Medical Surgical - Hepatobiliary / Endocrine System

FJRC.MS.MetabolicAlterations

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MEtaBol iC aLteRaTiONs

Francis Jordan Ramos Cusi, RN FJRC.MS.MetabolicAlterations

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EN DO CRI NE SYSTEM  Glands  Hormones  Receptors

Amines Polypeptides Steroids

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GLAN DS OF TH E EN DOC RINE SY STEM

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HYP OTH AL AM US  Lies dorsal to the pituitary gland  Nervous-Endo  Regulator ata ako! : A-PTH  Hypophyseal stalk  TRH, GnRH, GHRH, CRH, Dopamine FJRC.MS.MetabolicAlterations

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PI NEA L GLAN D  Cone-shaped  Back of the third ventricle of the brain  Mystery-mystery!  Melatonin

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PITUITAR Y GLAND  Under (below) hypothamalus  Bi-functional lobes + 1 Anterior and Posterior + pars intermedia  AKA: Hypophysis  Small (1 gram) FJRC.MS.MetabolicAlterations

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ANTE RIOR PITUITARY  ADENOhypophysis  Hormones: Proteins; 2nd-messanger system; regulated by hormonal stimuli  T – Thyroid stimulating hormone (TSH; Thyrotropin)  F – Follicle stimulating hormone  L – Luteinizing hormone  A – Adrenocorticotropic hormone  P - Prolactin  S – Somatotropin (Growth Hormone) FJRC.MS.MetabolicAlterations

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POS TERIO R PI TUI TAR Y

 Pede na rin  Hamak na imbakan  OXYTOCIN  ANTIDIURETIC HORMONE (Vasopressin) FJRC.MS.MetabolicAlterations

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T H YROI D GL AND H urray! Hurray! Le – H – eg H – either side H – istHmus connected TriiodotHyronine (T3) – more potent  THyroxine – less  Calcito-H-nin     

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PARA THY ROID GLA NDS

 Tagong kabit  Kaya hanggang 8, 4 ang legal (daw)  PARATHORMONE: most popular regulator of calcium ions FJRC.MS.MetabolicAlterations

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TH YMUS GLAND

 Upper thorax  Immuno-endo  Thymosin : T-lymphocytes maturation FJRC.MS.MetabolicAlterations

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ENDOC RI NE PANC REAS

Pancreatic islets : New-NSO reg GA-BIDS FJRC.MS.MetabolicAlterations

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ADRE NAL GL AND S  ADRENALINE:  R – esembles bean (each)  U – ri’y pituitary (glandular ; neural)  S – ituated top of the kidney  H – ati: Cortex(co), Medulla(mines) FJRC.MS.MetabolicAlterations

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GO NA DS OVARIES: mainly estradiol TESTES: testosterone FJRC.MS.MetabolicAlterations

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 These are blood examinations for the levels of individual hormones  Measurements can also be done after stimulation and suppression of the secretions- Stimulation and Suppression tests FJRC.MS.MetabolicAlterations

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 Usually done to diagnose hypo/hyperthyroidism  If T3 is elevated, T4 is elevated and TSH is depressed Primary HYPERthyroidism  If T3 is depressed,T4 is depressed and TSH is elevated Primary HYPOthyoidism FJRC.MS.MetabolicAlterations

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 This is a thyroid function test to measure the absorption of the injected iodine isotope by the thyroid tissue  Increased uptake may indicate HYPER functioning gland  Decreased uptake my FJRC.MS.MetabolicAlterations

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 Performed to identify nodules or growth in the thyroid gland  RAI is used  Pretest- Check for pregnancy, Thyroid medication may be withheld temporarily, advise NPO  Post-test- Ensure proper FJRC.MS.MetabolicAlterations

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 Aids in the diagnosis of Diabetes  Pre-test: NPO for 8 hours  Normal FBS- 80-109 mg/dL  DM- 126 mg/dL and above FJRC.MS.MetabolicAlterations

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 Aids in the diagnosis of DM  Pre-test: Provide highcarbohydrate foods x 3 days, instruct to avoid caffeine, alcohol and smoking, NPO 10 hours prior to test  Post-test: avoid strenuous activity for 8 hours  Normal OGTT- 1 and 2 hours FJRC.MS.MetabolicAlterations 30 post-prandial- glucose is less

 Blood glucose bound to RBC hemoglobin  Reflects how well blood glucose is controlled for the past 3 months  FASTING is NOT required! FJRC.MS.MetabolicAlterations

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 Normal levelexpressed as percentage of total hemoglobin  N- 4-7%  Good control- 7.5%or less  Fair control- 7.5 % to 8.9%  Poor control- 9% and above FJRC.MS.MetabolicAlterations 32

DISORDERS OF THE ENDOCRINE GLAND Disorders are generally grouped into:  HYPER- when the gland secretes excessive hormones  HYPO- when the gland does not secrete enough hormones FJRC.MS.MetabolicAlterations

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 Hyper and Hypo can be classified as PRIMARY when the Gland itself is the problem or SECONDARY when the pituitary or the hypothalamus is causing the problem

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THY RO ID DIS OR DE RS

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HYP ERTI RE DDYTI ES

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 A hypothyroid state characterized by decreased secretions of T3 and T4 CAUSES:  Hypofunctioning tumor, IDG, Pituitary tumor, Ablation therapy, Surgical removal of thyroid FJRC.MS.MetabolicAlterations

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 Decreased T3 and T4 decreased basal metabolism

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 1. Lethargy and fatigue  2. Weakness and paresthesia  3. COLD intolerance  4. Weight gain  5. Bradycardia, constipation FJRC.MS.MetabolicAlterations

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 6. Dry hair and skin, loss of body hair  7. Generalized puffiness and edema around the eyes and face8. Forgetfulness and memory loss  9. Slowness of movement  10. Menstrual irregularities and cardiac irregularities FJRC.MS.MetabolicAlterations

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 1. Monitor VS especially HR  2. Administer hormone replacement: usually Levothyroxine( Synthroid)should be taken on an empty stomach  3. Instruct patient to eat LOW calorie, LOW FJRC.MS.MetabolicAlterations

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 4. Manage constipation appropriately  5. Provide a WARM environment  6. Avoid sedatives and narcotics because of increased sensitivity to these medications  7. Instruct patient to report chest pain promptly FJRC.MS.MetabolicAlterations

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 Called GRAVE’S DISEASE  A hyperthyroid state characterized by increased circulating T3 and T4 CAUSES:  Auto-immune disorder, toxic FJRC.MS.MetabolicAlterations goiter and tumor

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 Increased hormone activity increased Basal Metabolism

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 1. Weight loss  2. HEAT intolerance  3. Hypertension  4. Tachycardia and palpitations  5. Exopthalmos  6. Diarrhea FJRC.MS.MetabolicAlterations

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 7. Warm skin  8. Diaphoresis  9. Smooth and soft skin  Oligomenorrhea to amenorrhea  10. Fine tremors and nervousness  11. Irritability, mood swings, personality changes and agitation FJRC.MS.MetabolicAlterations

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 1. Provide adequate rest periods in a quiet room  2. Administer anti-thyroid medications that block hormone synthesisMethimazole and PTU  3. Provide a HIGH-calorie diet, HIGH protein FJRC.MS.MetabolicAlterations

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 4. Manage diarrhea  5. Provide a cool and quiet environment  6. Avoid giving stimulants  7. Provide eye care  Hypoallergenic tape for eyelid closure  8. Administer PROPRANOLOL for tachycardia  9. Administer IODIONE preparation- Lugol’s solution and SSKI to inhibit the release of T3 and T4 FJRC.MS.MetabolicAlterations 50 FJRC.MS.MetabolicAlterations

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 10. Prepare clients for Radioactive iodine therapy  11. Prepare patient for thyroidectomy  12. Manage thyroid storm appropriately FJRC.MS.MetabolicAlterations

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 An acute LIFEthreatening condition characterized by excessive thyroid hormone

CAUSE:  Manipulation of the thyroid during surgery causing the release of excessive hormones in the FJRC.MS.MetabolicAlterations

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 1. HIGH fever  2. Tachycardia and Tachypnea  3. Systolic HYPERtension  4. Delirium and coma  5. Severe vomiting and diarrhea  FJRC.MS.MetabolicAlterations

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 1. Maintain PATENT airway and adequate ventilation  2. Administer anti-thyroid medications such as Lugol’s solution, Propranolol, and Glucocorticoids  3. Monitor VS FJRC.MS.MetabolicAlterations

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 4. Monitor Cardiac rhythms  5. Administer PARACETAMOL ( not Aspirin) for FEVER  6. Manage Seizures as required. FJRC.MS.MetabolicAlterations

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 Removal of the thyroid gland

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 1. Obtain VS and weight  2. Assess for Electrolyte levels, glucose levels and T3/T4 levels  3. Provide pre-operative teaching like coughing and deep breathing, early ambulation and support of the neck when moving  4. Administer prescribed FJRC.MS.MetabolicAlterations 57 medications

 1. Position patient: SemiFowler’s, neck on neutral position  2. Monitor for respiratory distress- apparatus at bedsidetracheostomy set, O2 tank and suction machine!  3. Check for edema and FJRC.MS.MetabolicAlterations 58 bleeding by noting the

 4. LIMIT client talking  5. Assess for HOARSENESS  Expected to be present only initially, limit excess vocalization  If persistent, may indicate damage to laryngeal nerve!  6. Monitor for Laryngeal Nerve damage – Respiratory distress, Dysphonia, voice changes, Dysphagia and restlessness FJRC.MS.MetabolicAlterations

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 7. Monitor for signs of HYPOCALCEMIA and tetany due to trauma of the parathyroid  8. Prepare Calcium gluconate  9. Monitor for thyroid storm FJRC.MS.MetabolicAlterations

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PAR ATHY ROI D DI SOR DERS

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 Hypo-secretion of parathyroid hormone CAUSES:  Tumor, removal of the gland during thyroid surgery FJRC.MS.MetabolicAlterations

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 Decreased PTH deranged calcium metabolism

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 1. Signs of HYPOCALCEMIA  2. Numbness and tingling sensation on the face  3. Muscle cramps  4. (+) Trosseau’s and (+) Chvostek’s signs  5. Bronchospasms, laryngospasms, and dysphagia FJRC.MS.MetabolicAlterations

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 6. Cardiac dysrhythmias  7. Hypotension  8. Anxiety, irritability ands depression

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 Monitor VS and signs of HYPOcalcemia  Initiate seizure precautions and management  Place a tracheostomy set. O2 tank and suction at the bedside  Prepare CALCIUM gluconate  Provide a HIGH-calcium and LOW phosphate diet FJRC.MS.MetabolicAlterations

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 Advise client to eat Vitamin D rich foods  Administer Phosphate binding drugs

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 Hypersecretion of the gland CAUSE:  Tumor

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 Increase PTH increased CALCIUM levels in the body

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 Fatigue and muscle weakness/pain  Skeletal pain and tenderness  Fractures  Anorexia/N/V epigastric pain  Constipation FJRC.MS.MetabolicAlterations

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 Hypertension  Cardiac Dysrhythmias  Renal Stones

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 Monitor VS, Cardiac rhythm, I and O  Monitor for signs of renal stones, skeletal fractures. Strain all urine.  Provide adequate fluids- force fluids  AdministerFJRC.MS.MetabolicAlterations prescribed 73

 Administer calcium chelators  Administer CALCITONIN  Prepare the patient for surgery FJRC.MS.MetabolicAlterations

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ADR EN OCO RT ICAL DI SO RDE RS

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 Decreased secretion of adrenal cortex hormones, especially glucocorticoids and mineralocorticoids CAUSE:  Tumor, idopathic FJRC.MS.MetabolicAlterations

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 Decreased Glucocorticoids decreased resistance to stress

 Decreased mineralocorticoids decreased retention of sodium and water Hypovolemia FJRC.MS.MetabolicAlterations

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 Weight loss  GI disturbances  Muscle weakness, lethargy and fatigue  Hyponatremia

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 Hyperkalemia  Hypoglycemia  dehydration and hypovolemia  Increased skin pigmentation FJRC.MS.MetabolicAlterations

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 Monitor VS especially BP  Monitor weight and I and O  Monitor blood glucose level and K  Administer hormonal agents as prescribed FJRC.MS.MetabolicAlterations

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 Observe for ADDISONIAN crisis  Educate the client regarding lifelong treatment, avoidance of strenuous activities, stress and seeking prompt consult during illness  Provide a high-protein, high carbohydrate and increased sodium intake FJRC.MS.MetabolicAlterations

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 A life-threatening disorders caused by acute severe adrenal insufficiency CAUSES:  Severe stress, infection, trauma or surgery FJRC.MS.MetabolicAlterations

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 Overwhelming stimuli mobilize body defense decreased stress hormones inadequate coping FJRC.MS.MetabolicAlterations

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 Severe headache  Severe pain  Severe weakness  Severe hypotension  Signs of Shock FJRC.MS.MetabolicAlterations

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 Administer IV glucocorticoids, usually hydrocortisone  Monitor VS frequently  Monitor I and O, neurological status, electrolyte imbalances and FJRC.MS.MetabolicAlterations

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 Administer IVF  Maintain bed rest  Administer prescribed antibiotics

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 A condition resulting from the hyper-secretion of glucocorticoids from the adrenal cortex CAUSES:  Pituitary tumor, adrenal tumor, abuse of steroids FJRC.MS.MetabolicAlterations

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 Increased Glucocorticoids exaggerated effects of the hormone

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Normal functions of Cortisol

1. Gluconeogenesis 2. Protein breakdown

3. Fat breakdown

Exaggerated functions HYPERGLYCEMIA OSTEOPOROSISS, delayed wound healing Purplish striae , Bleeding Muscle wasting THIN extremity, Truncal deposition

IMMUNOSUPPRESSIO N FJRC.MS.MetabolicAlterations

4. Decreased WBC

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Functions of Mineralocorticoids

Exaggerated functions

1. Sodium Retention

Hypernatremia

2.Secondary water retention

HypervolemaHypertension

3. Potassium excretion

HYPOKALEMIA

Function of androgen: Hair growth

HIRSUTISM

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 Generalized muscle weakness and wasting  Truncal obesity  Moon-face  Buffalo hump  Easy bruisability FJRC.MS.MetabolicAlterations

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 Reddish-purplish striae on the abdomen and thighs  Hirsutism and acne  Hypertension  Hyperglycemia  Osteoporosis  Amenorrhea FJRC.MS.MetabolicAlterations

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 Serum cortisol level  Serum glucose and electrolytes

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 Monitor I and O , weight and VS  Monitor laboratory valuesglucose, Na, K and Ca  Provide meticulous skin care  Administer prescribed medications like aminogluthetimide to inhibit adrenal hyperfunctioning FJRC.MS.MetabolicAlterations

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 Prepare client for surgical management- pituitary surgery and adrenalectomy  Protect patient from infection  Improve body image  Provide a LOW carbohydrate, LOW sodium and HIGH protein FJRC.MS.MetabolicAlterations

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ADR EN OMED ULLAR Y DI SO RDE R

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 Increased secretion of epinephrine and norepinephrine by the adrenal medulla CAUSE: Tumor FJRC.MS.MetabolicAlterations

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 Increased Adrenergic hormones exaggerated sympathetic effects FJRC.MS.MetabolicAlterations

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Hypertension Severe headache Palpitations Tachycardia Profuse sweating and Flushing  Weight loss, tremors FJRC.MS.MetabolicAlterations  Hyperglycemia and     

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 Monitor VS especially BP  Monitor for HYPERTENSIVE crisis  Avoid stimulation that can cause increased BP  Administer Antihypertensive agents like alpha-adrenergic blockersFJRC.MS.MetabolicAlterations

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 Prepare Phentolamine for hypertensive crisis  Monitor blood glucose and urine glucose  Promote adequate rest and sleep periods FJRC.MS.MetabolicAlterations

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 Provide HIGH calorie foods and Vitamins/mineral supplements  Prepare patient for possible surgery

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AN TER IOR PIT UIT ARY DI SO RDE RS

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 Hyposecretion of the anterior pituitary gland CAUSES: Congenital, Post-partal necrosis, infection and tumor

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 Depends on the major hormone/s depleted

Findings Retarded physical growth due to decreased GH dwarfism Low intellectual development Poor development of secondary sexual FJRC.MS.MetabolicAlterations

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 Provide emotional support to the family  Encourage client and family to express feelings  Administer prescribed hormonal replacement therapy FJRC.MS.MetabolicAlterations

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 The hyper-secretion of the gland  ACROMEGALY  CAUSES: tumor, congenital disorder FJRC.MS.MetabolicAlterations

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 Depends on the hormone/s that is/are increased

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 Increased growth Gigantism or Acromegaly  Large and thick hands and feet  Visual disturbances  Hypertension, hyperglycemia  Organomegaly FJRC.MS.MetabolicAlterations

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 Provide emotional support to clients and family  Provide frequent skin care  Prepare patient for surgeryremoval of pituitary gland FJRC.MS.MetabolicAlterations

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 Monitor VS, LOC and neurologic status  Place patient on SemiFowler’s  Monitor for Increased ICP, bleeding, CSF leakage  Instruct patient to AVOID sneezing, coughing and nose-blowing FJRC.MS.MetabolicAlterations

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 Monitor development of DImeasure I and O  Administer prescribed medications- antibiotics, analgesics and steroids

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POS TER IOR PIT UIT ARY DI SO RDE RS

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 A hypo-secretion of ADH CAUSES:  Conditions that increase ICP, Surgical removal of post pit. tumor FJRC.MS.MetabolicAlterations

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 Decreased ADH failure of tubular re-absorption of water increased urine volume

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 Polyuria of more than 4 liters of urine/day  Polydipsia  Signs of Dehydration  Muscle pain and weakness  Postural hypotension and tachycardia FJRC.MS.MetabolicAlterations

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 Urinary Specific gravity very low, 1.006 or less  Serum Sodium levels high

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 Monitor VS, neurologic status and cardiovascular status  Monitor Intake and Output  Monitor urine specific gravity FJRC.MS.MetabolicAlterations

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 Provide adequate fluids  Administer Chlorpropamide or Clofibrate as prescribed to increase the action of ADH if decreased  Administer VASOPRESIN. Desmopressin or Lypressin are given intranasal. Pitressin is given IM FJRC.MS.MetabolicAlterations

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 Hyper-secretion of ADH abnormally CAUSES:  Tumor, paraneoplastic syndromes FJRC.MS.MetabolicAlterations

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 Increased ADH water reabsorption water intoxication, hypervolemia

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 Urine specific gravity is increased (concentrated)  Hyponatremia  CBC shows hemodilution FJRC.MS.MetabolicAlterations

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 Signs of Hypervolemia  Mental status changes  Abnormal weight gain FJRC.MS.MetabolicAlterations

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 Hypertension  Anorexia, Nausea and Vomiting  HYPOnatremia FJRC.MS.MetabolicAlterations

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 Monitor VS and neurologic status  Provide safe environment  Restrict fluid intake (less than 500cc/day) FJRC.MS.MetabolicAlterations

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 Monitor I and O and daily weight  Administer Diuretics and IVF carefully  Administer prescribed Demeclocycline to inhibit action of ADH in the kidney FJRC.MS.MetabolicAlterations

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END O-P AN CRE AS DI SO RDE R

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 General information  Diabetes mellitus represents a heterogeneous group of chronic disorders characterized by hyperglycemia.  Hyperglycemia is due to total or partial insulin deficiency or insensitivity of the cells to insulin.  Characterized by disorders in the metabolism of carbohydrates, fat and protein, as well as changes in the structure and function of blood vessels FJRC.MS.MetabolicAlterations 133

 Most common endocrine problem; affects over 11 million people in the US  Exact etiology unknown, causative factors may include  Genetics, viruses, and/or autoimmune response in type I  Genetics and obesity in type II

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 Types  Type I (insulindependent diabetes mellitus [IDDM]) cells in the islets of Langerhans in the pancreas resulting in little or no insulin production; requires insulin injections  Usually occurs in children or in nonobese adults FJRC.MS.MetabolicAlterations

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 Type II (non-insulin-dependent diabetes mellitus [NIDDM])  May result from a partial deficiency of insulin production and/or an insensitivity of the cells to insulin  Usually occurs in obese adults over 40

 Diabetes associated with other conditions or syndromes, e.g., pancreatic disease, Cushing’s syndrome, use of certain drugs (steroids, thiazide diuretics, oral contraceptives) FJRC.MS.MetabolicAlterations

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 Lack of insulin causes hyperglycemia (insulin is necessary for the transport of glucose across the cell membrane).  Hypergycemia leads to osmotic diuresis as large amounts of glucose pas through the kidney; results in polyuria and glycosuria  Diuresis leads to cellular dehydration and fluid and electrolyte depletion causing polydipsia (excessive thirst).  Polyphagia (hunger and increased appetite) results from cellular starvation137 FJRC.MS.MetabolicAlterations

 The body turns to fats and protein for energy; but in the absence of glucose in the cell, fats cannot be completely metabolized and ketones (intermediate products of fat metabolism) are produced.  This leads to ketonemia, ketonuria (contributes to osmotic diuresis), and metabolic acidosis (ketones are acid bodies)  Ketones act as CNS depressants and can cause coma.  Excess loss of fluids and electrolytes leads to hypovolemia, hypotension renal failure, and decreased blood flow to the brain resulting in coma and death unless treated.  Acute complications of diabetes include diabetic ketoacidosis insulin reaction hyperglycemic insulin reaction FJRC.MS.MetabolicAlterations hyperglycemic 138

 Type I: insulin, diet, exercise  Type II: ideally managed by diet and exercise; may need oral hypoglycemic or occasionally insulin if diet and exercise are not effective in controlling hyperglycemia; insulin needed for acute stresses, e.g., surgery, infection FJRC.MS.MetabolicAlterations

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 Diet  Type I: consistency is imperative to avoid hypoglycemia  Type II: weight loss is important since it decreases insulin resistance  High fiber, low fat diet also recommended

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 Drug therapy  Insulin: used for Type I diabetes (also occasionally used in Type II diabetes)  short acting: used in treating ketoacidosis; during surgery, infection, trauma; management of poorly controlled diabetes; to supplement longer-acting insulin’s  intermediate; used for maintenance therapy  Long acting: used for maintenance therapy in clients who experience hyperglycemia during the night with intermediate-acting insulin FJRC.MS.MetabolicAlterations

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 Various preparations of short-, intermediate-, and long acting insulins are available  Insulin preparations can consist of mixture of beef and pork insulin, pure beef, pure pork, or human insulin. Human insulin is the purest insulin and has the lowest antigenic effect.  Human insulin is recommended for all newly diagnosed Type I diabetics, Type II diabetics who need short-term insulin therapy, the pregnant client, and diabetic clients with insulin allergy or severe insulin resistance. FJRC.MS.MetabolicAlterations

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 Insulin pumps are small, externally worn devices that closely mimic normal pancreatic functioning. Insulin pumps contain a 3 ml sringe attached to a long (42 inch), narrow-lumen tube with a needle or Teflon catheter is inserted into the subcutaneous tissue (usually on the abdomen) and secured with tape or a transparent dressing. The needle or catheter is changed at least every 3 days. The pump is worn either on a belt or in a pocket. The pump uses only regular insulin. Insulin can be administered via the basal rate (usually 0.5-2.0 units/hr) and by a bolus dose (which is activated by a series of button FJRC.MS.MetabolicAlterations pushes) prior to each meal.

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 All types: polyuria, polydipsia, polyphagia, fatigue, blurred vision, susceptibility to infection  Type I: anorexia, nausea, vomiting, weight loss  Type II: obesity; frequently no other symptoms FJRC.MS.MetabolicAlterations

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 Diagnostic tests  Fasting blood sugar  a level of 140 mg/dl or greater on at least two occasions confirms diabetes mellitus  may normal in Type II diabetes

Postprandial blood sugar: elevated Oral glucose tolerance test (most sensitive test): elevated  Glycosolated hemoglobin (hemoglobin A) elevated  

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 Administer insulin or oral hypoglycemic agents as ordered; monitor for hypoglycemia, especially during period of drug’s speak action  Provide special diet as ordered  Ensure that the client is eating all meals.  If all food is not ingested, provide appropriate substitutes according to the exchange lists or give measured amount of orange juice to substitute for leftover food; provide snack later in the day.

 Monitor urine sugar and acetone (freshly avoided specimen)  Perform finger sticks to monitor blood glucose levels as ordered (more accurate than urine tests). FJRC.MS.MetabolicAlterations  Observe for signs of hypo/hyperglycemia.

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 Provide meticulous skin care and prevent injury.  Maintain I&O; weight daily.  Provide emotional support; assist client in adapting to change n lifestyle and body image.

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 Observe for chronic complications and plan care accordingly.  Atherosclerosis: leads to coronary artery disease, MI, CVA, and peripheral vascular disease.  Microangiopathy: most commonly affects eyes and kidneys  Kidney disease  recurrent pyelonephritis  diabetic nephropathy

 Ocular disorders  1. premature cataracts  2. diabetic retinopathy

 Peripheral neuropathy  1. affects peripheral and autonomic nervous systems.  2. causes diarrhea, constipation, neurogenic FJRC.MS.MetabolicAlterations bladder, impotence, decreased sweating

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 Provide client teaching and discharge planning concerning  Disease process  Diet  Client should be able to plan meals using exchange lists before discharge  emphasize importance of regularity of meals; never skip meals

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 Insulin  How to draw up into syringe  gently roll vial between palms of hands  draw up insulin using sterile technique.

 Injection technique  systematically rotate sites to prevent lipodystrophy (hypertrophy or atrophy of tissue)  insert needle at a 45˚ or 90˚ angle depending on amount of adipose tissue

 May store current vial of insulin at room temperature; refrigerate extra supplies.  Provide many opportunities for return demonstration

 Oral hypoglycemic agents  stress importance of taking the drug regularly FJRC.MS.MetabolicAlterations  avoid alcohol intake while on medication

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 Urine testing (not very accurate reflection of blood glucose level)  May be satisfactory for Type II diabetics since therapy are more stable.  Use Clinitest, Test-tape, Diastix for glucose testing  Perform tests before meals and at bedtime.  Use freshly voided specimen.

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 Be consistent in brand of urine test used.  Report result in percentages.  Report results to physician if results are greater than 1%, especially if experiencing symptoms of hyperglycemia  Urine testing for ketones should be done by Type I diabetic clients when there is persistent glycosuria, increased blood glucose levels, or if the client is not feeling well (Acetest

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 Blood glucose monitoring  Instruct 1. Use for Type I diabetic clients since it gives exact blood glucose level and also detects hypoglycemia.  client in fingerstick technique, use of monitor device (if used), and recording and utilization of test results. FJRC.MS.MetabolicAlterations

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 General care  perform good oral hygiene and have regular dental exams.  have regular eye exams.  care for “sick days” (e.g., cold or flu)  a. do not omit insulin or oral hypoglycemic agents since infection causes increased blood sugar.  b. notify physician.  c. monitor urine or blood glucose levels and urine ketones frequently.  d. if nausea and/or vomiting occurs, sip on clear liquids with simple sugars. FJRC.MS.MetabolicAlterations

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 Foot care  wash feet with mild soap and water and p at dry.  apply lanolin to feet to prevent drying and cracking  cut toenails straight across  avoid constricting garments such s garters.  wear clean, absorbent socks (cotton or wool)  purchase properly fitting shoes and bread new shoes in gradually  never go barefoot  inspect feet daily and notify physician if cuts, blisters, or breaks in skin occur.

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 Exercise  undertake regular exercise; avoid sporadic, vigorous exercise  food intake may need to be increased before exercising  exercise is best performed after meals when the blood sugar is rising

 Complications  learn to recognize signs and symptoms of hypo/hyperglycemia  eat candy or drink orange juice with sugar added for insulin reaction (hypoglycemia).

 Need to wear a Medic- Alert bracelet FJRC.MS.MetabolicAlterations

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Sel ec ted End oc rin e PHA RM ACO LOGY

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En docrine Medic ations  Enhance re-absorption of water in the kidneys  Used in DI  Desmopressin and Lypressin intranasally  Pitressin IM FJRC.MS.MetabolicAlterations

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En docrine Medic ations  SIDE-effects  Flushing and headache  Water intoxication

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Th yr oid Me dic atio ns

 Levothyroxine (Synthroid) and Liothyroxine (Cytomel)  Replace hormonal deficit in the treatment of HYPOTHYROIDSM FJRC.MS.MetabolicAlterations

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Th yr oid Me dic atio ns  Nausea and Vomiting  Signs of increased metabolism= tachycardia, hypertension FJRC.MS.MetabolicAlterations

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Th yr oid Me dic atio ns

 Monitor weight, VS  Instruct client to take daily medication the same time each morning WITHOUT FOOD FJRC.MS.MetabolicAlterations

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Th yr oid Me dic atio ns  Advise to report palpitation, tachycardia, and chest pain  Instruct to avoid foods that inhibit thyroid secretions like cabbage, spinach and radishes FJRC.MS.MetabolicAlterations

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ANT I-Th yro id Me dications  Methimazole (Tapazole)  PTU (prophylthiouracil)  Iodine solution- SSKI and Lugol’s solution FJRC.MS.MetabolicAlterations

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ANT I-Th yro id Me dications  N/V  Diarrhea  AGRANULOCYTOSIS  Most important to monitor FJRC.MS.MetabolicAlterations

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ANT I-Th yro id Me dications  Monitor VS, T3 and T4, weight  The medications WITH MEALS to avoid gastric upset  Instruct to report SORE THROAT or unexplained FEVER  Monitor for signs of hypothyroidism. Instruct not to stop abrupt FJRC.MS.MetabolicAlterations

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 Used to decrease the vascularity of the thyroid  T3 and T4 production diminishes  Given per orem, can be diluted with juice  Use straw FJRC.MS.MetabolicAlterations

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STER OI DS  Replaces the steroids in the body  Cortisol, cortisone, betamethasone, and hydrocortisone FJRC.MS.MetabolicAlterations

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STER OI DS Side-effects  HYPERglycemia  Increased susceptibility to infection  Hypokalemia  Edema FJRC.MS.MetabolicAlterations

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STER OI DS Side-effects  If high dosesosteoporosis, growth retardation, peptic ulcer, hypertension, cataract, mood changes, hirsutism, and fragile skin FJRC.MS.MetabolicAlterations

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STER OI DS  Nursing responsibilities 1. Monitor VS, electrolytes, glucose 2. Monitor weight edema and I/O FJRC.MS.MetabolicAlterations

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STER OI DS 3. Protect patient from infection 4. Handle patient gently 5. Instruct to take meds WITH MEALS to prevent gastric ulcer formation FJRC.MS.MetabolicAlterations

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STER OI DS  Nursing responsibilities 6. Caution the patient NOT to abruptly stop the drug 7. Drug is tapered to allow the adrenal gland to secrete endogenous hormones FJRC.MS.MetabolicAlterations

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Hyp oth yro idism  Hyposecretion of thyroid hormones  Common causes: Iodine deficiency, Hashimotos  Manifestations: related to hypometabolic state: constipation, weight gain, cold intolerance, poor appetite, mental slowness  Nursing Management:  Provide warm environment  LOW calorie diet, HIGH fiber  Avoid sedatives  Drugs: Hormone FJRC.MS.MetabolicAlterations 175 replacement

Hyp ert hyroid ism  Hyper-secretion of thyroid hormones  Common cause: Graves, Toxic goiter  Manifestation: increased metabolism: weight loss, diarrhea, heat intolerance, hypertension  Nursing Management:     

Adequate rest and sleep Cool environment HIGH calorie foods Eye care FJRC.MS.MetabolicAlterations Drugs: anti-thyroid: PTU and

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EXO -P AN CRE AT IC AN D BI LIARY DI SO RDE RS

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PAN CREA TIT IS  Acute inflammation of the pancreas associated with auto-digestion  Enzymes secreted destroy the tissue of the pancreas  Consistent alcohol intake is the most causative factor

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CHO LECY STI TI S/ CHO L EL ITH IA SI S  Cholecystitis: inflammation of the gallbladder  Cholelithiasis: occurs when gallstones are formed due to bile that is usually stored in the gallbladder hardening into stonelike material  Cholesterol, bilirubin, and calcium precipitates FJRC.MS.MetabolicAlterations

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HE PAT IC DIS OR DE RS

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