Care of Clients with Problems In Oxygenation, Fluids and Electrolytes, Metabolism and Endocrine (NCM103) Patients With Endocrine

Alterations II

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Disorders of the Posterior Pituitary Gland

Diabetes Insipidus (DI)

A. Definition: A hyposecretion of ADH (Vasopressin) from the PG (Pituitary Gland) Deficiency of ADH may be partial / complete DI may be permanent / transient B. Etiologic Factors 1. Primary: Idiopathic 2. Secondary: (Central DI/ Neural DI) o Head Trauma, Neurosurgery, Aneurysm, Infection. Conditions that ICP. Surgical removal of Posterior Pituitary tumor 3. Nephrogenic DI: Inability of the kidneys to respond to ADH (Renal Disease and Medications) C. Pathophysiology

Topics Discussed Here Are: 1. Disorders of the Posterior Pituitary Gland Diabetes Insipidus SIADH 2. Disorders of the Adrenal Glands Pheocromocytoma Addisons Disease Cushings Syndrome Aldosteronism 3. Adrenalectomy

D. Clinical Manifestations 1. Marked Polyuria of more than 4L of urine/day 2. Polydipsia Drinks 4 40L of fluid and craves for COLD water 3. Signs of Dehydration 4. Muscle pain and weakness 5. Post hypotension and tachycardia 6. Appearance of urine is that of waters

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E. Diagnostic Test Test Urinalysis

Blood Test

Result Urine specific gravity: Very low, 1.006 or less Colorless urine Urine ADH (Absent) Serum Na Levels: High (135 145 mEq/L) Serum ADH (Decreased/Absent) Low urine osmolality (50 200 mOsm/kg) DILUTED URINE High plasma osmolality (Above 295 mOsm)

Water Deprivation Test: Confirmatory Diagnosis 1st Phase Withhold Water and measure weight 2nd Phase Test what type of DI: Central Primary Nephrogenic Gives ADH

Medical Management
Administration of ADH / Its derivative o Desmopressin acetate (ADH derivative) Administered intra-nasally, tablets, injection o Chlorpropamide and Clofibrate increases actions of ADH o Nephrogenic DI Chlorpropamide and Thiazide Diuretics

F.

Nursing Management o Nursing Diagnosis Deficient fluid volume Risk for deficient fluid volume o Nursing Intervention: Maintains adequate fluid volume Measures fluid intake and output accurately Obtain daily weight Monitor hemodynamic status Provide patient with ample water to drink and administer IV fluids as indicated o Monitor result of: Serum and urine osmolality Serum Na tests o Administer or teach self-administration of medications as prescribed and document clients response

Syndrome of Inappropriate Antidiuretic Hormone

A. Definition: - Hypersecretion of ADH abnormally - Syndrome is characterized by excessive release of ADH or vasopressin from the PPG or another source B. Etiologic Factors - Ectopic Tumors (Lung carcinoma) - Brain injury, infection and hemorrhage - Surgical operation (Hypothalamus) - Medications (Barbiturates, nicotine, morphine, diuretics)

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C. Pathophysiology

D. Clinical Manifestations - Signs of Hypervolemia - Abnormal weight gain - Hypertension - Hyponatremia o Anorexia, N/V o Mental Status Changes E. Diagnostic Test Test Result Urinalysis - Urine specific gravity: High - Concentrated urine - Urine ADH (Increased ) Blood Test - Serum Na Levels: Decreased (135 145 mEq/L) - Serum ADH: Increased

Medical Management:
Hypertonic Saline Diuretics (Furosemide) Demeclocycline (Declomycin) Blocks the action of ADH in the kidneys F. Nursing Management: - Nursing Diagnosis: o Fluid volume excess - Nursing Intervention: Maintain adequate fluid volume o Measures fluid intake and output accurately

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Obtain daily weight Monitor hemodynamic status Maintain fluid restriction to reduce serum dilution and normalize serum Na

Pheocromocytoma
A. Definition: - Secretion of epinephrine and norepinephrine by the Adrenal Medulla B. Etiologic Factors: - Cause: Tumor C. Pathophysiology

D. Clinical Manifestations: - Hypertension: Palpitation, Tachycardia, Pallor - Headache: Severe - Hyperglycemia and Glucosuria - Hypermetabolism: Weight Loss - Hyperhydrosis E. Diagnostic Test Test Result 24 Hour Urine Levels of metabolites of catecholamines Blood Test Serum levels of epinephrine and norepinephrine Imaging Studies MRI and CT Scan Medical Management Surgical Removal of the tumor Stabilization of the blood pressure Alpha-adrenergic blocking agents: Phentolamine Catecholamine Synthesis Inhibitors: Metyrosine F. Nursing Management - Nursing Diagnosis Anxiety related to systemic Risk for injury related to hypertensive - Nursing Intervention

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1. 2. 3. 4. 5. 6. 7. 8.

Monitor VS especially BP Monitor for Hypertensive crisis Prepare Phentolamine for hypertensive crisis Avoid stimulation that can cause BP Teach importance of avoiding foods and beverages with caffeine Monitor blood glucose and urine glucose Provide adequate rest and sleep periods Provide HIGH CALORIE foods and Vitamins / Minerals supplements Prepare client for possible surgery

Disorders of the Adrenal Glands

Adrenal Cortex: Aldosterone Cortisol Androgen

Addisons Disease
A. Definition: - Secretion of adrenal cortex hormones, especially glucocorticoids and mineralocorticoids B. Etiologic Factors - Primary: Auto-immune response, infection and idiopathic atrophy of the adrenal glands - Secondary: Pituitary hypofunction, surgery C. Pathophysiology
Addisons Disease
Auto-immune Response Primary Infection Idiopathic Atrophy Secondary Surgery Pituitary Hypofunction

ACTH Levels

Destruction of Adrenal Cortical Cells

Adrenal Atrophy

Hyperpigmentation

Decreased Mineralocorticoids

Low ALDOSTERONE

Decreased Glucocorticoids

Low Plasma Cortisol Levels

Disturbance in Na, K Water Metabolism

Decreased Gluconeogenesis CHON Metabolism Insulin Insensitivity

Anti-inflammatory response

Stress response

GI Disturbance

Renal Water Reabsorption

Hypoglycemia

Water Loss Dehydration Hyponatremia Hyperkalemia HYPOVOLEMIA

Fatigue, weakness, lethargy, weight loss

Serum Sodium Serum Potassium

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D. Clinical Manifestations: 1. Hyponatremia and Hyperkalemia 2. Water loss, dehydration, hypovolemia 3. Hypoglycemia 4. Weight loss, weakness, fatigue 5. GI disturbance (anorexia, N/V) 6. Mental status changes: Depression, irritability, anxiety 7. Skin pigmentation (Primary type) E. Diagnostic Test Test Blood Chemistry Result Potassium (K) Sodium (Na) and Glucose Cortisol and Aldosterone Level ACTH White Blood Cells (WBC) MRI and CT-Scan

Complete Blood Count Imaging Studies

Nursing Diagnosis Fluid volume deficit related to renal losses of sodium and water Activity intolerance related to decreased Cortisol production Risk for infection related to ineffective stress response F. Nursing Management - Nursing Interventions: 1. Assess Intake and Output, obtain daily weight 2. Monitor vital signs especially blood pressure 3. Monitor electrolyte levels 4. Provide a HIGH PROTEIN, HIGH CARBOHYDRATE and Na intake 5. Assist in performing ADLs, proper pacing of ADLs 6. Educate the patient regarding hormone therapy, avoidance of strenuous activities, stress and monitoring for infection 7. WOF: Addisonian Crisis Severe HYPOTENSION, N/V, WEAKNESS, LETHARGY, COMA & DEATH Medical Management Restore Fluid and electrolyte balance Na and K, Oral Fluid Intake (OFI) Glucocorticoid Deficit Treatment Hydrocortisone Prednisone Mineralocorticoid Deficient Treatment Fludrocortisone

Cushings Syndrome
A. Definition: - A condition resulting from the HYPERSECRETION of GLUCOCORTICOIDS from the adrenal cortex B. Etiologic Factors - Pituitary Cushings Syndrome (Cushings Disease) - Pituitary Adenoma / Hyperplasia - Adrenal Cushings Syndrome - Adrenal Cortex Carcinoma - Ectopic: Extra pituitary tumors secreting ACTH

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- Iatrogenic: Exogenous Glucocorticoid Administration C. Pathophysiology

Cushings Syndrome
Ineffective Feedback mechanism of Adrenocortical function

Excessive production of adreno-cortical Hormones

Mineralocorticoids

Androgens

Glucocorticoids

Blood Volume

Women: Virilism Hirsutism Breast atrophy Enlarged clitoris Masculine voice Loss of libido, menstruation ACNE

Abnormal Fat Mobilization

Gluconeogenesis

Antiinflammatory Effect

Vascular sensitivity to catecholamine

Truncal Obesity

Moon Face

Buffalo Hump

CHON Metabolism

Serum Glucose

PRONE to infection

Vasoconstriction

WEIGHT GAIN

Muscle Wasting

Osteoporosis

Collagen

Hypertension

Skin thinning

Easy bruising

More visible capillaries

Purple striae

D. Clinical Manifestations 1. General muscle weakness and wasting 2. Truncal obesity 3. Moon face 4. Buffalo hump 5. Easy bruisability

Reddish-purplish Striae on the abdomen and thighs 7. Hirsutism 8. HTN 9. Hyperglycemia 10. Osteoporosis 11. Amenorrhea

6.

E. Diagnostic Tests Test Blood Test Result Excessive Cortisol level Glucose Na, K Reduced Eosinophils MRI and CT-Scan

Complete Blood Count Imaging Studies F. Nursing Management Nursing Diagnosis Impaired Self-care deficit Altered body image Risk for infection Disturbed body image

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G. Nursing Intervention 1. Monitor Intake and Output, Weight and VS 2. Monitor laboratory values. Glucose, Na and Ca 3. Provide meticulous skin care 4. Administer prescribed medications like 5. Prepare client for surgical management Pituitary surgery and adrenalectomy 6. Protect patient from infection 7. Improve body image 8. Provide a LOW CARBOHYDRATE, LOW Na and HIGH PROTEIN Diet

Aldosteronism / Conns Disease

A. Definition: - Hypersecretion of Aldosterone from the adrenal cortex B. Etiologic Factors - Primary Hyperaldosteronism (Conns Disease) Tumor, Pituitary Tumor - Secondary Hyperaldosteronism Sustained elevation of renin and activation of Angiotensin II C. Pathophysiology

1. 2. 3. 4.

Function of Mineralocorticoid Sodium Retention Secondary Water Retention Potassium Excretion Functions of Androgen: Hair Growth

Exaggerated Effects Hypernatremia Hypervolemia HTN Hypokalemia Hirsutism

D. Clinical Manifestations: 1. Symptoms of Hypokalemia 2. Hypertension 3. Hypernatremia 4. Headache / N/V 5. Visual Changes

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Muscle weakness, Fatigue and Nocturia

E. Diagnostic Test 1. Urine specific gravity: LOW Due to Polyuria 2. Serum Na: HIGH (Above 145) 3. Serum K: VERY LOW 4. Urinary K 5. Serum and Urinary Aldosterone F. Nursing Intervention Nursing Diagnosis o Fluid volume excess Nursing Intervention 1. Monitor VS, I&O, urine specific gravity 2. Monitor serum K and Na 3. Provide K rich foods and supplements 4. Administer prescribed diuretics Spironolactone 5. Maintain Na Restricted Diet 6. Prepare patient for possible surgical interventions Medical Management 1. Surgical removal of tumor 2. Diuretics: Spironolactone 3. Na Restriction: NO SALINE Na Diet 4. K Supplementation 5. Anti-Hypertensive therapy

Adrenalectomy
Unilateral or Bilateral removal of adrenal glands Indications: - Adrenal tumors - Cushings Syndrome - Hyperaldosteronism Accomplished through abdominal / flank incision

PREOPERATIVE MANAGEMENT Blood Pressure and Fluid Volume are optimized and frequently assessed Surgery and Nursing care are explained to the client Glucocorticoids will be given to cover period of stress (Surgery), because at least one adrenal gland will be removed POSTOPERATIVE MANAGEMENT Usual postop care for abdominal surgery, includes: o Frequent checking of VS o Assessing hemorrhage o Turning o Coughing IV Hydrocortisone (Solu-cortet) is given as directed to prevent adrenal crisis Non stressful environment is maintained, rest is promoted, meticulous care is given to protect the client from infection and from other complications that could cause adrenal crisis Serum electrolytes and blood pressure are monitored Buti pa ung ihi sweet dahil sa diabetes XD

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