Endocrine-disorders-Copy2.pdf

Disorders of the parathyroid gland 1 Hyperparathyroidism ⩥ caused by overproduction of parathormone by the parathyroid glands and is characterized by bone decalcification and the development of renal calculi (kidney stones) containing calcium Clinical manifestations Apathy fatigue, muscle weakness n...

Disorders of the parathyroid gland 1 Hyperparathyroidism ⩥ caused by overproduction of parathormone by the parathyroid glands and is characterized by bone decalcification and the development of renal calculi (kidney stones) containing calcium Clinical manifestations Apathy fatigue, muscle weakness nausea, vomiting, constipation hypertension, cardiac dysrhythmias Psychological effects may vary from irritability and neurosis to psychoses ⩥ nephrolithiasis ⩥ ⩥ ⩥ ⩥ ⩥ 3 Assessment and diagnostic findings ⩥ persistent elevation of serum calcium levels and an ⩥ ⩥ ⩥ ⩥ ⩥ ⩥ elevated concentration of parathormone Radioimmunoassays double-antibody parathyroid hormone test Ultrasound MRI thallium scan fine-needle biopsy 4 Surgical management ⩥ Parathyroidectomy ⩥ Surgery is recommended for asymptomatic patients who meet one or more of the following criteria: ⊳ (1) younger than 50 years, ⊳ (2) any patient unable or unlikely to participate in follow up care, ⊳ (3) serum calcium elevations of 1-1.6 mg/dl (0.25-0.4 mmol/liter) above the accepted normal range, ⊳ (4) GFR < 60 mL/min ⊳ (5) urinary calcium level greater than 400 mg/day (10 mmol/day) ⊳ (6) bone density at hip, lumbar spine, or distal radius with T score < -2.5 or previous fracture fragility at any site ⊳ (7) nephrolethiasis or nephrocalcinosis 5 Hydration Therapy ⩥ daily fluid intake of 2,000 mL or more ⩥ Instruct the patient to report other manifestations of renal calculi, such as abdominal pain and hematuria 6 Pharmacologic management ⩥ Lasix- to promote calciuria after rehydration has occurred ⩥ IV saline solutions- expand blood volume and acts in the kidneys to inhibit the reabsorption of the calcium ⩥ Oral or IV phosphate ⊳ Calcitonin ⊳ Mithracin ⊳ Gallium Nitrate 7 Nursing management ⩥ Closely monitor the patient for signs and symptoms of tetany. ⩥ Prevent injury ⩥ Encourage weight bearing 30 mins/day ⩥ Low calcium diet ⩥ Encourage patient to avoid dairy products 8 hypoparathyroidism ⩥ Deficiency of PTH due to hyposecretion of parathyroid gland ⩥ Serum calcium levels are abnormally low, serum phosphate levels are abnormally high and pronounced neuromuscular irritability (tetany) may develop. 9 causes ⩥ Iatrogenic ⊳ Surgery (thyroidectomy) ⊳ Infarction of the parathyroid glands because of inadequate blood supply during surgery ⩥ Idiopathic/autoimmune disorder 10 Physical assessment ⩥ Acute hypoparathyroidism ⊳ Positive Chvostek’s Sign and Trousseau Sign ⊳ Hyperactive Deep tendon reflexes ⊳ Paresthesia: numbness and tingling of fingers 11 Physical assessment ⩥ Chronic hypoparathyroidism ⊳ Lethargy, weakness, fatigue ⊳ Thin, patchy hair ⊳ Brittle nails ⊳ Dry scaly skin ⊳ Cataract ⊳ Permanent brain damage 12 Diagnostic findings ⩥ ⩥ ⩥ ⩥ ⩥ ⩥ Decreased serum calcium levels (1.75 mEq/L) Low PTH levels Decreased urine calcium Ophthalmic exam: calsification of lens Radiograph- increased bone density of skull 13 Medical management ⩥ Active form of vitamin D ⊳ Rocatrol ⊳ Hytakerol (Dihydortachysterol) ⩥ IV Calcium ⊳ 10% Calcium Chloride and Calcium gluconate ⩥ Supplemental calcium (oral, dietary) ⩥ Parathyroid hormone replacement 14 Nursing management ⩥ Teach the patient to consume high calcium, low phosphate diet ⩥ Avoid milk and cheese (high in phosphorus) ⩥ Assess for signs of tetany ⩥ Implement seizure precautions ⩥ Maintain patent airway, keep trachea set at bedside ⩥ Keep ampule of IV calcium at bedside 15 Disorders of the adrenal gland 16 Cushing’s syndrome ⩥ Excess secretion of the adrenal cortex hormones Etiology ⩥ Iatrogenic causes: excessive cortisol levels from chronic therapy with glucocorticoids ⩥ Primary cause: excessive cortisol production from adrenal neoplasms such as adenomas or carcinomas ⩥ Secondary cause: excessive production of ACTH from the anterior PG due to pituitary carcinoma or ectopic ACTH secretion by neoplasm of the lungs, kidneys, etc. 18 Increased glucocorticoids ⩥ Increased blood glucose ⩥ Fat catabolism ⊳ Increased blood cholesterol ⊳ Acne, oily skin ⩥ Protein catabolism ⊳ Muscle wasting ⊳ Osteoporosis ⩥ Decreased immunity ⊳ Slow wound healing ⊳ infection 19 Increased mineralocorticoids ⩥ Na retention- lead to imbalance of Na-K pump ⊳ CNS instability ⩥ Water is reabsorbed ⩥ Weight gain, obesity, lethargy ⩥ Hypertension, heart failure 20 Increased androgens ⩥ ⩥ ⩥ ⩥ ⩥ Voice deepens Hirsutism Amenorrhea Breast atrophy Loss of libido 21 22 Diagnostic findings ⩥ Serum cortisol ⩥ Urinary cortisol ⩥ Low-dose dexamethasone (Decadron) suppression test ⩥ Hypernatremia, hypokalemia, hyperglycemia, hypercholesterolemia 23 Imaging studies ⩥ CT scan or MRI of adrenal glands ⩥ MRI of pituitary gland 24 Medical management ⩥ Treatment depends on the cause ⩥ Pituitary adenoma ⊳ Transsphenoidal hypophysectomy ⊳ Pituitary irradiation ⊳ Stereotactic radiotherapy (gamma knife) 25 Medical management ⩥ Adrenal neoplasm ⊳ Surgical resection of the affected adrenal gland ⊳ Glucocorticoid replacement for approximately 9 to 12 months after surgery to allow time for the contralateral adrenal gland to recover from its prolonged suppression. ⩥ Ectopic ACTH ⊳ Surgical resection of the ACTH-secreting neoplasm 26 Nursing management ⩥ Encourage foods high in protein, calcium and vitamin D; low ⩥ ⩥ ⩥ ⩥ ⩥ ⩥ ⩥ in sodium and calories Instruct patient to avoid persons with current infection Frequently assess patient for signs of infection Help patient to plan rest periods and activity Teach the patient meticulous skin care Avoid use of adhesive tape Change position frequently Encourage the patient and family to verbalize their feelings and concerns 27 Nursing management ⩥ Instruct the patient not to stop corticosteroid use abruptly. ⩥ Regularly monitor blood pressure, blood glucose levels and weight ⩥ Instruct patient to wear a medical alert bracelet 28 Addison’s disease ⩥ Primary adrenocortical insufficiency that is characterized by inadequate secretion of corticosteroids resulting from partial or complete destruction of the adrenal glands. 29 Etiology ⩥ ⩥ ⩥ ⩥ Autoimmune destruction of the adrenal glands Carcinomatous destruction of the adrenal glands Adrenal infarction Advance stages of AIDS 30 Clinical manifestations ⩥ Muscle weakness, emaciation, anorexia, weight loss ⩥ Increased pigmentation ⩥ Hypotension ⩥ GI disturbances ⩥ Hypoglycemic manifestations, salt craving ⩥ Mental status changes ⩥ Amenorrhea and loss of axillary hair in women 31 Laboratory results ⩥ Blood cortisol level 100 mg/dL ⩥ Hyperkalemia, hyponatremia ⩥ Decreased glucose levels ⩥ Mild normocytic, normochromic anemia, neutropenia ⩥ Decreased 24- hour urinary cortisol 32 Treatment ⩥ Hydrocortisone, 15 to 20 mg PO every morning and 5 to 10 mg in late afternoon or ⩥ Prednisone, 5 mg in the morning and 2.5 mg at bedtime ⩥ Oral fludrocortisone 0.05 mg/day to 0.20 mg/day ⩥ Increase glucocorticoid replacement in times of stress ⩥ Parenteral glucocorticoid if diarrhea or vomiting occurs 33 Complication Addisonian crisis ⩥ Trigger: ⊳ Surgery ⊳ Infection ⊳ Emotional trauma ⊳ Physical trauma ⊳ Sudden withdrawal from steroids or postadrenalectomy ⩥ Manifestations: ⊳ Hypotension ⊳ Tachycarida ⊳ Dehydration ⊳ Hypoglycemia ⊳ Hyponatremia ⊳ Hyperkalemia ⊳ Fever, weakness 34 management ⩥ Measure plasma cortisol level ⩥ Administer hydrocortisone 50 mg IV q8h for 24 hours ⩥ Provide adequate volume replacement with D5NS solution until hypotension, dehydration and hypoglycemia are completely corrected. 35 Nursing management ⩥ Monitor for signs and symptoms of shock ⩥ Avoid physical and psychological stressors such cold, overexertion, infection and emotional stress ⩥ Assess for signs of dehydration ⩥ Monitor BP (lying, sitting and standing) ⩥ Encourage the patient to consume foods and fluids high in sodium during GI disturbances and very hot weather 36 Thank you for listening. Any questions? 37