PARATHYROID GLAND DISORDERS
The parathyroid glands secrete PTH. Aided by vitamin D, PTH regulates the amount of calcium and phosphorus in the blood and, thus, regulates bone formation.
Hyperparathyroidism
Hyperparathyroidism stems from an excess of PTH that causes blood calcium levels to rise, resulting in calcium depletion in bones (osteomalacia). Bones become soft and weak, leading to skeletal tenderness. They tend to break easily, even in the absence of pressure or injury (pathologic fractures). The skull may enlarge. Muscles weaken, and the client complains of fatigue, nausea, and constipation. Kidney stones, urinary tract infections, and uremia may develop. The person may become disoriented and paranoid and may lose consciousness. This condition may be secondary to chronic nephritis.
Hyperparathyroidism is detected by a consistently high blood level of parathormone and by x-ray indications of skeletal changes or pathologic fractures.
A diuretic agent, such as furosemide (Lasix), and large amounts of fluids are often given to prevent renal disorders such as stones, which develop because of the high blood calcium levels. Phosphates may be given cautiously to reduce the serum calcium level. A thyroid lobectomy to remove part of the thyroid gland containing the parathyroid may be done.
Preoperatively, encourage exercise to help prevent the bones from releasing some calcium. Calcium in the diet is limited in some cases. If tetany occurs postoperatively, calcium gluconate is given to restore the blood’s calcium-phosphorus balance.
Keep a tracheostomy tray and IV calcium at the bedside for emergency use. The postoperative diet is high in calcium, fat, and carbohydrate. The client needs special care to avoid injury until bones are recalcified.
Hypoparathyroidism
Hypoparathyroidism, the deficiency of PTH, results from lowered production of the hormone, with a consequent reduction in the amount of calcium available to the body and an accumulation of phosphorus in the blood. Accidental removal of the parathyroid glands during a thyroidectomy may cause hypoparathyroidism.
Lack of calcium causes tremors and tetany, the characteristic sign. Cardiac output decreases. A positive Trousseau’s sign (carpopedal spasm caused by blocking the blood flow to the arm for 3 minutes using a blood pressure cuff) or a positive Chvostek’s sign (twitching of the mouth, nose, and eye after tapping the area over the facial nerve just in front of the parotid gland and anterior to the ear) suggests latent tetany (see Fig. 79-3). This extreme muscular irritability may be so pronounced that laryngospasm or seizures occur. Other symptoms include hair loss, skin coarsening, brittle nails, arrhythmias, and possible heart failure.
Treatment is to increase the client’s serum calcium level. Calcium salts (calcium gluconate) must be given, usually intravenously (IV). (Never give calcium preparations intramuscularly [IM]; they injure tissues.) Large doses of vitamin D are also given because vitamin D helps regulate body calcium levels. Administration of sedatives or anticonvulsants may also be necessary in the acute phase of hypoparathyroidism (to prevent seizures). Client teaching about medications and the need for follow-up is important.
ADRENAL GLAND DISORDERS
The adrenal glands contain two parts: the cortex and the medulla. The cortex (outer covering) secretes various types of steroid hormones that control many vital functions. These hormones regulate metabolism to supply quick energy, help maintain fluid and electrolyte balance, and regulate the development of secondary sex characteristics. The medulla is stimulated by the sympathetic nervous system; it secretes the hormones epinephrine (adrenaline) and norepinephrine .
Cushing’s Syndrome
Cushing’s syndrome (hyperadrenalism) results from overproduction of hormones secreted by the adrenal cortex. It can also result from overuse of corticosteroids or tumors of the adrenal glands or the pituitary.
Fat distribution is abnormal. The face is rounded (“moon face”), the abdomen is heavy and hangs down, and the arms and legs are thin. There is a noted fat pad in the neck and supraclavicular area sometimes referred to as a “buffalo hump.” As the disease progresses, the client becomes weaker, the bones soften, and the client may have a backache. Edema develops and urinary output decreases. Hypokalemia (low blood potassium levels) is usually present. Hypernatremia (high blood sodium levels) and hyperglycemia (abnormally high blood glucose) follow. The client is hypertensive. Wounds do not heal, and the client bruises easily. Mood swings are common; the client may be irritable or euphoric. Striae may develop because of an enlarged abdominal girth.
If hyperadrenalism occurs in childhood, puberty starts early for boys. Girls develop masculine traits (e.g., hirsutism), owing to increased secretion of male sex hormones by the adrenal glands.
Nursing Alert Many young people, especially athletes, use large doses of steroids to enhance muscle development. This dangerous practice often leads to long-term disability and can be fatal. In addition to sexual dysfunction and heart dysrhythmias, the person is at risk for severe behavior problems. In some cases, the person becomes aggressive, loses touch with reality or shows manic symptoms.
Treatment
Treatment depends on the cause. Surgical removal of the adrenal gland may be indicated. Adrenocortical hormones are given as indicated. After surgery, the client is treated as for Addison’s disease. If the cause is pituitary in origin, various controversial methods of treatment are possible.
Nursing Considerations
Nursing care primarily is symptomatic. Institute measures to protect the client from injury and infection, such as monitoring and protecting skin integrity, promoting good hygiene, and removing or minimizing environmental hazards. Monitor the client’s weight daily and take vital signs frequently. Check electrolyte and glucose levels for changes.
Primary Aldosteronism
A rare condition of the adrenal cortex, primary aldosteronism is characterized by excessive secretion of aldosterone. Symptoms include hypertension and muscle weakness owing to low potassium levels. If tumors or excessive growth of the adrenal glands exist, surgery to remove the glands is the treatment of choice.
Addison’s Disease
Destruction or degeneration of the adrenal cortex causes a condition called Addison’s disease, a relatively rare disorder. Tuberculosis, cancer, or a massive infection can be the underlying cause, but in most cases, the gland atrophies (wastes away) for unknown reasons. It may be a secondary response to pituitary malfunction. In this case, the pituitary gland fails to produce ACTH in sufficient amounts; thus, adrenal function diminishes.
Signs and Symptoms
With Addison’s disease, the production of adrenal hormones decreases, resulting in fluid and electrolyte imbalances and hypoglycemia. In addition, thyroid function is abnormally low, with hyponatremia and hyperkalemia.
The first symptom is usually a darkening of the skin and oral mucous membranes so that the skin looks bronzed. Dehydration, anemia, and weight loss are seen. Blood pressure drops. The hair thins. Strain or stress of any kind may cause adrenal shock, with abnormally low blood pressure, nausea and vomiting, diarrhea, headache, and restlessness. Tremors and disorientation may arise, progressing to loss of consciousness and seizures.
Addisonian crisis occurs when adrenal function falls to a critically low point. This condition is marked by nausea, vomiting, weight loss, and extreme hypotension, leading to vascular shock, which can be fatal. A stressful situation is usually the precipitating factor.
Intravenous administration of hydrocortisone is the treatment of choice. In some cases, vasopressors, such as dopamine hydrochloride, are given to raise blood pressure. Salts (sodium and potassium ions) lost by vomiting are replaced in an IV solution of saline with added electrolytes. The exact solution and electrolyte content, to be given several times daily, are determined by the laboratory test results.
Treatment
Treatment consists of supplying needed hormones (fludrocortisone acetate [Florinef]) to restore normal fluid and electrolyte balance. Typically, the prescribed diet is high in protein and sodium and low in potassium.
Nursing Considerations
Because this client is dehydrated, fluid replacement is key. Because sodium loss results from previous hormone imbalance, sodium also must be replaced in the diet. Although water intake is restricted, increased sodium will aid in fluid retention without excess fluid intake. Rationale: Excess water overloads the system.
Five or six small meals per day may be prescribed, or the client may receive between-meal snacks of milk and crackers. Rationale: The person may be too weak to eat a large meal at one time. The diet is planned to combat dehydration.
Watch the person for dizziness or lowered blood pressure and protect him or her from falling. Accurately record all food and fluid intake, including the type and amount. Also document the volume and specific gravity of each voiding. Daily weights are important. Rationale: All these measurements help determine the body’s fluid and electrolyte balance. Therapy continues until these values are normal.
Client teaching is vital. Enlist the client’s cooperation and urge the client to maintain regular follow-up visits with his or her primary healthcare provider and avoid strain or stress, such as overwork, infection, or exposure to cold. By protecting his or her health, the client with Addison’s disease can do very well.
Key Concept The client should wear an identification tag with instructions for hormone dosage in case the prescribing physician cannot be contacted.
Adrenal Neoplasms
Pheochromocytoma is a tumor, usually benign, that originates in the adrenal medulla. A tumor of the adrenal medulla increases secretion of the hormones epinephrine and norepinephrine, which in turn causes extreme hypertension, tremor, headache, nausea and vomiting, dizziness, and increased urination. Treatment is surgical removal of the tumor—a dangerous operation because it may cause sudden and extreme changes in blood pressure. Before surgery, a 24-hour urine test (VMA test) will be ordered to confirm the diagnosis. In addition, a CT scan of the adrenal glands, along with IV pyel-ogram (IVP), may be used to locate the tumor. After surgery, a repeat 24-hour urine for VMA and catecholamines will be done to evaluate return-to-normal levels. If the client has a bilateral adrenalectomy, he or she must be treated for Addison’s disease postoperatively; adrenal hormones must be supplied artificially for life.
PANCREATIC ENDOCRINE DISORDERS
Hormonal disorders of the pancreas include hypoinsulinism and hyperinsulinism. Hyperinsulinism is not common, but it may be a precursor to hypoinsulinism. Lowered amounts, lack of, or ineffective use of insulin leads to the disorders of diabetes mellitus. Diabetes mellitus has various forms, including type 1 diabetes, type 2 diabetes, gestational diabetes, and impaired glucose tolerance or homeostasis. Understanding the various types, treatments, and implications of diabetes mellitus is critical for any healthcare provider. Table 79-3 looks at the basic concepts of type 1 and type 2 diabetes. Healthcare statistics are showing that the onset of type 2 diabetes is increasingly found in individuals younger than age 30.
TABLE 79-3. Type 1 and Type 2 Diabetes Mellitus
|
CONSIDERATION |
TYPE 1 |
TYPE 2 |
|
Typical age of onset |
Younger than 30 years |
Older than 30 years* |
|
Classic symptoms |
Nearly always present |
Usually not present |
|
Hereditary factors |
Occasionally present |
Usually present |
|
Weight |
Normal or underweight |
Usually overweight |
|
Susceptible to ketoacidosis |
Yes |
No |
|
Usual treatment |
Insulin, meal plan, exercise |
Meal plan, exercise, possibly oral medications or insulin |
*The "typical" age of onset is still unchanged but there is an increased number of individuals younger than age 30.
Diabetes Mellitus
Specialized cells of the pancreas produce a hormone called insulin to regulate metabolism. Without this hormone, glucose cannot enter body cells and blood glucose levels rise. As a result, the individual may begin to experience symptoms of hyperglycemia. Simply stated, this process is the development of diabetes mellitus.
Numbers have increased in recent years because so many Americans are overweight. Also, testing accuracy has improved, thus confirming more cases. The number of people with diabetes is expected to double as more people live to middle and old age.
Classification
• Type 1 (Formerly known as type I; insulin-dependent diabetes mellitus [IDDM]; or juvenile diabetes)
• Type 2 (Formerly known as type II; non-insulin-dependent diabetes mellitus [ ]; or adult-onset diabetes)
• Gestational diabetes mellitus (GDM): Occurring during pregnancy and disappearing on delivery; these women are susceptible to the development of diabetes mellitus (DM) later in life.
• Prediabetes is a term that refers to the condition of impaired glucose homeostasis (IGH) that occurs when blood glucose levels are higher than normal, but not high enough for the definitive diagnosis of diabetes mellitus. This condition may also be referred to as impaired fasting glucose (IFG) or impaired glucose tolerance (IGT). Prediabetes is considered a risk factor for future diabetes. It is often possible for individuals with prediabetes to delay or prevent the onset of type 2 diabetes with diet and lifestyle changes.
Diagnosis of prediabetes can be made by either the fasting plasma glucose test (FPG) or the oral glucose tolerance test (OGTT). These tests consist of the client fasting overnight with follow-up blood glucose monitoring (BGM) testing in the morning. The FPG consists of documenting the blood glucose level in the morning before eating. The OGTT consists of checking blood glucose levels in the morning with a follow-up test 2 hours after drinking a high glucose drink. Prediabetes is determined if the BGM falls between 100 and 125 mg/dL. The diagnosis of diabetes is considered if the level is above 126 mg/dL.
Signs and Symptoms
Diabetes can present a wide variety of signs and symptoms. Often clients have no symptoms; but, when present, they may include the three “polys”: polyuria (excessive urination), polydipsia (excessive thirst), and polyphagia (excessive hunger). Metabolic syndrome is a combination of at least three conditions that are commonly found in a prediabetic or diagnosed diabetic state. These symptoms include abdominal obesity, hypertension, high blood glucose, insulin resistance and/or dyslipidemia. Dyslipidemia (abnormal amounts of fat in the blood) may include low high-density lipoprotein (HDL), elevated cholesterol, and elevated triglyceride levels. Metabolic syndrome is associated with the complications of both type 1 and type 2 diabetes.
The classic symptoms of polyuria, polydypsia, and polyphagia are found more often in type 1 diabetes and come on rapidly.
Other signs and symptoms may include:
• Fatigue
• Blurred vision
• Mood changes
• Numbness and tingling in extremities
• Dry skin
• Infections (urinary tract, vaginal yeast infections)
• Weight loss (most often in type 1)
Type 1 Diabetes Mellitus
Type 1 diabetes results from destruction of the pancreatic beta cells because the beta cells of the pancreas have been damaged or destroyed by an autoimmune process. Research has shown an inherited tendency for developing the disease. Environmental factors, lifestyles, or unknown factors may contribute to triggering the disease. Idiopathic diabetes has developed spontaneously or without an identifiable cause.
When type 1 diabetes is diagnosed, the goal is to achieve metabolic stabilization, restore body weight, and relieve symptoms of hyperglycemia. Ongoing goals focus on achieving and maintaining normal metabolic functions and minimizing the negative impact of diabetes on the person’s life (see In Practice: Nursing Care Plan 79-1).
Type 2 Diabetes Mellitus
Type 2 diabetes can occur at any age. More than 80% of clients are overweight and do not always experience classic symptoms. The pancreas is often still functional at diagnosis, which means it still produces insulin. Levels may be normal, low, or elevated. The person may show decreased tissue sensitivity to insulin, called insulin resistance. Clients with type 2 diabetes do not depend on insulin injections to sustain life, but they may require insulin for adequate glucose control.
IN PRACTICE NURSING CARE PLAN 79-1
THE CLIENT WITH TYPE 1 DIABETES
Medical History: D.W, a 24-year-old male client, diagnosed with diabetes mellitus type 1 approximately 6 months ago, comes to the clinic for a follow-up visit. Fasting blood glucose this morning was 210 mg/dL. Vital signs are within acceptable parameters. Currently he is prescribed insulin twice daily, in the morning and before dinner with self-monitoring of blood glucose level before meals and at bedtime. Client states, "I forgot to check my blood and take my shot last night before dinner”
Medical Diagnosis: Diabetes mellitus, type 1, poorly controlled
DATA COLLECTION/NURSING OBSERVATION
Client is an active 24-year-old sales executive. He reports skipping meals several times a week. "When I’m on the road, I stop to get some fast food, like french fries and a milkshake.” He reports that he hasn’t been keeping a log of his blood glucose results. He stated, "I’m too busy and I don’t always have my monitor with me. So I forget.” History reveals that client performs self-monitoring of blood glucose levels on the average of once a day He states that he has been taking his insulin as prescribed, but does admit to forgetting insulin on the average of 1 to 2 times per week. "I can give myself the injection without a problem, I just can’t remember to do all these things.” (Although other nursing diagnoses may be appropriate, a priority nursing diagnosis is addressed below.)
NURSING DIAGNOSIS
Ineffective therapeutic regimen management related to lack of knowledge about control of blood glucose and difficulty integrating diabetes into daily activities as evidenced by client’s statements of skipping meals and insulin and being too busy.
PLANNING
Short-term Goals
1. Client will verbalize the importance of adhering to prescribed regimen.
2. Client will demonstrate understanding of interconnection of diet, activity insulin administration, and blood glucose monitoring in diabetes control.
Long-term Goals
3. Client will maintain a written log of insulin administration and selfmonitoring of blood glucose level, bringing it with him at next visit.
4. Client will demonstrate ability to integrate diabetes into his lifestyle.
IMPLEMENTATION
Nursing Action
Review underlying physiologic components of the disorder and rationale for specific monitoring activities. Rationale: Review of information reinforces the necessity and the reasons for adhering to the regimen. Nursing Action
Have client demonstrate techniques for insulin injection and selfmonitoring of blood glucose level. Rationale: Having the client demonstrate techniques provides an opportunity to evaluate the client’s ability to perform them adequately.
Nursing Action
Question client about usual activities for the day, including time spent in car on the road, at the office, and at home. Work with the client to develop a plan for the day that includes aspects of his diabetic regimen. Rationale: Determining the client’s usual activities helps to develop an individualized plan for this client. Working with the client provides the client an opportunity to participate in the plan, providing him with some feelings of control over the situation.
EVALUATION
Client states, "I didn’t realize that this disorder could really hurt me and that the insulin was so important.” Client able to demonstrate techniques for insulin injection and blood glucose monitoring without difficulty. Client reports that he carries an appointment topic with him at all times; appointment topic has a planning section with an area for "things to do.” Progress to meeting Goal 1.
Nursing Action
Discuss the correlation among diet, activity, and insulin. Reinforce the need for a well-balanced diet with periodic snacks. Rationale: Discussing the interconnection among diet, activity, and insulin helps to stress the need for adherence to the regimen.
Nursing Action
Offer suggestions for appropriate food choices when client is on the road. Enlist the aid of a dietitian to help with this. Rationale: Offering suggestions in conjunction with help from a dietitian provides the client with some alternatives and choices, enhancing his feelings of control over the situation.
EVALUATION
Client talking about ways to make sure he eats when out on the road. He stated, "I really need to take better care of myself. It’s going to be some work, but it is important to stay healthy.” Client will carry blood glucose monitor with him in his briefcase; will record glucose levels in appointment topic and bring to next visit. Goal 1 met; progress to meeting Goal 2 and Goal 3.
Nursing Action
Question client about ways he will use to monitor his diabetes. Provide feedback and direction as needed. Rationale: Having the client propose methods for monitoring promotes client participation in his care and provides a sense of control over the situation, thereby enhancing the chances for success and adherence.
EVALUATION
Client stating that he will take fresh fruit with him to work, and have some snacks readily available in the car when he is on the road; verbalizing appropriate food choices and times for insulin administration and blood glucose monitoring. Goal 2 met.
Nursing Action
Arrange for follow-up visit for client in 2 weeks, with phone call follow-up for review of log and activities in 4 days and at 1 week. Rationale: Follow-up provides a means for determining adherence to instructions and plan, and client’s ability to begin implementing the plan.
EVALUATION
Follow-up phone call on the fourth day: client reported using insulin twice each day and monitoring blood glucose twice the first day, three times the next, and four times the past 2 days; blood glucose values within acceptable ranges. Client reported appropriate food choices. He stated, "I haven’t stopped for any fast food since my visit.” Progress to meeting Goal 3 and Goal 4.
Risk factors for developing diabetes include heredity, obesity, age, stress, and lack of exercise. The individual with type 2 diabetes may have an inherited tendency to develop the disorder, which is triggered by environmental factors. (Type 2 diabetes carries about twice the heredity risk when compared with type 1.) The specific etiology of type 2 diabetes is yet unknown; however, autoimmune destruction of pancreatic beta cells does not occur. This type of diabetes develops more frequently in women with prior GDM and in individuals with metabolic syndrome.
Most clients with this form of diabetes are obese, and obesity itself can cause some degree of insulin resistance: The muscle cells of obese people are less responsive to insulin than are the muscle cells of thinner people, and most glucose breakdown occurs in the muscle cells. Without the normal response to insulin in the muscle cells, the cells cannot take up glucose, leading to increased glucose concentration in the bloodstream (high blood glucose, hyperglycemia).
Clients who are not obese may have an increased percentage of body fat in their abdominal regions. Ketoacidosis (see “Hyperglycemia” section) seldom occurs, but may arise in the presence of another illness. Type 2 diabetes can remain undiagnosed for many years. Because hyperglycemia develops gradually, clients may not notice any classic diabetes symptoms. However, they are at increased risk for development of macrovascular (large blood vessels) and microvas-cular (small blood vessels) complications, discussed later.
The major goals for treatment are to achieve metabolic control and to prevent vascular complications. Recommended treatment includes meal planning, an exercise program, weight loss, and medication, if needed. Weight management is a primary concern because losing as little as 5 to 10 pounds can significantly improve blood glucose control.
Key Concept In type 1 diabetes, insulin deficiency is absolute; insulin injections are necessary for survival. In type 2 diabetes, insulin deficiency ranges from insulin resistance with relative insulin deficiency to a predominantly secretory defect with insulin resistance.
