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FJRC.MS.

MetabolicAlterations 1
MEtaBol iC
aLteRaTiONs

Francis Jordan Ramos Cusi, RN


FJRC.MS.MetabolicAlterations 2
EN DO CRI NE SYSTEM

 Glands
 Hormones
 Receptors

Amines
Polypeptides
Steroids
FJRC.MS.MetabolicAlterations 3
GLAN DS OF
TH E
EN DOC RINE
SY STEM

FJRC.MS.MetabolicAlterations 4
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
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FJRC.MS.MetabolicAlterations 6
FJRC.MS.MetabolicAlterations 7
PI NEA L GLAN D

 Cone-shaped
 Back of the third ventricle of
the brain
 Mystery-mystery!
 Melatonin

FJRC.MS.MetabolicAlterations 8
PITUITAR Y GLAND

 Under (below) hypothamalus


 Bi-functional lobes + 1
Anterior and Posterior
+ pars intermedia
 AKA: Hypophysis
 Small (1 gram)
FJRC.MS.MetabolicAlterations 9
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 10
POS TERIO R PI TUI TAR Y

 Pede na rin
 Hamak na imbakan
 OXYTOCIN
 ANTIDIURETIC HORMONE
(Vasopressin)
FJRC.MS.MetabolicAlterations 11
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
FJRC.MS.MetabolicAlterations 12
FJRC.MS.MetabolicAlterations 13
PARA THY ROID GLA NDS

 Tagong kabit
 Kaya hanggang 8,
4 ang legal (daw)
 PARATHORMONE:
most popular regulator of
calcium ions
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FJRC.MS.MetabolicAlterations 15
TH YMUS GLAND

 Upper thorax
 Immuno-endo
 Thymosin : T-lymphocytes
maturation
FJRC.MS.MetabolicAlterations 16
ENDOC RI NE PANC REAS

Pancreatic
islets : New-NSO
reg
GA-BIDSFJRC.MS.MetabolicAlterations 17
FJRC.MS.MetabolicAlterations 18
FJRC.MS.MetabolicAlterations 19
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)
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FJRC.MS.MetabolicAlterations 21
FJRC.MS.MetabolicAlterations 22
GO NA DS
OVARIES:
mainly estradiol
TESTES:
testosterone
FJRC.MS.MetabolicAlterations 23
FJRC.MS.MetabolicAlterations 24
 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 25
 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 26
 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 27
 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 28
 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 29
 Aids in the diagnosis of DM
 Pre-test: Provide high-
carbohydrate 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 31
 Normal level-
expressed 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 33
 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

FJRC.MS.MetabolicAlterations 34
THY RO ID
DIS OR DE RS

FJRC.MS.MetabolicAlterations 35
HYP ERTI RE DDYTI ES

FJRC.MS.MetabolicAlterations 36
 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 37
 Decreased T3 and T4
decreased basal
metabolism

FJRC.MS.MetabolicAlterations 38
 1. Lethargy and fatigue
 2. Weakness and
paresthesia
 3. COLD intolerance
 4. Weight gain
 5. Bradycardia,
constipation
FJRC.MS.MetabolicAlterations 39
 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 40
 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 41
 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
FJRC.MS.MetabolicAlterations 42
report chest pain promptly
 Called GRAVE’S
DISEASE
 A hyperthyroid
state
characterized by
increased
circulating T3
and T4
CAUSES:
 Auto-immune
disorder, toxicFJRC.MS.MetabolicAlterations 43

goiter and tumor


 Increased hormone
activity increased Basal
Metabolism

FJRC.MS.MetabolicAlterations 44
 1. Weight loss
 2. HEAT intolerance
 3. Hypertension
 4. Tachycardia and
palpitations
 5. Exopthalmos
 6. Diarrhea
FJRC.MS.MetabolicAlterations 45
 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
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FJRC.MS.MetabolicAlterations 48
 1. Provide adequate rest
periods in a quiet room
 2. Administer anti-thyroid
medications that block
hormone synthesis-
Methimazole and PTU
 3. Provide a HIGH-calorie
diet, HIGH protein
FJRC.MS.MetabolicAlterations 49
 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 50
 10. Prepare clients for
Radioactive iodine
therapy
 11. Prepare patient for
thyroidectomy
 12. Manage thyroid storm
appropriately
FJRC.MS.MetabolicAlterations 51
 An acute LIFE-
threatening condition
characterized by
excessive thyroid
hormone
CAUSE:
 Manipulation of the
thyroid during surgery
causing the release of
FJRC.MS.MetabolicAlterations 52

excessive hormones in the


 1. HIGH fever
 2. Tachycardia and
Tachypnea
 3. Systolic HYPERtension
 4. Delirium and coma
 5. Severe vomiting and
diarrhea
FJRC.MS.MetabolicAlterations 53


 1. Maintain PATENT airway
and adequate ventilation
 2. Administer anti-thyroid
medications such as Lugol’s
solution, Propranolol, and
Glucocorticoids
 3. Monitor VS
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 4. Monitor Cardiac
rhythms
 5. Administer
PARACETAMOL ( not
Aspirin) for FEVER
 6. Manage Seizures as
required.
FJRC.MS.MetabolicAlterations 55
 Removal of the thyroid
gland

FJRC.MS.MetabolicAlterations 56
 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
medicationsFJRC.MS.MetabolicAlterations 57
 1. Position patient: Semi-
Fowler’s, neck on neutral
position
 2. Monitor for respiratory
distress- apparatus at bedside-
tracheostomy set, O2 tank and
suction machine!
 3. Check for edema and
bleeding by noting the
FJRC.MS.MetabolicAlterations 58
 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 59
 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 60
PAR ATHY ROI D
DI SOR DERS

FJRC.MS.MetabolicAlterations 61
 Hypo-secretion of
parathyroid hormone

CAUSES:
 Tumor, removal of the
gland during thyroid
surgery
FJRC.MS.MetabolicAlterations 62
 Decreased PTH deranged
calcium metabolism

FJRC.MS.MetabolicAlterations 63
 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 64
 6. Cardiac dysrhythmias
 7. Hypotension
 8. Anxiety, irritability ands
depression

FJRC.MS.MetabolicAlterations 65
FJRC.MS.MetabolicAlterations 66
 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 67
 Advise client to eat Vitamin
D rich foods

 Administer Phosphate
binding drugs

FJRC.MS.MetabolicAlterations 68
 Hyper-
secretion of
the gland

CAUSE:
 Tumor
FJRC.MS.MetabolicAlterations 69
 Increase PTH increased
CALCIUM levels in the
body

FJRC.MS.MetabolicAlterations 70
 Fatigue and muscle
weakness/pain
 Skeletal pain and tenderness
 Fractures
 Anorexia/N/V epigastric pain
 Constipation
FJRC.MS.MetabolicAlterations 71
 Hypertension
 Cardiac Dysrhythmias
 Renal Stones

FJRC.MS.MetabolicAlterations 72
 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 74
ADR EN OCO RT ICAL
DI SO RDE RS

FJRC.MS.MetabolicAlterations 75
 Decreased secretion of
adrenal cortex hormones,
especially glucocorticoids
and mineralocorticoids

CAUSE:
 Tumor, idopathic
FJRC.MS.MetabolicAlterations 76
 Decreased Glucocorticoids
decreased resistance to stress

 Decreased
mineralocorticoids
decreased retention of
sodium and water
Hypovolemia
FJRC.MS.MetabolicAlterations 77
 Weight loss

 GI disturbances

 Muscle weakness, lethargy


and fatigue

 Hyponatremia
FJRC.MS.MetabolicAlterations 78
 Hyperkalemia

 Hypoglycemia

 dehydration and
hypovolemia

 Increased skin pigmentation


FJRC.MS.MetabolicAlterations 79
 Monitor VS especially BP
 Monitor weight and I and O
 Monitor blood glucose level
and K
 Administer hormonal agents
as prescribed
FJRC.MS.MetabolicAlterations 80
 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 81
 A life-threatening disorders
caused by acute severe
adrenal insufficiency

CAUSES:
 Severe stress, infection,
trauma or surgery
FJRC.MS.MetabolicAlterations 82
 Overwhelming stimuli
mobilize body defense
decreased stress
hormones inadequate
coping
FJRC.MS.MetabolicAlterations 83
 Severe headache
 Severe pain
 Severe weakness
 Severe hypotension
 Signs of Shock

FJRC.MS.MetabolicAlterations 84
 Administer IV
glucocorticoids, usually
hydrocortisone
 Monitor VS frequently
 Monitor I and O,
neurological status,
electrolyte imbalances and
FJRC.MS.MetabolicAlterations 85
 Administer IVF
 Maintain bed rest
 Administer prescribed
antibiotics

FJRC.MS.MetabolicAlterations 86
 A condition resulting from
the hyper-secretion of
glucocorticoids from the
adrenal cortex

CAUSES:
 Pituitary tumor, adrenal
tumor, abuse of steroids
FJRC.MS.MetabolicAlterations 87
 Increased Glucocorticoids
exaggerated effects of the
hormone

FJRC.MS.MetabolicAlterations 88
Normal functions of Exaggerated
Cortisol functions
1. Gluconeogenesis HYPERGLYCEMIA
2. Protein OSTEOPOROSISS,
breakdown delayed wound
healing
Purplish striae ,
Bleeding
Muscle wasting
3. Fat breakdown THIN extremity,
Truncal deposition
4. Decreased WBC IMMUNOSUPPRESSIO
N
FJRC.MS.MetabolicAlterations 89
Functions of Exaggerated functions
Mineralocorticoids

1. Sodium Retention Hypernatremia

2.Secondary water Hypervolema-


retention Hypertension

3. Potassium excretion HYPOKALEMIA

Function of androgen: HIRSUTISM


Hair growth

FJRC.MS.MetabolicAlterations 90
 Generalized muscle
weakness and wasting
 Truncal obesity
 Moon-face
 Buffalo hump
 Easy bruisability
FJRC.MS.MetabolicAlterations 91
 Reddish-purplish striae on
the abdomen and thighs
 Hirsutism and acne
 Hypertension
 Hyperglycemia
 Osteoporosis
 Amenorrhea

FJRC.MS.MetabolicAlterations 92
FJRC.MS.MetabolicAlterations 93
FJRC.MS.MetabolicAlterations 94
 Serum cortisol level

 Serum glucose and


electrolytes

FJRC.MS.MetabolicAlterations 95
 Monitor I and O , weight and
VS
 Monitor laboratory values-
glucose, Na, K and Ca
 Provide meticulous skin care
 Administer prescribed
medications like
aminogluthetimide to inhibit
adrenal hyperfunctioning
FJRC.MS.MetabolicAlterations 96
 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 97
ADR EN OMED ULLAR Y
DI SO RDE R

FJRC.MS.MetabolicAlterations 98
 Increased secretion of
epinephrine and nor-
epinephrine by the adrenal
medulla

CAUSE: Tumor
FJRC.MS.MetabolicAlterations 99
 Increased Adrenergic
hormones
exaggerated
sympathetic effects

FJRC.MS.MetabolicAlterations 100
 Hypertension
 Severe headache
 Palpitations
 Tachycardia
 Profuse sweating and
Flushing
 Weight loss, tremors
FJRC.MS.MetabolicAlterations 101
 Hyperglycemia and
 Monitor VS especially BP
 Monitor for HYPERTENSIVE
crisis
 Avoid stimulation that can
cause increased BP
 Administer Anti-
hypertensive agents like
alpha-adrenergic blockers-
FJRC.MS.MetabolicAlterations 102
 Prepare Phentolamine for
hypertensive crisis
 Monitor blood glucose and
urine glucose
 Promote adequate rest and
sleep periods

FJRC.MS.MetabolicAlterations 103
 Provide HIGH calorie foods
and Vitamins/mineral
supplements
 Prepare patient for
possible surgery

FJRC.MS.MetabolicAlterations 104
AN TER IOR
PIT UIT ARY
DI SO RDE RS

FJRC.MS.MetabolicAlterations 105
 Hyposecretion of the anterior
pituitary gland

CAUSES: Congenital, Post-partal


necrosis, infection and tumor

FJRC.MS.MetabolicAlterations 106
 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 107
FJRC.MS.MetabolicAlterations 108
 Provide emotional support
to the family
 Encourage client and family
to express feelings
 Administer prescribed
hormonal replacement
therapy
FJRC.MS.MetabolicAlterations 109
 The hyper-secretion of the
gland
 ACROMEGALY
 CAUSES: tumor, congenital
disorder

FJRC.MS.MetabolicAlterations 110
 Depends on the
hormone/s that
is/are increased

FJRC.MS.MetabolicAlterations 111
FJRC.MS.MetabolicAlterations 112
 Increased growth
Gigantism or Acromegaly
 Large and thick hands and
feet
 Visual disturbances
 Hypertension,
hyperglycemia
 Organomegaly
FJRC.MS.MetabolicAlterations 113
 Provide emotional support
to clients and family
 Provide frequent skin care
 Prepare patient for surgery-
removal of pituitary gland

FJRC.MS.MetabolicAlterations 114
 Monitor VS, LOC and
neurologic status
 Place patient on Semi-
Fowler’s
 Monitor for Increased ICP,
bleeding, CSF leakage
 Instruct patient to AVOID
sneezing, coughing and
nose-blowing
FJRC.MS.MetabolicAlterations 115
 Monitor development of DI-
measure I and O
 Administer prescribed
medications- antibiotics,
analgesics and steroids

FJRC.MS.MetabolicAlterations 116
POS TER IOR
PIT UIT ARY
DI SO RDE RS

FJRC.MS.MetabolicAlterations 117
 A hypo-secretion of ADH

CAUSES:
 Conditions that increase
ICP, Surgical removal of
post pit. tumor

FJRC.MS.MetabolicAlterations 118
 Decreased ADH failure of
tubular re-absorption of
water increased urine
volume

FJRC.MS.MetabolicAlterations 119
FJRC.MS.MetabolicAlterations 120
 Polyuria of more than 4
liters of urine/day
 Polydipsia
 Signs of Dehydration
 Muscle pain and weakness
 Postural hypotension and
tachycardia
FJRC.MS.MetabolicAlterations 121
 Urinary Specific gravity
very low, 1.006 or less
 Serum Sodium levels high

FJRC.MS.MetabolicAlterations 122
 Monitor VS, neurologic
status and cardiovascular
status

 Monitor Intake and Output

 Monitor urine specific


gravity FJRC.MS.MetabolicAlterations 123
 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 124
 Hyper-secretion of ADH
abnormally

CAUSES:
 Tumor, paraneoplastic
syndromes

FJRC.MS.MetabolicAlterations 125
 Increased ADH water re-
absorption water
intoxication, hypervolemia

FJRC.MS.MetabolicAlterations 126
 Urine specific gravity is
increased (concentrated)

 Hyponatremia

 CBC shows hemodilution


FJRC.MS.MetabolicAlterations 127
 Signs of Hypervolemia

 Mental status changes

 Abnormal weight gain

FJRC.MS.MetabolicAlterations 128
 Hypertension

 Anorexia, Nausea and


Vomiting

 HYPOnatremia
FJRC.MS.MetabolicAlterations 129
 Monitor VS and neurologic
status

 Provide safe environment

 Restrict fluid intake (less


than 500cc/day)
FJRC.MS.MetabolicAlterations 130
 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 131
END O-P AN CRE AS
DI SO RDE R

FJRC.MS.MetabolicAlterations 132
 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

FJRC.MS.MetabolicAlterations 134
 Types
 Type I (insulin-
dependent
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 135
 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 136
 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 139
 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

FJRC.MS.MetabolicAlterations 140
 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 141
 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 142
 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
pushes) prior to each meal.
FJRC.MS.MetabolicAlterations 143
FJRC.MS.MetabolicAlterations 144
 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 145
 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

FJRC.MS.MetabolicAlterations 146
 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 147
 Observe for signs of hypo/hyperglycemia.
 Provide meticulous skin care and
prevent injury.
 Maintain I&O; weight daily.
 Provide emotional support; assist
client in adapting to change n life-
style and body image.

FJRC.MS.MetabolicAlterations 148
 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 149
bladder, impotence, decreased sweating
 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

FJRC.MS.MetabolicAlterations 150
 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 151
 avoid alcohol intake while on medication
 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.

FJRC.MS.MetabolicAlterations 152
 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

FJRC.MS.MetabolicAlterations 153
 Blood glucose
monitoring
 Instruct 1. Use
for Type I
diabetic clients
since it gives
exact blood
glucose level and
also detects
hypoglycemia.
 client in finger-
stick technique,
use of monitor
device (if used),
and recording
and utilization of
test results.
FJRC.MS.MetabolicAlterations 154
 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 155
 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.
FJRC.MS.MetabolicAlterations 156
 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 157
Sel ec ted
End oc rin e
PHA RM ACO LOGY

FJRC.MS.MetabolicAlterations 158
En docrine Medic ations

 Enhance re-absorption of water in


the kidneys
 Used in DI
 Desmopressin and Lypressin
intranasally
 Pitressin IM
FJRC.MS.MetabolicAlterations 159
En docrine Medic ations

 SIDE-effects
 Flushing and headache
 Water intoxication

FJRC.MS.MetabolicAlterations 160
Th yr oid Me dic atio ns

 Levothyroxine (Synthroid)
and Liothyroxine
(Cytomel)
 Replace hormonal deficit
in the treatment of
HYPOTHYROIDSM
FJRC.MS.MetabolicAlterations 161
Th yr oid Me dic atio ns

 Nausea and Vomiting

 Signs of increased
metabolism=
tachycardia,
hypertension
FJRC.MS.MetabolicAlterations 162
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 163
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 164
ANT I-Th yro id
Me dications

 Methimazole (Tapazole)
 PTU (prophylthiouracil)
 Iodine solution- SSKI and
Lugol’s solution

FJRC.MS.MetabolicAlterations 165
ANT I-Th yro id
Me dications

 N/V
 Diarrhea
 AGRANULOCYTOSIS
 Most important to monitor

FJRC.MS.MetabolicAlterations 166
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
FJRC.MS.MetabolicAlterations 167
not to stop abrupt
 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 168
STER OI DS

 Replaces the steroids


in the body
 Cortisol, cortisone,
betamethasone, and
hydrocortisone

FJRC.MS.MetabolicAlterations 169
STER OI DS
Side-effects
 HYPERglycemia
 Increased susceptibility
to infection
 Hypokalemia
 Edema
FJRC.MS.MetabolicAlterations 170
STER OI DS
Side-effects
 If high doses-
osteoporosis, growth
retardation, peptic
ulcer, hypertension,
cataract, mood
changes, hirsutism,
and fragile skin
FJRC.MS.MetabolicAlterations 171
STER OI DS
 Nursing responsibilities
1. Monitor VS, electrolytes,
glucose
2. Monitor weight edema
and I/O

FJRC.MS.MetabolicAlterations 172
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 173
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 174
Hyp oth yro idism
 Hyposecretion of thyroid hormones
 Common causes: Iodine deficiency,
Hashimotos
 Manifestations: related to hypo-
metabolic state: constipation, weight
gain, cold intolerance, poor appetite,
mental slowness
 Nursing Management:
 Provide warm environment
 LOW calorie diet, HIGH fiber
 Avoid sedatives
 Drugs: Hormone replacement
FJRC.MS.MetabolicAlterations 175
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 176
 Drugs: anti-thyroid: PTU and
EXO -P AN CRE AT IC
AN D BI LIARY
DI SO RDE RS

FJRC.MS.MetabolicAlterations 177
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

FJRC.MS.MetabolicAlterations 178
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 179
HE PAT IC
DIS OR DE RS

FJRC.MS.MetabolicAlterations 180
FJRC.MS.MetabolicAlterations 181
FJRC.MS.MetabolicAlterations 182