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Endocrine Disorders (Pituitary Disorders (Diabetes Insipidus (Clinical…

- - - - Without the action of ADH on the distal nephron of the kidney, an enormous daily output of very dilute, water-like urine with a speciﬁc gravity of 1.001 to 1.005 occurs.
        Because of the intense thirst, the patient tends to drink 2 to 20 L of ﬂuid daily and craves cold water.
        Attempts to restrict ﬂuids cause the patient to experience an insatiable craving for ﬂuid and to develop hypernatremia and severe dehydration
    - - The ﬂuid deprivation test is carried out by withholding ﬂuids for 8 to 12 hours or until 3% to 5% of the body weight is lost. The inability to increase the speciﬁc gravity and osmolality of the urine is characteristic of DI. The patient continues to excrete large volumes of urine with low speciﬁc gravity and experiences weight loss, increasing serum osmolality, and elevated serum sodium levels.
        Other diagnostic procedures include concurrent measurements of plasma levels of ADH and plasma and urine osmolality as well as a trial of desmopressin therapy and intravenous infusion of hypertonic saline solution.
    - - DI is a disorder of the posterior lobe of the pituitary gland that is characterized by a deﬁciency of ADH (vasopressin).
        It may occur secondary to head trauma, brain tumor, surgical ablation/irradiation of the pituitary gland, infections of the central nervous system, tumors, or failure of the renal tubules to respond to ADH.
    - - The objectives of therapy are to replace ADH, to ensure ad-equate ﬂuid replacement, and to identify and correct the underlying pathology.
    - - The nurse must teach the patient and family about follow-up care and emergency measures and provide speciﬁc verbal and written instructions, including the actions and side effects of all medications. In addition to demonstrating correct medication administration, the nurse should observe return demonstrations. It is necessary to provide information regarding the signs and symptoms of hyponatremia. Finally, the nurse should advise wearing a medical identiﬁcation bracelet and carrying medication and information about DI at all times.
  - - - -patients with bronchogenic carcinoma
        -patients with severe pneumonia, pneumothorax, and other disorders of the lungs
        -patients with malignant tumors that affect other organs
        -patients with disorders of the central nervous system
        -medications that either directly stimulate the pituitary gland or increase the sensitivity of renal tubules to circulating ADH.
    - - -eliminate the underlying cause
        -restrict ﬂuid intake; Diuretics such as furosemide may be used along with ﬂuid restriction if severe hyponatremia is present.
    - - The syndrome of inappropriate antidiuretic hormone(SIADH) secretion includes excessive ADH secretion from the pituitary gland. Patients cannot excrete a dilute urine, retain ﬂuids, and develop a sodium deﬁciency known as dilutional hyponatremia.
    - - Monitor:
        -fluid intake and output
        -daily weight
        -urine and blood chemistries
        -neurologic status
        Supportive measures and explanations of procedures and treatments assist the patient in managing this disorder.
- - - - -Autoimmune disease
        -Atrophy of thyroid gland with aging
        -Therapy for hyperthyroidism
        -Thyroidectomy
        -Medications
        -Radiation to head and neck
        -Inﬁltrative diseases of the thyroid
        -Iodine deﬁciency and iodine excess
    - - -Extreme fatigue
        -Hair loss
        -Brittle nails
        -Dry skin
        -Hoarse voice
        -Menstrual disturbances
        -Subnormal temp and HR
    - - Inadequate secretion of thyroid hormone during fetal and neonatal development results in stunted physical and mental growth (cretinism) because of general depression of metabolic activity. In adults, hypothyroidism manifests as lethargy, slow mentation, and generalized slowing of body functions.
    - - The primary objective in the management of hypothyroidism is to restore a normal metabolic state by replacing the missing hormone.
    - - The patient and family require education and support to manage this disorder. Oral and written instructions should be provided regarding the following:
        •Desired actions and side effects of medications
        •Correct medication administration
        •Importance of continuing to take the medications as prescribed even after symptoms improve
        •When to seek medical attention
        •Importance of nutrition and diet to promote weight loss and normal bowel patterns
        •Importance of periodic follow-up testing
  - - - The disorder may appear after an emotional shock, stress, or an infection. Other common causes of hyperthyroidism include thyroiditis and excessive ingestion of thyroid hormone.
    - - -Irritable
        -Flushed skin
        -Palpitations
        -Abnormal HR
        -Fine tremor of hand
        -Exophthalmos
        -Increased appetite
        -Weight loss
        -Amenorrhea
    - - Oversecretion of thyroid hormones (hyperthyroidism) is manifested by a greatly increased metabolic rate. Many of the other characteristics of hyperthyroidism result from the increased response to circulating catecholamines. Oversecretion of thyroid hormones is usually associated with an enlarged thyroid gland known as a goiter. Goiter also commonly occurs with iodine deﬁciency.
    - - The thyroid gland invariably is enlarged to some extent. It is soft and may pulsate; a thrill often can be palpated, and a bruit is heard over the thyroid arteries. These are signs of greatly increased blood ﬂow through the thyroid gland. In advanced cases, the diagnosis is made on the basis of the symptoms, a decrease in serum TSH, increased free T4 and an increase in radioactive iodine uptake.
    - - Appropriate treatment of hyperthyroidism depends on theunderlying cause and often consists of a combination oftherapies, including antithyroid agents, radioactive iodine,and surgery. Treatment of hyperthyroidism is directed to-ward reducing thyroid hyperactivity to relieve symptomsand preventing complications.
- - - - The most common cause of hypoparathyroidism is inade-quate secretion of parathormone after interruption of theblood supply or surgical removal of parathyroid gland tissueduring thyroidectomy, parathyroidectomy, or radical neckdissection.
    - - Tetany
        numbness, tingling,and cramps in the extremities, and the patient complains ofstiffness in the hands and feet. In overt tetany, the signs in-clude bronchospasm, laryngeal spasm, carpopedal spasm(ﬂexion of the elbows and wrists and extension of the car-pophalangeal joints and dorsiﬂexion of the feet), dysphagia,photophobia, cardiac dysrhythmias, and seizures. Othersymptoms include anxiety, irritability, depression, and evendelirium. ECG changes and hypotension also may occur
    - - Deﬁciency of parathormone results in increased bloodphosphate (hyperphosphatemia) and decreased blood cal-cium (hypocalcemia) levels. In the absence of parathor-mone, there is decreased intestinal absorption of dietary cal-cium and decreased resorption of calcium from bone andthrough the renal tubules. Decreased renal excretion ofphosphate causes hypophosphaturia, and low serum calciumlevels result in hypocalciuria.
    - - A positive Trousseau’s sign or a positive Chvostek’s sign sug-gests latent tetany.
        Tetanydevelopsatserumcalciumlevelsof5to6mg/dL(1.2to1.5mmol/L)orlower.Serumphosphatelevelsareincreased,andx-raysofboneshowincreaseddensity.Calciﬁcationisdetectedonx-raysofthesubcutaneousorparaspinalbasalgangliaofthebrain
    - - The goal of therapy is to increase the serum calcium level to9 to 10 mg/dL (2.2 to 2.5 mmol/L) and to eliminate thesymptoms of hypoparathyroidism and hypocalcemia.
        Parenteral parathormone can be administered to treatacute hypoparathyroidism with tetany.
        Because of neuromuscular irritability, the patient withhypocalcemia and tetany requires an environment that isfree of noise, drafts, bright lights, or sudden movement.
        A diet high in cal-cium and low in phosphorus is prescribed.
    - - Care of postoperative patients who have undergonethyroidectomy, parathyroidectomy, or radical neckdissection is directed toward detecting early signs ofhypocalcemia and anticipating signs of tetany,seizures, and respiratory difﬁculties.•Calcium gluconate is kept at the bedside with equip-ment necessary for emergency IV administration. Ifthe patient requiring administration of calcium glu-conate has a cardiac disorder, is subject to dysrhyth-mias, or is receiving digitalis, the calcium gluconate isadministered slowly and cautiously.•Calcium and digitalis increase systolic contractionand also potentiate each other; this can produce po-tentially fatal dysrhythmias. Consequently, the car-diac patient requires continuous cardiac monitoringand careful assessment.An important aspect of nursing care is teaching aboutmedications and diet therapy. The patient needs to knowthe reason for high calcium and low phosphate intake andthe symptoms of hypocalcemia and hypercalcemia; he orshe should know to contact the physician immediately ifthese symptoms occur
  - - - Apathy, fatigue, muscle weakness, nausea, vomit-ing, constipation, hypertension, and cardiac dysrhythmias may occur. skeletal pain and tenderness, especially of the back andjoints; pain on weight bearing; pathologic fractures; defor-mities; and shortening of body stature.
    - - Radioimmunoassays, double-antibody parathyroidhormone test, Ultrasound, MRI, thallium scan, and ﬁne-needle biopsy
    - - Primary hyperparathyroidism occurs two to four timesmore often in women than in men and is most common inpeople between 60 and 70 years of age. Its incidence is ap-proximately 25 cases per 100,000 (Suliburk & Perrier,2007). The disorder is rare in children younger than 15years of age, but its incidence increases 10-fold between theages of 15 and 65 years. Half of the people diagnosed withhyperparathyroidism do not have symptoms.Secondary hyperparathyroidism, with manifestationssimilar to those of primary hyperparathyroidism, occurs inpatients who have chronic renal failure and so-called renalrickets as a result of phosphorus retention, increased stimu-lation of the parathyroid glands, and increased parathor-mone secretion.
    - - Surgical Management
        -Parathyroidectomy
        Hydration Therapy
        -Daily fluid intake of 2L or more
        Mobility
        -Walking or using a rocking chair to provide normal stress on the bones
        Diet/Medications
        -No diet with restricted or excess calcium
        -Prune juice, stool softeners, physical activity and fluid intake to help with constipation
    - - Excess parathormone can result in markedly increased levels of serum calcium, a potentially life-threatening situation.
        Hyperparathyroidism, which is caused by overproduction of parathormone by the parathyroid glands, is characterized by bone decalciﬁcation and the development of renal calculi(kidney stones) containing calcium.
    - - The insidious onset and chronic nature of hyperparathy-roidism and its diverse and commonly vague symptoms mayresult in depression and frustration. The family may haveconsidered the patient’s illness to be psychosomatic. Anawareness of the course of the disorder and an understand-ing approach by the nurse may help the patient and familydeal with their reactions and feelings.
        The nursing management of the patient undergoingparathyroidectomy is essentially the same as that of a patientundergoing thyroidectomy. However, the previously de-scribed precautions about airway patency, dehydration, im-mobility, and diet are particularly important in the patientwho is awaiting or recovering from parathyroidectomy. Al-though not all parathyroid tissue is removed during surgeryin an effort to control the calcium–phosphorus balance, thenurse closely monitors the patient to detect symptoms oftetany (which may be an early postoperative complication).Most patients quickly regain function of the remainingparathyroid tissue and experience only mild, transient post-operative hypocalcemia. In patients with signiﬁcant bonedisease or bone changes, a more prolonged period ofhypocalcemia should be anticipated. The nurse reminds thepatient and family about the importance of follow-up to en-sure return of serum calcium levels to normal
- - - - Measurements of urine and plasma levels of catecholamines and metanephrine are the most direct and conclusive tests for over activity of the adrenal medulla. A new test for detecting pheochromocytoma has recently been developed that measures free MN in plasma by high-pressure liquid chromatography and electrochemical detection. A negative test result virtually excludes pheochromocytoma. However, increased levels of at least one catecholamine or MN can occur in 10% of patients with essential hypertension. A clonidine suppression test may be performed if the results of plasma and urine tests of catecholamines are inconclusive. Imaging studies, such as CT, MRI, and ultrasonography,may also be carried out to localize the pheochromocytoma and to determine whether more than one tumor is present
    - - During an episode or attack of hypertension, tachycardia,anxiety, and the other symptoms of pheochromocytoma,bed rest with the head of the bed elevated is prescribed topromote an orthostatic decrease in blood pressure.
        Medications can also be used to control/lower blood pressure in the case that it is needed.
        The deﬁnitive treatment of pheochromocytoma is surgicalremoval of the tumor, usually with
        adrenalectomy. Bilateral adrenalectomy may be necessary if tumors are present in both adrenal glands.
    - - The nature and severity of symptoms of functioning tumors of the adrenal medulla depend on the relative proportions of epinephrine and norepinephrine secretion. The typical triad of symptoms is headache, diaphoresis, and palpitations in the patient with hypertension.
        Other symptoms may include tremor, headache, ﬂushing, and anxiety. Hyperglycemia may result from conversion of liver and muscle glycogen to glucose due to epinephrine secretion; insulin may be required to maintain normal blood glucose levels
    - - The patient who has undergone surgery to treat pheochromocytoma has experienced a stressful preoperative and postoperative course and may remain fearful of repeated attacks. Although it is usually expected that all pheochromocytoma tissue has been removed, there is a possibility that other sites were undetected and that attacks may recur. The patient is monitored for several days in the intensive care unit with special attention given to ECG changes, arterial pressures, ﬂuid and electrolyte balance, and blood glucose levels. Several IV lines are inserted for administration of ﬂuids and medications.
        During the preoperative and postoperative phases of care, the nurse informs the patient about the importance of follow-up monitoring to ensure that pheochromocytoma does not recur undetected. After adrenalectomy, use of corticosteroids may be needed. Therefore, the nurse instructs the patient about their purpose, the medication schedule, and the risks of skipping doses or stopping their administration abruptly.It is important to teach the patient and family how to measure the patient’s blood pressure and when to notify the physician about changes in blood pressure. In addition, the nurse provides verbal and written instructions about the procedure for collecting 24-hour urine specimens to monitor urine catecholamine levels.
    - - Pheochromocytoma may occur at any age, but its peak incidence is between 40 and 50 years of age affecting men and women equally.
    - - Pheochromocytoma is a tumor that is usually benign and originates from the chromafﬁn cells of the adrenal medulla.