Hypothyroidism underactive state of the thyroid gland hyposecretion

of thyroid hormone

most common in women, middle-age

Causes : thyroidectomy pituitary / hypothalamic dysfunction iodine deficiency autoimmune thyroiditis (Hashimoto’s disease) –

immune system attacks the thyroid gland

idiopathic (unknown)

DX: decreased T3, T4 Elevated TSH, cholesterol

Med. Mgt. – thyroid replacement therapy Levothyroxine (Synthyroid) , liothyronine Expected effects: diuresis, puffiness, improved

reflexes and muscle tone, PR

Nsg. Interventions provide a warm environment, conducive to rest avoid use of all sedatives assist client in choosing calorie, cholesterol diet fluid and fiber to relieve constipation physical activity and sensory stimulation gradually as condition improves monitor cardiovascular response to increased hormone levels carefully provide info. about prescribed medications (name, dosage, side effects) and importance of lifelong medical supervision

Hyperthyroidism

over-secretion of the thyroid gland also called thyrotoxicosis, tissues are stimulated

by excessive thyroid hormone

a recurrent syndrome, may appear after emotional stress or infection

occurs mostly in women 20-50 yrs old

Causes : adenoma, goiter, viral inflammation, auto-immune glandular stimulation, grave’s disease - most common cause

Hyperthyroidism (cont.)

DX: > elevated T3, T4 values•abnormal findings in the thyroid scan

Goiter – enlargement of the thyroid gland •due to stimulation of the thyroid gland by TSH

Simple goiter – enlarged thyroid gland•due to iodine deficiency, intake of goitrogenic foods cabbage, turnips, soybeans•may be hereditary

Grave’s Disease disorder char. by one or more of the ff:

diffuse goiter

hyperthyroidism

infiltrative opthalmopathy exophthalmos seen in females under age 40 result from stimulation of the thyroid gland by thyroid-stimulating immunoglobulins (TSI) cause is unknown, may be hereditary, gender-related, often occurs after severe emotional stress or infection

Thyroid Storm or Crisis

a medical emergency pts. develop severe manifestation of hyperthyroidism

temp., tachycardia, dysrhythmias worsening tremors, restlessness delirious or psychotic state or coma abdominal pain BP and RR

Precipitated by a major stressor: infection trauma or surgery (thyroidectomy) inadequate treatment

Complications :

cardiovascular disease (HPN, Angina, CHF) Exophthalmos – abnormal protrusion of the

eyeballs- caused by abnormal deposits of fat and fluid in the retroocular tissue

Corneal abrasion Thyroid storm or crisis life-threatening

hypermetabolism and excessive adrenergic response (HR, RR, BP)

Pathophysiology:

hypertrophy and hyperplasia of the thyroid gland excessive secretion of thyroid hormone

hypermetabolic condition exaggeration of all metabolic processes metabolic rate, excessive heat production appetite neuromuscular and CVS activity hyperactivity of sympathetic NS personality changes

Anxiety Flushed, smooth skin Heat intolerance Mood swings Diaphoresis Tachycardia Palpitations Dyspnea Weakness Wt. loss

Assessment Findings

Nsg. Interventions: Provide calm, restful envt. Provide calm, restful envt.

1. physical comfort, cool envt. temp., bathe frequently w/ cool water

2. provide adequate rest, avoid muscle fatigue33 stressors in the envt.— noise and lights4. relaxation techniques

Provide adequate nutrientsProvide adequate nutrients33 calorie, protein, balanced diet (4,000-

5,000 cal/day)33 fluid intake3. Restrict stimulants (tea, coffee, alcohol)4. small, frequent feedings if hypermotility is

present5. Daily wt.

Nsg. Interventions:

Provide emotional supportProvide emotional support

Provide eye careProvide eye care1. eye drops, dark glasses, patch eyes if

necessary2. elevate head of bed for sleep3. restrict dietary sodium4. assess adequacy of lid closure

Be alert for complicationsBe alert for complications

Post-op care after Thyroidectomy

O2 therapy, suction secretions Monitor for signs of bleeding and excessive edema elevate head of bed 30o, support head and neck – to avoid tension on suturescheck dressing frequently, check behind the neck for bleeding assess for signs of resp. distress, hoarseness (laryngeal edema or damage) keep tracheostomy set in patient’s room for emergency use

Post-op Complications: be alert for the possibility of:

1. Tetany (due to hypocalcemia caused by accidental removal of parathyroid glands)

assess for numbness, tingling or muscle twitching Chvostek’s sign and Trousseau’s sign Ca+ gluconate IV

2. HemorrhageWOF: hypotension, tachycardia, other signs of hypovolemiaWOF: irregular breathing, swelling, choking---possible hemorrhage and tracheal compressionWOF: early signs of hemorrhage: repeated clearing of the throat, difficulty swallowing

Post-op Complications: be alert for the possibility of:

3. Thyroid storm - life-threatening- sudden release of thyroid hormone- fever, tachycardia, increasing restlessness

and agitation, delirium

administer food and fluid with care (dysphagia is common) encourage client to gradually ROM of neckteach about medications, frequent follow-up

total thyroidectomy – life long replacement medication (T3, T4)subtotal thyroidectomy – careful monitoring of return of thyroid function

Diabetes MellitusDiabetes Mellitus

is a chronic disorder of carbohydrate, protein, and fat metabolism resulting from insulin deficiency or abnormality in the use of insulin

Predisposing factors: exact cause of diabetes mellitus remain unknown genetic / hereditary predisposition viruses pancreatitis pancreatic tumor autoimmune disorder obesity (overweight people require more insulin to metabolize the food they eat or the number of insulin receptor sites in cells is decreased)

Types1.Insulin – Dependent Diabetes Mellitus (IDDM) or Type I

destruction of beta cells of the pancreas little or no insulin production requires daily insulin admin. may occur at any age, usually appears below age 15

2.Non Insulin–Dependent Diabetes Mellitus (NIDDM) or Type II

probably caused by:1. disturbance in insulin reception in the cells2. number of insulin receptors3. loss of beta cell responsiveness to glucose leading to slow or insulin release by the pancreas

occurs over age 40 but can occur in children common in overweight or obese w/ some circulating insulin present, often do not require insulin

Clinical Manifestations ( Signs and Symptoms)

- Polyuria - weakness- Polydipsia - fatigue- Polyphagia - blood sugar / glucose level- weight loss - (+) glucose in urine (glycosuria)- nausea / vomiting - changes in LOC (severe hyperglycemia) (sleepiness, drowsiness coma)- recurrent infection, prolonged wound healing- altered immune and inflammatory response, prone to infection (glucose inhibits the phagocytic action of WBC resistance)- genital pruritus – (hyperglycemia and glycosuria favor fungal growth : candidal infection – resulting in pruritus, common presenting symptom in women)

1. Fasting Blood Sugar (FBS) NPO for 12 hours Normal value= 80-120 mg/dl 140 mg/dl or more – diagnostic of DM

2. Postprandial blood sugar Blood is withdrawn 2 hrs. after a meal N value = < 120mg/dl 200 mg/dl or more is diagnostic of DM

3. Oral Glucose Tolerance Test (OGTT) NPO 12 hrs, no smoking, coffee or tea, minimize

activity, minimize stress obtain FBS, administer 100 gm. Glucose by mouth

diluted in juice; obtain blood and urine specimen after 1, 2 and 3 hrs.

N value = blood glucose rise to 140 mg/dl in the 1st hour and returns to normal by 2nd and 3rd hrs.

Abnormal = blood glucose does not return to normal by 2nd and 3rd hrs.; all urine specimen positive for glucose

4. Glycosylated hemoglobin Provides information about blood glucose

level during the previous 3 months bec. glucose in the bloodstream attaches to

some of the hemoglobin and stay attached during the 120-day lifespan of the RBC

Interventions for Diabetes MellitusA.Dietary Management

1. Follow individualized meal plan and snacks as scheduled Balanced diabetic diet – 50% CHO, 30% fats,

20% CHON, vitamins and minerals diet based on pts. size, wt., age, occupation and

activity2. Pt. must have adequate CHO intake to correspond to

the time when insulin is most effective• Routine blood glucose testing before each meal and

at bedtime is necessary during initial control, during illness and in unstable pts.

• Do not skip meals• Measure foods accurately, do not estimate • Less added fat, fewer fatty foods and low-cholesterol

Interventions for Diabetes MellitusA.Dietary Management

7. Advise use of complex carbohydrates to help stabilize blood sugar. Meal should include more fiber and starch and fewer simple or refined sugars.

8. Avoid concentrated sweets, high in sugar (jellies, jams, cakes, ice cream)

9. If taking insulin, eat extra food before periods of vigorous exercise

10.Avoid periods of fasting and feasting11.Keep weight at normal level, obese diabetics should

be on a strict weight control program and should lose weight.

B. Teach pt. on correct administration of insulin and other hypoglycemic agents.

1. insulin in current use may be stored at room temp., all others in ref. or cool area

2. avoid injecting cold insulin lead to tissue reaction3. roll insulin vial to mix, do not shake, remove air

bubbles from syringe4. press (do not rub) the site after injection (rubbing

may alter the rate of absorption of insulin)5. avoid smoking for 30 mins. after injection (cigarette

smoking absorption)6. Rotate sites7. Failure to rotate sites may lead to Lipodystrophy8. Lipodystrophy – localized disturbance of fat

metabolism9. Ex. Lipohypertrophy – thickening of subcutaneous

tissue at injection site, feel lumpy or hard, spongy result to absorption of insulin making it

difficult to control the pt.’s blood glucose

Factors that influence the body’s need for Factors that influence the body’s need for insulininsulin33 need : trauma, infection, fever, severe psychological or physical stress, other illnesses2. need : active exerciseHypoglycemiaHypoglycemia

low blood glucose (usually below 60mg/dl) results from too much insulin, not enough food,

and/or excessive physical activity may occur 1-3 hrs after regular insulin injection

S/Sx:1.Sweating, tremor, pallor, tachycardia, palpitations and nervousness

caused by release of epinephrine from the CNS when blood glucose falls rapidly

2.Headache, light-headedness, confusion, numbness of lips and tongue, slurred speech, drowsiness, convulsions and coma

• caused by depression of the CNS because of glucose supply of brain cells

Management of Hypoglycemia

1.Give simple sugar orally if pt. is conscious and can swallow – orange juice, candy, glucose tablets, lump of sugar2.Give Glucagon (SQ or IM) if pt. is unconscious or cannot take sugar by mouth3.As soon as pt. regains consciousness, he should be given carbohydrate by mouth4.If pt. does not respond to the above measures, he is given 50 ml of 50% glucose I.V. or 1000 ml of 5%-10% glucose in water I.V.

Preventing Hypoglycemic Reactions Due to Insulin

Instruct the pt. as follows:1.Hypoglycemia may be prevented by maintaining regular exercise, diet and insulin2.Early symptoms of hypoglycemia should by recognized and treated3.Carry at all times some form of simple carbohydrate (orange juice, sugar, candy)4.Extra food should be taken before unusual physical activity or prolonged periods of exercise5.Between-meal and bedtime snacks may be necessary to maintain a normal glucose level.

Oral Antidiabetic Agents

Teach pt. to estabilish and maintain a pattern of regular exercise Benefits of exercise :

promotes use of CHO & enhances action of insulin blood glucose levels need for insulin the no. of functioning receptor sites for insulin

perform exercise after meals to ensure an adequate level of blood glucosecarry a rapid-acting source of glucose during exerciseexcessive or unplanned exercise may trigger hypoglycemiatake insulin and food before active exercise

Teach pt. to practice good personal hygiene and positive health promotion to avoid diabetic complications

1.teach pt. about diabetic foot care2.teach pt. the adjustments that must be made in the event of minor illness (e.g. colds, flu)

continue taking insulin or oral hypoglycemic agents maintain fluid intake frequency of blood testing or urine testing

3.help pt. identify stressful situations in lifestyle that might interfere with good diabetic control4.encourage good daily hygiene5.advise regular eye exams6.teach aggressive care for minor skin cuts and abrasions

Diabetic Ketoacidosis (DKA) Coma

S/Sx:polyuria, thirstnausea, vomiting, abdominal pain –-- due to

acidosisweakness, headache, fatigue --- due to acidosis and

F/E imbalancedim vision, flushed facedehydration, hypovolemic shock (PR, BP, dry

skin, wt. loss)hyperpnea (Kussmaul’s breathing)acetone breath (fruity odor)lethargy COMABlood glucose level > 250-350 mg/100 ml.

Hyperglycemic, Hyperosmolar, Non-Ketotic Coma (HHNC)

can occur when the action of insulin is severely inhibitedseen in pts. w/ NIDDM, elderly persons w/ NIDDM

Precipitating factors:infection, renal failure, MI, CVA, GI hemorrhage,

pancreatitis, CHF, TPN, surgery, dialysis, steroids

S/Sx:polyuria oliguria (renal insufficiency)lethargytemp, PR, BP, signs of severe fluid deficitConfusion, seizure, comaBlood glucose level > 600 mg/100 ml.

Interventions for DKA and Hyperosmolar Coma

Regular insulin IV push or IV drip 0.9% NaCl IV – 1 L during the 1st hr, 2-8 L over 24

hrs. administer sodium bicarbonate IV to correct acidosis Monitor electrolyte levels, esp. serum K+ levels administer K+, monitor UO hourly (30ml/hr)

Long-term Complications of DM

1.Vascular Changesa.) Macroangiopathy – hardening and damage of the walls of large arteries

Coronary Artery DiseaseCVA (Stroke)Peripheral vascular disease – foot ulcers and gangrene

b. ) Microangiopathy – destruction of small blood vesselsRetinopathy – damage to retinal capillaries; hemorrhage, blindnessNephropathy – damage microcirculation of kidneys; CRF

2. Neuropathy Damage to the neurons caused by vascular insufficiency and blood glucoseSensory and motor impairmentNumbness, tingling, pain in extremities Painless neuropathyImpotence

INSULIN ONSET PEAK DURATION

Ultra rapid acting Insulin analog (Humalog)

15 mins. 2-4 hrs. 6-8 hrs.

Rapid acting: Regular (Semilente)

½-1 hr 2-4 hrs. 6-8 hrs.

Intermediate: NPH (Lente)

1-2 hrs. 7-12 hrs. 24-30 hrs.

Long acting: Protamine Zinc (Ultralente)

4-6 hrs. 18 + hrs 30-36 hrs.