration rises, production of that hormone is inhibited.  When the hormone concentration falls, the rate of production of that hormone increases.  This mechanism for regulating hormone concentration in the bloodstream is called negative feedback to maintain the homeostasis. Negative feedback  Health history The nurse asks the patient about:  Fatigue and changes in energy levels (activities of daily life)  Changes in heat and cold tolerance  Changes in weight: changes in adrenal and thyroid disorders and may be a result of changes in fat distribution or fluid loss or retention.  Changes in sexual function and secondary sex characteristics  Changes in mood, memory and altered sleep patterns  Family history of endocrine disorder (Diabetes or thyroid disorder )  Physical examination  Started with height & weight  Vital signs are measured :Change in blood pressure may occur with change of the adrenal cortex  Compare with the baseline Inspection : Changes in appearance  Changes in the skin texture  Eye changes, such as exophthalmos (hyperthyroidism)  Changes in physical appearance ✓ Appearance of facial hair in women or moon face ✓ obesity of the trunk and thinness or increased size of the extremities or edema That may signify disorders of the thyroid, adrenal cortex, or pituitary gland. Exophthalmos Moon face  Palpation  The thyroid gland is the only palpable endocrine gland  It is difficult to palpate So supply the person with a glass of water and first inspect the neck as the person takes a sip and swallows ◼ Thrill (vibration) often can be palpated  Thyroid tissue moves up with a swallow  Find two position for palpation of thyroid gland : posterior approach Anterior approach  Palpate all peripheral pulses.  If the pulse is diminished ,it will indicate circulatory impairment  Palpate the skin turgor by gently pinching a small pieces of skin.The good place is sternum  If a tent of skin remains in place ,the patient may be dehydrated (ADH deficiency)  Auscultation and percussion They aren't part of normal an endocrine assessment but we can use the auscultation in abnormal thyroid gland ◼ bruit (vascular murmur heard over hyperactive thyroid gland), is heard over the thyroid arteries (due to increase blood flow through the thyroid gland)  Blood tests:- for indicating hormone level direct likeT3 &T4 or indirect hormone like calcium level or glucose level Urine tests:- amount of hormone excrete in 24 hrs. in urine Nuclear scanning ‫المسح النووي‬ Radiographic tests Ultrasound Biopsy  Nuclear scanning  Thyroid scan to determine the presence of tumors or nodules ◼ Radioactive iodine uptake like thyroid scan but scans taken over 24 hrs., It determines the location, size, shape, and anatomic function of the thyroid gland, Identifies areas of increased function (“hot” areas) or decreased function (“cold” areas) can assist in diagnosis. Nuclear scanning cont’d  PET(position emission tomography) A type of nuclear medicine procedure that measures metabolic activity of the cells of body tissues used to differentiate between benign and malignant.  Radiographic tests :CT or MRI to locate a tumor or identify hypertrophy of a gland  Ultrasound: for thyroid or parathyroid to find masses  Biopsy: to obtain tissue to examine for cancerous cells under local anesthesia or surgical incision Nursing Intervention before thyroid test ◼ Take thorough history; ◼ thyroid medication must be discontinued 7-10 days prior to test; ◼ medications containing iodine, cough preparations, excess intake of iodine rich products, and tests using iodine eg. IVP intraveous polygram (x-ray images of the kidneys, ureters, and bladder) can invalidate the test. ◼ Assure client that no radiation precautions are necessary  Causes of endocrine problems Insufficient hormone activity Excess hormone activity  Gland hypo function  Gland hyper function  Lack of tropic or stimulating  Excess tropic or stimulating hormone hormone production  Target tissue insensitivity to  Self administration of too hormone much replacement hormone  Thyroid hormone affects metabolic activity of cells throughout the body.  Hypothyroidism Hyperthyroidism Definition Deficit secretion of thyroid Excess secretion of thyroid hormones. hormones. Pathophysiology Primary hypothyroidism: the Primary hyperthyroidism most cases : Fails to produce problem within thyroid enough TH that stimulate gland causes excess TSH is secreted by the hormone release. pituitary gland. Secondary hypothyroidism: Secondary hyperthyroidism low levels of TSH which fail Excess TSH from pituitary to stimulate release of TH. so overstimulation of Tertiary hypothyroidism: thyroid gland. inadequate release of Tertiary hyperthyroidism TRH(thyrotropin-releasing Excess TRH hormone) secreted by hypothalamus. low level of hormones that High level of thyroid slow metabolism hormone increase the metabolic rate  Hypothyroidism Hyperthyrodism Etiology Primary hypothyroidism : Graves disease congenital ,inflammation or (hyperactive):autoimmune iodine deficiency, disorder (hereditary ) autoimmune disorder Thyroid nodules , (Hashimoto’s thyroiditis) inflammation or tumor , ,thyroid surgery, radiation medication therapy Secondary Secondary or tertiary : Malfunctioning pituitary pituitary or hypothalamic Malfunctioning lesion or postpartum hypothalamus pituitary necrosis or Risk factor treatment of hyperthyroidism Risk factor. iodine intake, common in woman age 50 and over, man the 30's and 40's women age 60 and over. excessive doses of thyroid high cholesterol hormone autoimmune disease such as  Hypothyroidism Hyperthyrodism Signs and Cardiovascular: symptom Bradycardia , decreased cardiac Tachycardia , palpitation , output , cool skin , cold increased cardiac out put , warm intolerance, fatigue skin , heat intolerance, chest pain Neurologic: Lethargy , slowed movements , loss Fatigue , restlessness , concentration , confusion, exophthalmose, hyperactive depression, muscles weakness, reflexes , tremor , insomnia , hoarse voice emotional instability Pulmonary : Dyspnea , hypoventilation Dyspnea Integumentary : cool, dry skin, brittle , dry hair Diaphoresis , warm , moist skin , hair loss (eyebrow) fine soft hair, Hair loss, goiter Gastrointestinal : Decreased appetite , weight gain , Increased appetite ,weight loss , constipation , increased serum frequent stools , decreased serum lipid levels lipid levels Reproductive : Decreased libido , erectile Decreased libido , erectile Simple Goiter: Enlargement of the thyroid gland not caused by inflammation or neoplasm Types Endemic: ❖ caused by nutritional iodine deficiency, most common in the areas where salt and water are deficient in iodine; ❖ occurs most frequently during adolescence and pregnancy. Sporadic: ❖ caused by Ingestion of large amounts of goitrogenic foods (contain agents that decrease thyroxine production) eg. Cabbage, soybeans, peanuts, peaches, peas ❖ Use of goitrogenic drugs: large doses of iodine, para-amino salicylic acid, cobalt, lithium Exophthalmos goiter  Hypothyroidism Hyperthyroidism Complications 1. Myxedema coma 1. Thyrotoxic crisis Hypothermic , decreased (thyroid storm) is respiration severe hyperthyroidism Depressed mental Death in as little as 2 function and lethargy hrs. if untreated (high Blood glucose drops , fever , tachycardia 130 cardiac output drops , hypertension , Reduced perfusion of dehydration , kidney , non pitting restlessness and coma edema 2.Hypothyroidism long Death from respiratory term disease as result of failure treatment 2. Cretinism a decreased production of T4 and results in mental retardation, stop t HYPOTHYROIDISM  Hypothyroidism Hyperthyrodism Diagnostic test Level of T3&T4 are Level of T3&T4are low high Level of TSH low or ↑Radioactive iodine high depend on cause uptake test Serum cholesterol and Palpation of thyroid triglycerides are gland elevated TSI(thyroid stimulating Antibodies present in immunoglobulin) is autoimmune disease present in Graves ↓Radioactive iodine disease uptake test Diagnostic studies :- ◼ Radioactive iodine uptake scan- ◼ Thyroid ultrasound ◼ Thyroid Needle Biopsy ◼ Thyroid scan ◼ Computed Tomography-CT ◼ Magnetic Resonance Imaging-MRI  Hypothyroidism Hyperthyrodism Therapeuti 1- thyroid replacement 1- anti-thyroid drug c measure hormone (Levothyroxine ) Propylthiouracil (PTU) Doses are started low and are And methimazole slowly increased to prevent (Tapazole) continue for symptoms of hyperthyroidism 12-18 months or cardiac complication 2- beta-blocker 2- Iodine Deficiency Propranol (indral) Iodized Salt 3- Radioactive iodine Increase intake of seafood 4- Surgery SSKI- saturated solution (thyroidectomy) of potassium iodide 5-. Nutritional Therapy 3. Nutritional Therapy High-calorie, high-protein diet, carbohydrates A low-calorie diet to promote Frequent meals weight loss or prevent weight gain HYPERTHYROIDISM Antithyroid Medications ◼ Patients taking antithyroid medications are instructed: ◼ not to use decongestants ◼ Taken on an empty stomach ◼ PTU (Propylthiouracil) is the treatment of choice during pregnancy (decrease dose to prevent fetal hypothyroidism) ◼ contraindicated in late pregnancy it produce goiter and cretinism (physical deformity and learning disabilities) in the fetus. ◼ Thyroid hormone administer with antithyroid medications to put the thyroid gland at rest. Nursing Care of the Patient Receiving Radioactive Iodine At Home In Hospital; Limit Time Spent with Avoid Close Contact for a Patient Week Glove and Gown Sleep Alone Avoid if Pregnant Wash Hands Carefully After Take Precautions with Urine, Urinating Emesis, Body Fluids. Drink Fluids Double Flush Toilet Avoid Pregnancy for at Least a Year  Thyroidectomy  Can be done with a traditional (open approach) or with newer minimally invasive techniques ( tiny incision and an endoscopy) that faster recovery and the patient can go to home the same day Two types:  Total thyroidectomy : performed if cancer is present, after thyroidectomy lifelong replacement hormone must be taken  Subtotal (partial) thyroidectomy :may done for hyperthyroidism leaving a portion of the thyroid gland to secrete TH (in multi-nodular goiter) ◼ Today, surgery is reserved for special circumstances as ◼ pregnant women who are allergic to antithyroid medications ◼ Large goiters ◼ patients who are unable to take antithyroid agents ◼ Surgery is performed soon after the thyroid function has re-turned to normal (4 to 6 weeks) PTU is administered before  Preoperative care  The patient should be in a euthyroid state that is accomplished with the use of antithyroid medication.  Surgery is performed after the thyroid function has returned to normal (4 to 6 weeks) SSKI: saturated solution of potassium iodide may be administered to decrease the size and vascularity of the gland ,reducing the risk of bleeding during surgery  Do a baseline assessment of vital signs and voice quality to compare after postoperative ◼ Assess Nutrition Status ◼ Strictly avoid all anti‐inflammatory (NSAIDs) for two weeks pre‐operatively and at least one week after surgery. As aspirin, ibuprofen, Celebrex ….., it increase risk of bleeding  Preoperative Teaching Explain what the patient can expect before ,during and after surgery to clarify the misconceptions Teaching how to perform gentle range of motion exercise of the neck , how to support the neck during position change (to avoid placing pressure on the suture lines) how to use an incentive spirometer, Cough and deep breathing after surgery (to prevent pneumonia. ) Possible hoarseness(is temporary and may last a few days). beside the routine care of preoperative care  Postoperative care  Monitor vital signs , oxygen saturation ,drain if present ,dressing every 15 minutes initially , progressing to every 4 hours  Decreased blood pressure with increased pulse should alert to blood loss that possibility to shock  Tachycardia , fever , mental status changes may indicate thyrotoxic crisis ◼ Elevate head of the bed 30-45 degrees (semi fowler position) for the first 3-4 days to reduce edema and promote comfort ◼ Support Neck During Position Changes ◼ Careful note is made of daily output from drain. Drain removed after 48 hours or when drainage falls to less than 30ml /d ◼ Avoid excessive bending, straining, or exercising 2 wks. post operative ❑ Keep a tracheotomy tray at the patient's bedside for 24 hours after surgery, and be prepared to assist with emergency tracheotomy, if necessary.  Assess for signs of hemorrhage, which may cause shock, tracheal compression, and respiratory distress.  Observe for signs of respiratory distress including respiratory rate ,dyspnea or stridor ❑ Check for laryngeal nerve damage by asking the patient to speak as soon as he awakens from anesthesia.  Report any abnormality immediately  Instruct the patient for breathing and cough exercise to maintain clear of the airway from secretion  Monitor swallowing and gag reflex before offering clear liquids to guard against aspiration, ◼ Oral intake initiated from next day, starting with ‘clear fluids’, going on to ‘free fluids’, then to soft diet and finally to normal diet  Administer pain medication as prescribed  Consult dietitian to assist patient with potential dietary changes  Assess for hypocalcemia, which may occur when the parathyroid glands are damaged.  Monitor serum calcium levels and watch for tetany occur 24 to72 hours postoperative  Test for Chvostek's and Trousseau's signs, indicators of neuromuscular irritability from hypocalcemia.  Keep calcium gluconate available for emergency I.V administration ◼ Post-operative complications include tetany which is caused by a decreased calcium. Tetany is seen as muscle twitching and hyperirritability of the nervous system. Hypocalcemia may occur if the parathyroids are accidentally removed during the thyroidectomy. A positive Chvostek’s or Trousseau’s sign, indicate the hypocalcemic state of tetany. ◼ Chvostek’s sign is the muscle twitching of the upper lid of the eye elicited by touching the facial nerve adjacent to the ear. ◼ Trousseau’s sign is the contraction of the fingers when a blood pressure cuff is inflated. ◼ Positive Chvostek’s ◼ Positive Trousseau’s Sign Sign  Teach about importance of follow up to avoid any complications. How to administer replacement hormone if indicated How to change the dressing and report bleeding and signs of infection at the site Importance for change of vital signs Importance of follow up of lab investigation Teach him to recognize and report signs of hypothyroidism and hyperthyroidism Nutritional therapy for hyperthyroidism 1. high-calorie diet (4000 to 5000 cal/day) may be ordered to satisfy hunger, prevent tissue breakdown, and decrease weight loss. 2. six full meals a day and snacks high in protein, carbohydrates, minerals, and vitamins. The protein content should be 1 to 2 g/kg of ideal body weight. 3. Teach the patient to avoid highly seasoned and high-fiber foods because these foods can further stimulate the already hyperactive GI tract. 4. Instruct the patient to avoid caffeine-containing liquids such as coffee, tea, and cola to decrease the restlessness and sleep disturbances associated with these fluids. 1- Imbalanced nutrition :less than body requirement related to increased metabolism 2- Diarrhea related to an increase in peristalsis as evidenced by frequent loose stools. 3- Loss of concentration related to insomnia 4- Anxiety related to knowledge deficit 5- Risk for injury related to muscles weakness ◼ Maintaining Normal Body Temperature ◼ The patient with hyperthyroidism frequently finds a normal room temperature too warm because of an exaggerated metabolic rate and increased heat production ◼ If the patientis hospitalized, the nurse maintains the environment at a cool, comfortable temperature ◼ and changes bedding and clothing as needed. ◼ Cool baths and cool or cold fluids are encouraged, because they may provide relief. 1- Ineffective breathing pattern related to depressed ventilation 2- Activity intolerance related to fatigue 3-Imbalanced nutrition :more than body requirements related to decreased metabolic rate as evidenced by weight gain 4- Deficient knowledge about the therapeutic regimen for lifelong thyroid replacement therapy 5- Risk for impaired skin integrity related to dry skin ,inactivity  patient & caregiver teaching guide with hypothyroidism 1. Discuss the importance of thyroid hormone therapy. Need for lifelong therapy Taking thyroid hormone in the morning before food Need for regular follow-up care 2. Caution the patient not to switch brands of the hormone unless prescribed, since the bioavailability of thyroid hormones may differ. 3. Emphasize the need for a comfortable, warm environment because of intolerance to cold. 4. Teach measures to prevent skin breakdown. Soap should be used sparingly and lotion applied to skin.  patient & caregiver teaching guide with hypothyroidism cont, 5. Caution the patient, especially if an older adult, to avoid sedatives. If they must be used, suggest that the lowest dose be used. Caregiver should closely monitor mental status, level of consciousness, and respirations. 6. Discuss with the patient and the caregiver measures to minimize constipation, including Gradual increase in activity and exercise Increased fiber in diet, Use of stool softeners Regular bowel elimination time 7. Tell patient to avoid using enemas because they produce vagal stimulation (the tenth cranial nerve ), which can be hazardous if cardiac disease is present Regulation of calcium on the body Parathyroid glands Secret parathyroid hormone in response to low serum calcium levels  PTH raises serum calcium levels by promoting calcium movement from bones to blood by increasing absorption of dietary calcium and increasing resorption of calcium by the kidneys  Decreased PTH activity is called hypoparathyroidism  Increased PTH activity is called hyperparathyroidism  pathophysiology Hypoparathyroidism Hyperparathyroidism Overactive of hypoactive of gland parathyroid glands so decreased in PTH so increased in PTH Decreased in calcium absorption by GIT & Effect on absorption in decreased resorption in small intestine and the kidney reabsorption by the kidney The calcium stay in the bone instead to blood Calcium move from The result decreased bone into blood serum calcium level and The result increased phosphate levels rise level of calcium  hypoparathyroidism hyperparathyroidism Hormone secretion Insufficient PTH Excess PTH Signs and Hypocalcaemia , Hyper-calcaemia ,fatigue symptoms neuromuscular , pathological fractures, irritability, tetany , kidney stones, bone and positive chvostek’s and joint pain trousseau’s signs Diagnostic tests Serum PTH ,calcium Serum PTH ,calcium and phosphate and phosphate Therapeutic Calcium and vitamin D Calcitonin. measure replacement low Parathyroidectomy phosphorous diet Nursing diagnosis Risk for injury related Risk for injury related to to hypocalcaemia & bone demineralization tetany Risk for injury related to hypocalcaemia & tetany  Goal :the patient will remain free from injury and signs of tetany will be treated quickly Nursing intervention  Monitor signs of tetany  Make sure a tracheostomy set ,endotracheal tube and intravenous calcium are available for emergency use if laryngospasm  Consult a dietitian for high calcium diet  Teach the patient about importance of long term diet , medication and follow up laboratory testing  Risk for injury related to bone demineralization Goal : the patient will remain free from injury Nursing intervention:  monitor and report signs of calcium imbalance  Encourage oral fluid to prevent dehydration and kidney stones and help excrete calcium  Encourage exercise to help keep calcium in the bones  Provide safe environment  Encourage smoking cessation.smoking causes bone loss