Endocrine Disorders

This section of Lesson is a review of the

many diseases and disorders affecting the
endocrine system.
NCLEX TIPS
 The endocrine system consists of organs or glands
that secrete hormones and release them directly
into the circulation.
 Think!
Is it? Hypersecretion or hyposecretion of
hormones from an organ or gland.
NCLEX TIPS
 When an excess of the hormone occurs, treatment
is aimed at blocking hormone release using
medication or surgery.
 Whena deficit of the hormone exists, treatment is
aimed at replacement therapy.
 Focus on the gland and think about its function, then
determine whether the condition is one that causes an
excess or a deficit of the hormone.
Disorders of the Pituitary Gland
Hypopituitarism
 Deficiency of one or more pituitary hormones.
 Depending on the disorder in question,
assessment may reveal obesity, infertility, sexual
dysfunction, fatigue, or low blood pressure.
 Nursing Considerations
 Treatment consists of replacing the deficient
hormone.
Disorders of the Pituitary Gland
Hyperpituitarism
 Involves hypersecretion of growth hormone.
 Affected individuals exhibit:
 Large hands and feet
 Thickened heel pads
 Thickening and protrusion of the jaw and coarsened
facial features
 Visual disturbances
 Organomegaly
 Enlarged but weak skeletal muscles
Nursing Considerations
Hyperpituitarism
 Treatment involves medication, hypophysectomy,
and radiation therapy.
 Ifsurgery is performed, take the appropriate
interventions.
Hypophysectomy:
Interventions
 Initiate postoperative care like that for client who has
undergone craniotomy.
· Complications include increased intracranial pressure (ICP),
bleeding, and meningitis.
· Monitor vital signs, neurological status, and level of
consciousness.
· Elevate the head of the bed.
· Monitor the client for postnasal drip, which may indicate
leakage of cerebrospinal fluid.
· Instruct the client to avoid sneezing, coughing, and
blowing the nose.
Hypophysectomy:
Interventions
Monitor electrolyte values and watch for temporary
diabetes insipidus caused by disturbances in the level of
antidiuretic hormone (ADH).
 Monitor intake and output and avoid water intoxication.
 Glucocorticoids, antibiotics, analgesics, and antipyretics
may be prescribed. Instruct the client in administration of
prescribed medications, which may include hormones and
glucocorticoids if the entire gland has been removed
Key Players: DI and SIADH
ADH- Antidiuretic hormone/vasopressin,
regulating amount of water in the body,
constricts blood vessels
Kidney= ADH causes renal tubules to retain
water
Hypothalamus- produces ADH, thirst center
Pituitary gland- anterior and posterior
Posterior P.gland= secrete and store ADH
Diabetes Insipidus
 Hyposecretion of antidiuretic hormone (ADH) and deficiency of
vasopressin.
 Causes: problem with the kidney, trauma to the brain, gestational
 Signs/symptoms include:
 Polyuria (4 to 20 L/day)
 Polydipsia

 Signs of dehydration
 Urine specific gravity of 1.005 or less
 Fatigue

 Muscle pain and weakness

 Postural hypotension
 Tachycardia
 Hypernatremia
Nursing Considerations
 Monitor electrolyte values and watch for signs of dehydration.
 Monitor intake and output, weight, and specific gravity of urine.
 Maintain adequate intake of fluids.
 Instruct the client to avoid foods or liquids that exert a diuretic
action.
 Aqueousvasopressin, or desmopressin acetate may be prescribed
when ADH deficiency is severe.
 Instruct the client to wear a MedicAlert bracelet.
 Diabinese: Increase ADH= hypoglycemia
 Desmopressin (Stimate)= ADH replacement
Syndrome of Inappropriate
Antidiuretic Hormone/SIADH
 Continued release of ADH/vasopressin
 Causes:Lung Cancer, damage to the hypothalamus, infection,
Diabinase(Chlorpropramide)= properties that increases ADH
 S/sx.
 Changes in the level of consciousness and mental status
 Weight gain
 Hypertension

 Tachycardia

 Anorexia, nausea and vomiting

 Hyponatremia= euvolemic hyponatremia
 Low urine output (concentrated)
Nursing Considerations
 Diuretics and intravenous (IV) fluids may be prescribed.
 Monitor
intake and output, paying attention to IV fluids
because of the risk for water intoxication.
 Weigh the client daily.
 Watch for signs of fluid-volume excess.
 Monitor fluid and electrolyte balances.
 Restrict fluid intake as prescribed.
 Declomycin(tetracycline family)= ADH inhibitor, DO
NOT give CALCIUM RICH FOODS.
Self-Check Question 1
 A nurse is reading the medical record of a client admitted to the
hospital with a diagnosis of diabetes insipidus. Which of these
signs/symptoms should the nurse expect to see documented in the
client's record? Select all that apply.
 1. Anuria
 2. Tachycardia
 3. Complaints of thirst
 4. Moist mucous membranes
 5. Complaints of muscle weakness
 6. Blood pressure of 168/98 mm Hg
Answer: 2, 3, 5
 RATIONALE: Diabetes insipidus is a disorder of
water metabolism caused by hyposecretion of ADH
and a deficiency of vasopressin. Signs/symptoms
include polyuria (5 to 20 L/day), polydipsia, signs
of dehydration, inability to concentrate urine and a
low urinary specific gravity of 1.006 or less,
fatigue, muscle pain and weakness, postural
hypotension and tachycardia.
Key players: Cushing’s and
Addison’s
 Adrenal Cortex= top of kidneys, releases steroid hormones
 Steroid Hormone: Aldosterone and cortisol
 Aldosterone= regulates BP thru RAAS, retains NA, secretes
K+
 Cortisol=stress hormone, increase glucose, breaks down
fats CHON, CHO and regulates electrolytes
 Hypothalamus= CRH (corticotropin release hormone)
 Pituitary = ACTH (Adrenocorticotropic hormone)
 ADRENAL CORTEX=CORTISOL
Disorders of the Adrenal Glands
Addison's Disease
 involves the hyposecretion of adrenal cortex hormones
(glucocorticoids=cortisol and mineralocorticoids=aldosterone).
 Autoimmune disorder due to CANCER/TB/TRAUMA.
 Affected individuals experience a host of issues:
 Lethargy
 Fatigue
 Muscle pain and weakness
 Joint pain
 Gastrointestinal (GI) disturbances
 Menstrual changes
 Impotence
 Weight loss
 Postural (orthostatic) hypertension
Disorders of the Adrenal Glands
Addison's Disease cont.
 Affected individuals experience a host of
issues:
 Hypoglycemia
 Hyperkalemia
 Hyponatremia
 Hypercalcemia

 Hyperpigmentation
Nursing Considerations
 Monitor vital signs (BP) weight, and intake and output.
 Monitor WBC count, electrolytes levels, blood glucose, and calcium.
 Glucocorticoids or mineralocorticoid medications may be
prescribed.
 Watch for Addisonian crisis resulting from stress, infection, trauma,
or surgery.
 Stress the need for lifelong glucocorticoid therapy.
 The client should be encouraged to wear a MedicAlert bracelet.
 Fludrocortisone (Florinef)=consume adequate NA
 Diet: high CHON, CHO, normal NA
Addisonian Crisis=adrenal gland crisis=
hasn’t taken’t he medication low doses

5S
 Sudden pain= abdomen back and legs
 Syncope
 Shock
 Super low blood pressure
 Severe vomiting, diarrhea, headache
 Treatment= IV cortisol ASAP= Solu-Cortef
 Start IV fluids
 Disorders of the Adrenal
Glands
Cushing's Syndrome
is a condition resulting from hypersecretion of
glucocorticoids/CORTISOL from the adrenal cortex.
 Cushing syndrome= an outside cause due to medical
treatment such as glucocorticoid therapy
 Cushing’s disease= inside source producing too much
CORTISOL= PITUITARY GLAND produces ACTH
 The affected individual exhibits a wide range of
signs and symptoms.
Nursing Intervention

Prep for hypophysectomy

Prep for adrenalectomy- if this is done
educate the patient about cortisol
therapy/hormone replacement therapy
Watch for blood glucose levels
Provide emotional support
Key Player: Pheochromocytoma
 Adrenal gland: R and L
 cortex= outer layer
 Adrenal medulla= middle layer, secrets the catecholamines, low
amount of dopamine in response to SNS
 Chromaffin cells= secretes catecholamines
 Catecholamines= how organs and tissues work, SNS stimulation
(increase fat metabolism, basal metabolic rate, high BP and HR,
high glucose, increase thermogenesis)
Disorders of the Adrenal Glands
Pheochromocytoma
 This catecholamine-producing tumor is usually found in the adrenal glands but may also
develop in the abdomen.
 hypersecretion of hormones of the adrenal medulla, epinephrine, and norepinephrine.
 The individual with a pheochromocytoma may experience:
 Hypertension
 Severe headaches
 Palpitations
 Flushing
 Profuse diaphoresis
 Pain in the chest or abdomen
 Nausea and vomiting
 Heat intolerance
 Weight loss
 Tremors
 Hyperglycemia
Triggers to signs and
symptoms
 Eating foods with tyramine=BP regulation
 Surgery
 Trauma
 Injury
 Emotional stress
 MAOIS
 DX: 24 hour urine= catecolamine, MRI and CT
scan
Nursing Considerations
 Monitor vital signs, particularly blood pressure.
 Watch for hypertensive crisis.
 Administer a β-adrenergic blocking agent, as prescribed,
to control hypertension.
 Adrenalectomy may be performed=pre op beta alpha
adrenergic blocker= hormone replacement therapy
 High Calorie diet, stop smoking, caffeine
Key Players: Adrenal Crisis
 Adrenal cortex: produces CORTISOL
 Pituitarygland: regulates CORTISOL, BY RELEASING THE
HORMONE ACTH (adrenocorticotropic hormone)= causing
release of cortisol
 CORTISOL= steroid hormone (glucocorticoid) stress hormone
Glucose metabolism, breaks fats, CHON, CHO, fats, elec
balance
Cause: damage to adrenal cortex, not taking the medications,
trauma, surgery, medications
Disorders of the Adrenal Glands
Addisonian Crisis/Adrenal Crisis

 Thislife-threatening disorder is caused by acute adrenal

insufficiency precipitated by stress, infection, trauma, or
surgery.
 Addisonian
crisis may result in hyponatremia,
hyperkalemia, hypoglycemia, and shock.
 Theaffected individual experiences severe headache;
severe abdominal, leg, and lower back pain; changes in the
level of consciousness; severe hypotension.
Nursing Considerations
 Prepare to administer IV glucocorticoids as prescribed (Solu-cortef)
 After resolution of the crisis, administer oral glucocorticoids and
mineralocorticoids as prescribed. (Prednisone=take religiously)
 Monitor vital signs, particularly the blood pressure.
 Monitor neurological status.
 Monitor intake and output.
 Monitor laboratory values, particularly sodium, potassium, and
blood glucose.
 Administer IV fluids as prescribed to restore electrolyte balance.
 Protect the client from infection.
 Restrict the client to bed rest and provide a quiet environment.
Self-Check Question 2
A nurse is reviewing the laboratory results of a
client with Addison's disease. Which finding should
the nurse expect to note?
 1. Calcium level of 8.6 mg/dL (2.15 mmol/L)
 2. Sodium level of 145 mEq/L (145 mmol/L)
 3. Potassium level of 5.5 mEq/L (5.5 mmol/L)
 4. Blood glucose level of 110 mg/dL (6.1 mmol/L)
Answer: 3
 RATIONALE; Laboratory testing in Addison's
disease reveals hypoglycemia, hyperkalemia,
hyponatremia, and hypercalcemia. The normal
blood glucose level ranges from 70 to 110 mg/dL.
The normal potassium level ranges from 3.5 to
5.0 mEq/L. The normal sodium level ranges from
135 to 145 mEq/L. The normal calcium level
ranges from 8.6 to 10 mg/dL.
Key Players: Hypothyroidism
 Thyroid:
produces thyroid hormones, metabolism, Btemp, growth
and development
 Thyroid cannot make T3, T4 without IODINE!!!
 T3,T4: burn calories, digestion (how fast), stimulate SNS,
increase BTEMP, HR, regulation of the TSH
 TSH:produced in anterior P gland= stimulates T3 and T4
production
 Hypothalamus- TRH(thyrotropin releasing hormone-anterior pit.
Gland- TSH- Thyroid hormones
 Parathyroid: calcium levels
Disorders of the Thyroid Gland
Hypothyroidism
 the under secretion of thyroid hormones (T3, T4), is characterized by a slowed metabolic rate.
Signs and symptoms . (slow and low= HYPO)
 Lethargy
 Fatigue
 Intolerance to cold
 Weight gain
 Dry skin and hair and loss of body hair
 Weakness, muscle aches, paresthesia
 Bradycardia
 Constipation
 Generalized puffiness and edema around eyes and face (myxedema)
 Forgetfulness, loss of memory
 Menstrual disturbances
 Cardiac enlargement
 Causes: women
 Hashimoto’s
Thyroiditis= MOST COMMON!
Autoimmune!
 Iodine deficiency( seafoods, egg, seaweeds)
 Tumor
Nursing Considerations
 Administer thyroid replacement.
 Instruct client to consume a low-calorie, low-cholesterol, low–saturated
fat diet.
 Provide a high-fiber diet and fluids to help prevent constipation.
 Provide a warm environment for the client.
 Avoid sedatives and opioids because of the client’s increased
sensitivity to these medications.
 Medications: Synthroid(take in am without food), Cytomel, Liotrix
 Monitor the client for signs of thyroid medication overdose,
characterized by tachycardia, restlessness, nervousness, and insomnia.
 Instruct the client to report chest pain immediately.
 Never stop medication abruptly= myedema coma
Disorders of the Thyroid Gland
Hyperthyroidism
Hypersecretion of thyroid hormone, is characterized by an increased
metabolic rate.
A common cause is Graves' disease, also known as toxic diffuse
goiter, autoimmune=PROTRUDING EYEBALLS
Assessment findings include: (HYPER) accelerated
rate
Enlarged thyroid gland
Cardiac dysrhythmias (e.g., tachycardia, palpitations)
Protruding eyeballs (exophthalmos)
Hypertension
Heat intolerance and diaphoresis
Weight loss
Diarrhea
Smooth, soft skin and hair
Nervousness and fine tremors of hands
Irritability and agitation
Personality changes and mood swings
Nursing Considerations
 Provide a cool, quiet environment.
 Weigh the client daily and provide a high-calorie diet.
 Avoid the administration of stimulants.
 Administerantithyroid medications as prescribed to block
thyroid production.
 Administer propranolol for tachycardia.
 Prepare the client for radioactive iodine therapy to destroy
thyroid cells or for thyroidectomy.
 Monitorfor Thyroid storm= exaggerated symptoms LIFE
threatening condition, had thyroidectomy
Medications:

 Anti-thyroid medication: stop T3 and T4

 Methimazole (Tapazole)= most commonly
used fewer side effect, cannot be used in
the 1st trimester.
 PTU-SAFE IN 1ST TRIMESTER= liver failure
s/e agranulocytosis, aplastic anemia
 Never stop abruptly! Same time each day.
Key Players: Myxedema Coma
 Thyroid gland- produces thyroid hormone
 Hypothalamus- TRH- anterior P. gland- TSH- thyroid
gland- T3 and T4
 Iodine- needed to release T3 and T4
 T3and T4= burn calories, digestion, stimulates SNS,
btemp, HR, BP
 Causes: risk factor: elderly women with
Hypothyroidism, illness, stress, medication (Lithium-
inhibits TSH release), sedatives, unreligious intake of
hormone replacement, thyroidectomy, hypothermia
Disorders of the Thyroid Gland
Myxedema Coma
 Result
of persistent low thyroid production that occurs in
Hypothyroidism .
 Assessment findings include:
 Hypotension

 Bradycardia

 Hypothermia- not just intolerance to cold

 Hyponatremia- increased ADH
 Hypoglycemia- decrease metabolism
 Respiratory failure
 Coma

 Myxedema
 Drowsy
Nursing Considerations
 Maintain a patent airway and institute aspiration precautions.
 Prepareto administer IV fluids, IV levothyroxine sodium, IV glucose,
and corticosteroids as prescribed.
 IVthyroid hormone- SYNTHROID- causes adrenal insufficiency by
increasing metabolism of glucocorticosteriods.
 Check the client’s temperature frequently.
 Monitor the blood pressure.
 Keep the client warm.
 Monitor the client for changes in mental status.
 Monitor electrolyte and glucose levels.
Key Player: Thyroid
Storm/Thyrotoxin crisis
 Thyroid gland- produces thyroid hormone
 Hypothalamus- TRH- anterior P. gland- TSH- thyroid gland-
T3 and T4
 Iodine- needed to release T3 and T4
 T3 and T4= burn calories, digestion, stimulates SNS,
btemp, HR, BP
 Causes: untreated/undiagnosed hyperthyroidism, illness,
stress, trauma, sepsis, DKA, surgery (thyroidectomy),
Graves disease, uncompliant with meds., meds like ASA,
radioactive Iodine.
Disorders of the Thyroid Gland
Thyroid Storm
 anacute, life-threatening condition, is uncontrollable
hyperthyroidism.
 Antithyroidmedications, beta-blockers, glucocorticoids,
and iodides are administered to the client before thyroid
surgery to prevent its occurrence.
The affected individual experiences:
Fever
Tachycardia
Systolic hypertension
Nausea, vomiting and diarrhea
Agitation, tremors, anxiety
Irritability,
agitation, restlessness, confusion,
and seizures as condition progresses
Delirium and coma
Nursing Considerations
 Maintain a patent airway and adequate ventilation.
 Administerantithyroid medications, sodium iodide solution,
propranolol, and glucocorticoids as prescribed.
 Tapazole (Methimazole)- do not use in 1 st trimester or PTU
(Propylthiouracil)= watch for agranulocytosis and thrombocytopenia.
 Iodidesolution (Lugol’s solution)- block secretion of thyroid hormone-
metal taste in the mouth
 Assess the client continually for cardiac dysrhythmias.
 Administer nonsalicylate antipyretics (Tylenol) as prescribed.
(Salicylates increase the level of free thyroid hormone.)
 Betablockers (Inderal)- do not give when there is asthma,
bronchospasm, caution in DM.
 Use a cooling blanket to lower the client’s temperature as prescribed.
Thyroidectomy
 Thyroidectomy is surgical removal of the thyroid gland.
Nursing Considerations
 Beforesurgery, instruct the client in how to perform
coughing and deep-breathing exercises and how to
support the neck when coughing and moving in the
postoperative period.
 Administer antithyroid medications, sodium iodide
solution, propranolol, and glucocorticoids as prescribed
before surgery to prevent thyroid storm.
 After surgery, perform the appropriate interventions:
 Monitor the client for respiratory distress.
 Have a tracheotomy set, oxygen, and suction at the bedside.
 Maintain the client in semi-Fowler position
 After surgery, perform the appropriate interventions:

 Monitor the surgical site for edema and signs of bleeding; check the
dressing anteriorly and at the back of the neck.
 Have the client limit talking and assess the degree of hoarseness.
 Monitor the client for laryngeal nerve damage, evidenced by
respiratory obstruction, dysphonia, high-pitched voice, stridor,
dysphagia, or restlessness.
 Be alert for signs hypocalcemia and tetany, which may result
from trauma to the parathyroid gland.
 Prepare to administer calcium gluconate as prescribed for tetany.
 Monitor the client for thyroid storm.
Signs of Tetany
 Chvostek sign
 Trousseau sign
 Wheezing and dyspnea (bronchospasm, laryngospasm)
 Dysphagia
 Numbness and tingling of the face and extremities
 Carpopedal spasm
 Visual disturbances (photophobia)
 Muscle and abdominal cramps
 Cardiac dysrhythmias
 Seizures
Self-Check Question 3
 Which interventions should the nurse include in the plan of care
for a client with hypothyroidism? Select all that apply.
 1. Providing a cool environment for the client
 2. Instructing the client to consume a high-fat diet
 3. Instructing the client about thyroid-replacement therapy
 4. Encouraging the client to consume fluids and high-fiber foods
 5.Instructing the client to contact the health care provider if
chest pain occurs
 6.Informing the client that radioactive iodine preparations may
be prescribed to treat the disorder
Answer: 3, 4, 5
 RATIONALE; The signs/symptoms of hypothyroidism are the result of
decreased metabolism caused by low levels of thyroid hormones.
Interventions are aimed at replacing the hormones and addressing
the signs and symptoms of decreased metabolism. The nurse
encourages the client to consume a balanced diet that is low in fat
for weight reduction and high in fluids and high-fiber foods to help
prevent constipation. The client is often intolerant of cold and
requires a warm environment. The client should be instructed to
notify the health care provider if chest pain occurs, because this
could be an indication of overreplacement of thyroid hormone.
Radioactive iodine preparations may be used to destroy thyroid
cells in the treatment of hyperthyroidism.
Key players:
Hypoparathyroidism
 Normal Ca: 8.6-10 mg/dl
 Normal Phosphate: 2.7-4.5 mg/dl
 LowCa stimulates release of PTH= INCREASED Ca level= kidneys will
reabsorb Ca, excrete phosphate, activate Vit. D- small intestine causes
reabsorption of Ca
 PTH-causes the bones to stimulate osteoclast= break down bones= bone
resorption= release of Ca in the blood- increase Ca level
 Causes:
destruction/manipulation of parathyroid gland- thyroidectomy,
treatment of cancer in the neck,
 Hypomagnesemia- inhibit PTH secretion
 Autoimmune
 Body resistant to parathyroid hormone
Disorders of the Parathyroid Gland
Hypoparathyroidism
 is insufficient secretion of parathyroid hormone (PTH) by the
parathyroid gland.
 The affected individual may experience:
 Hypocalcemia
 Hyperphosphatemia (phosphate binders give after meals) aluminum carbonate
 Numbness and tingling of the face
 Muscle cramps, including those of the abdomen or extremities
 Trousseau sign or Chvostek sign
 Hypotension
 Anxiety
 Irritability
 Depression
Nursing Considerations
 Watch for signs of hypocalcemia and tetany.
 Initiate seizure precautions.
 Place a tracheotomy set, oxygen, and suction equipment at the bedside.
 Prepare to administer IV calcium gluconate for hypocalcemia.
 Providea high-calcium (spinach, dairy), low-phosphorus diet soft drink,
meats, eggs).
 Calcium gluconate- can cause Digoxin toxicity
 Instructthe client in the use of calcium supplements- constipation, kidney
stones (flank pain)- interfere with the absorption of iron and thyroid hormone.
 Instruct the client in the use of vitamin D supplements.
 Instruct
the client in the use of phosphate binders to promote excretion of
phosphate through the GI tract.= take after meals aluminum carbonate
 Instruct the client to wear a MedicAlert bracelet.
 Natpara IV (PTH): s/e paresthesia, monitor Ca, GI issues.
Key Players:
Hyperparathyroidism
 Normal Ca: 8.6-10 mg/dl
 Normal Phosphate: 2.7-4.5 mg/dl
 LowCa stimulates release of PTH= INCREASED Ca level=
kidneys will reabsorb Ca, excrete phosphate, activate Vit. D-
small intestine causes reabsorption of Ca
 PTH-causes
the bones to stimulate osteoclast= break down
bones= bone resorption= release of Ca in the blood- increase
Ca level
 Causes:Primary: noncancerous adenoma (common),
hyperplasia, cancer growth
 Secondary:
chronic failure: overwork parathyroid,
hypocalcemia, vitamin D deficiency
Disorders of the Parathyroid Gland
Hyperparathyroidism
 is hypersecretion of parathyroid hormone by the parathyroid gland.
 The individual with hyperparathyroidism may exhibit:
 Hypercalcemia
 Hypophosphatemia
 Fatigue, muscle weakness
 Skeletal pain and tenderness
 Bone deformities resulting in pathological fractures
 Anorexia, nausea and vomiting, epigastric pain= gastrin acid level
 Weight loss
 Constipation
 Hypertension
 Cardiac dysrhythmias (short QT interval)
 Renal stones
 Frequent urination
Nursing Considerations
 Monitor the client for cardiac dysrhythmias.
 Monitor intake and output.
 Watch for signs of renal stones.
 Monitor the client for skeletal pain and move the client slowly and carefully.
 Encourage the consumption of fluids, low calcium, high phosphate
 Monitor the calcium and phosphorus levels.
 Diuretics, IV fluids, phosphates, or calcium chelators may be prescribed to lower
the calcium level.
 Notify the health care provider immediately if the calcium level decreases
precipitously and assess the client for muscle tingling and numbness and signs of
hypocalcemia.
 Prepare the client for parathyroidectomy- monitor Respitatory status= semi-
fowlers- drainage and swelling- trach set- monitor nerve damage (hoarseness of
voice, diff swallowing, speaking
Medications:
 Decrease the parathyroid hormone, calcium level
 Calcimimetics (Sensipar) mimic the role of calcium, give with
food
 Calcitonin- suppress osteoclast activity
 Loop diuretics – decrease CA level, inhibit CA resorption
 Biphosphonates (Aredia/Pamidronate or
Fosamax/Alendronate)- protect the bones from losing Ca in
the bones- take in an empty stomach, full glass of water, sit
for 30 minutes- can cause severe ulcers, wait for 30 minutes
before taking new medications.
Parathyroidectomy
In this procedure, one or more of the parathyroid glands is removed.

 Nursing Considerations
 Before surgery, monitor the client’s electrolyte, calcium, phosphate,
and magnesium levels and ensure that the calcium level is
decreased to near-normal.
 Inform the client that talking may be painful for a day or two after
surgery.
 Perform the appropriate postoperative interventions:
 Monitor the client for respiratory distress.
 Place a tracheotomy set, oxygen, and suction equipment at the bedside
 Position the client in a semi-Fowler position.
 Assess the neck dressing for bleeding; 1 to 5 mL of serosanguineous drainage
is expected.
Nursing Considerations

 Monitor the client for hypocalcemic crisis, evidenced by

tingling and twitching in extremities and face.
 Assessthe client for the Trousseau sign or Chvostek
sign, which may indicate the presence of tetany.
 Monitor the client for signs of laryngeal nerve damage
(e.g., hoarseness, persistent changes in voice pattern).
 Instruct
the client in the use of calcium and vitamin D
supplements.
Self-Check Question 4
A nurse is monitoring a client with
hyperparathyroidism for signs of hypocalcemia and
prepares to test the client for the Trousseau sign.
Which item should the nurse obtain to perform this
test?
 1. Cotton
 2. Tongue blade
 3. Reflex hammer
 4. Blood pressure cuff
Key Players: Diabetes Mellitus
 Glucose- sugar, cannot enter the cell without insulin stored in
the liver in the form of glycogen,
 Insulin-
regulates amount of glucose in the body, secreted in
the Beta cells of pancreas in the ISLE OF LANGERHANS
 Glucagon- works in the opposite of insulin, increasing blood
sugar, causes the liver to turn glycogen into glucose
 Liver-
sensitive to insulin levels in the body- cause the body to
absorb the extra glucose and turn it to glycogen.
 Increase BS- pancreas releases insulin- glucose enter the cells
 Low BS- pancreas will release glucagon-cause the liver to
release glycogen- glucose is released.
Causes:
Type 1- beta cells are destroyed- not related to
lifestyle, genetic, autoimmune ( thin,
young(children) ketone in the urine
Type 2- insulin resistant, pancreas keeps
secreting insulin – hyperinsulinemia (metabolic
syndrome)- related to lifestyle (overweight)
Gestational- pregnant
Diabetes Mellitus
 Disorder of impaired glucose intolerance and carbohydrate,
protein, and lipid metabolism resulting from insulin
deficiency.
 Increasedblood glucose level (normal is 70 to 110 mg/dL
(3.9 to 6.1 mmol/L)).
 Type 1 (nearly absolute deficiency of insulin) or type 2
(relative lack of insulin or resistance to the action of insulin);
oral hypoglycemics are usually prescribed for individuals with
type 2.
 The affected individual experiences polyuria, polydipsia,
and polyphagia; hyperglycemia; weight loss; blurred
vision; infections due to slow wound healing and vaginal
infections.
Pediatric Assessment Findings

 Failto grow at a normal rate and may experience

delayed maturation.
 Findings include headaches, stomach aches,
enuresis in a previously toilet-trained child, and
vaginitis in adolescent girls (caused by Candida,
which thrives in hyperglycemic tissue).
Nursing Considerations: Diet

 Consistency in timing and amount of food intake helps control the

blood glucose level.
 Recommendations of the American Diabetic Association
 CHO (45%) in a day – grain, potato, corn, cookies, soda, dry beans
 FAT (20%)- limit saturated fat, get monosaturated (avocados nuts,
 CHON (15-20%)- chicken, fish, beans, egg whites,
Pediatric Considerations
 The total number of calories= based on child's age and growth
expectations.
 Dietary intake should include three meals a day, eaten at
consistent intervals, plus a midafternoon carbohydrate snack and
a bedtime snack high in protein.
 Consistent intake of carbohydrates at each meal and snack is
necessary.
 Should carry a source of glucose, such as glucose tablets, always.
 Incorporate the child's needs, likes and dislikes, lifestyle, and
cultural and socioeconomic factors into the diet.
 Allow the child to participate in making food choices to provide a
sense of control.
Nursing Considerations:
Exercise
 Instruct the client in dietary adjustments that should be made when
the client is exercising.
 Aerobic exercise(helps body use insulin) cardio, walking, swimming-
check glucose before exercise= <100 mg/dl take snacks simple
carbs.
 Teach the client to check the blood glucose level before exercising; if
the client plans to participate in an extended period of exercise, the
blood glucose level should be checked before, during, and after
exercise.
 Initially the client who requires insulin should be instructed to eat a
15 g carbohydrate snack (a fruit exchange), or a snack of complex
carbohydrate with a protein before engaging in moderate exercise,
to help prevent hypoglycemia.
Nursing Considerations: Exercise
cont.
 Extrafood consumed during exercise to prevent
hypoglycemia need not be deducted from the regular
meal plan.
 Ifthe blood glucose level is greater than 250 mg/dL
(13.9 mmol/L) and urinary ketones are present, the
client should not exercise until the blood glucose is closer
to normal and ketones have disappeared from the urine.
Pediatric Considerations
 Helpthe child plan an appropriate exercise
regimen, considering the child's developmental
stage.
 Instruct
the child to check the blood glucose level
before exercising.
 Remind the child that extra food, usually 10 to 15 g
of carbohydrate for every 30 to 45 minutes of
increased activity, must be consumed.
Medications:
 Sulfonylureas(Glyburide, Glipezide, Diabenese, Amaryl,
generic names ends with “ides, zides, mides, rides.-
stimulate the beta cells to make insulin= hypoglycemia,
no alcohol= extreme hypoglycemia
 Meglitinides (end with “glinide” like Repaglinide) same
as above
 Take medication before food.
 Biguanides(Metformin/Glucophage) decrease liver storage of
glucose- held 48 hours prior to surgery- causes diarrhea
 Alpha-glucoside inhibitors (Precose, Glyset)- take with food
 Thiazolidinedione (TZDs) Glitazone, Actos) decrease glucose
production in the liver – watch for LFT.
Nursing Considerations:
Insulin
 All insulin is given SC except regular insulin (IV).
 Illness,infection, and stress increase the need for insulin;
insulin should not be withheld at these times, because
hyperglycemia and ketoacidosis may result.
 Instruct
the client to recognize symptoms of hypoglycemia
and hyperglycemia.
 Laboratory
evaluation of glycosylated hemoglobin
(HbA1c) should be performed every 3 months.
Nursing Considerations: Insulin
cont.
 When the client is being kept from eating or drinking for a special
procedure, verify with the health care provider the need to withhold
the morning insulin and determine when food, fluids, and insulin are
to be given.
 Instruct the client to always have a spare bottle of insulin available.
 Advise the client to obtain a Medic-Alert bracelet that indicates type
and daily dosage of insulin.
 Instruct the spouse, significant other, or parents in the
administration of intramuscular or subcutaneous glucagon for when
the client experiences a hypoglycemic reaction and is unable to
consume glucose-containing items orally.
Pediatric Considerations

 Dilutedinsulin may be required for some infants to

provide small enough doses to avoid
hypoglycemia; diluted insulin should be clearly
labeled to avoid dosage errors.
 Instruct
the child and parents in the age- and
development-appropriate administration of insulin.
 TYPE ONSET PEAK DURATION
RAPID (Humalog, 15 1 hour 3 hours
Novolog) minutes
 “15 minutes feels like an (1hour) hour during 3 rapid
responses”
Short- 30 2 hours 8 hours
acting/Regular minutes
(Humulin R,  “Short staff nurses went from 30 patient 2(to) 8
Novolin R) patients”
Intermediate 2 hours 8 hours 16 hours
(Humulin N,  “Nurses play hero 2(to) eight 16-year olds”
Novolin N)
Long-acting 2 hours No duration 24 hours
(Levemir, Lantus)  “The two (2) long nursing shifts never peak but
lasted 24 hours”
Nursing Considerations: Complications of
Insulin Therapy Lipodystrophy and
Lipohypertrophy
 Lipodystrophy as a result of repeated insulin injections,
appears as slight dimpling or pitting of subcutaneous fat;
the use of human insulin helps prevent this complication.
 Lipohypertrophy= development of fibrous fatty masses at
the injection site, is caused by the repeated use of an
injection site; rotating injection sites will help prevent this
complication.
Injection Site Rotation
Nursing Considerations: Complications
of Insulin Therapy
Dawn Phenomenon

 isa result of reduced tissue sensitivity to insulin

and, possibly, nocturnal release of growth hormone,
resulting in an increase in the blood glucose level
between 5 and 8 AM
 Treatment includes an evening dose (or an
increase in a current dose) of intermediate-
acting insulin around 10 PM.
Nursing Considerations: Complications of Insulin
Therapy
Somogyi Phenomenon
a normal or increased blood glucose level is present at
bedtime, a decrease to the hypoglycemic range occurs at 2
to 3 AM, and a subsequent increase occurs as a result of
production of counterregulatory hormones; by 7 AM,
hyperglycemia is present.
 Treatmentincludes decreasing the evening (predinner or
bedtime) dose of intermediate-acting insulin or ensuring
consumption of an appropriate snack at bedtime.
Considerations: Self-
Monitoring of Blood Glucose
 Self-monitoring provides the client with the current blood glucose level and
information to maintain good glycemic control.
 Monitoring requires a finger prick to obtain a drop of blood for testing.
 Alternative site testing (obtaining blood from the forearm, upper arm,
abdomen, thigh, or calf) is now available with the use of specific
measurement devices.
 Testing must be performed with caution in the client with diabetic neuropathy.
 Tell the client to follow the manufacturer’s instructions for using the
glucometer.
 Tell the client that if the blood glucose reading does not seem reasonable, he
or she should reread the instructions, reassess technique, check the
expiration date of test strip, and perform the procedure again to verify the
finding.
Skin Sensor and Insulin Pump
A skin sensor is a device that monitors the client's
blood glucose continuously; the information is
transmitted to the pump, determines the need for
insulin, and then the insulin is injected.
 Thepump holds up to a 3-day supply of insulin and
can be easily disconnected for activities such as
bathing.
Nursing Considerations: Urine
Testing
Urine testing for glucose is not a reliable indicator of the
blood glucose level and is not used for monitoring
purposes, but the presence of ketones may indicate
impending diabetic ketoacidosis.
 Urineketone testing should be performed whenever a
diabetic client is ill and whenever the client with type 1
diabetes mellitus has persistently increased blood glucose
readings (i.e., higher than 240 mg/dL (13.3 mmol/L) for
two consecutive testing periods).
Acute Complications:
Hypoglycemia
 Blood glucose level of less than 70 mg/dL (3.9
mmol/L), is caused by a too-large dose of insulin or
oral hypoglycemic agent, too little food, or excessive
activity.
 Initialsymptoms include hunger, weakness, shakiness,
irritability, sweating, palpitations, and headache;
untreated, hypoglycemia becomes more severe.
 IM SWEATY COLD AND CLAMMY, GIVE ME SOME CANDY.
Nursing Considerations
Instruct the client to always carry some form
of fast-acting simple carbohydrate, such as
glucose tablets;
High-fat foods slow the absorption of
glucose.
Nursing Considerations
 Ifthe client is hospitalized, the nurse should immediately
check the client’s blood glucose level and then give the
client 10 to 15 g of carbohydrate; the client’s vital signs
are checked, and the blood glucose rechecked in 15
minutes.
 Once symptoms have resolved, a snack containing protein
and carbohydrate (e.g., milk or cheese and crackers) is
recommended unless the client plans to eat a regular
meal within 60 minutes.
Self-Check Question 5
A nurse provides instructions to a client with type 1
diabetes mellitus about home care measures to treat
hypoglycemia. The nurse determines that the client
understands the instructions if which statement is
made?
 1. I will eat six saltine crackers
 2. I will call the health care provider
 3. I will report to the emergency department
 4. I will take an additional dose of regular insulin
Answer: 1
 RATIONALE; Hypoglycemia is the term used to describe a blood glucose
level below 70 mg/dL. If hypoglycemia is suspected, the client should
obtain a glucose reading immediately. The client must consume a
substance that contains 10 to 15 g of carbohydrates — for instance,
commercially prepared glucose tablets, six to 10 Life Savers or other
hard candies, 4 teaspoons of sugar, four sugar cubes, 1 tablespoon of
honey or syrup, a half-cup of fruit juice or regular (nondiet) soft drink, 8
oz of low-fat milk, six saltines, or three graham crackers. Administering
regular insulin will lower the blood glucose. It is not necessary to notify
the health care provider or to report to the emergency department for
a single episode of hypoglycemia. The client should, however, contact
the health care provider if hypoglycemia were to persist or
hypoglycemic episodes were frequent.
Key Players: DKA
 Glucose- fuels the cell with energy, in DKA glucose is not
being used= absence of insulin – more than 300 mg/dl
 Insulin- takes glucose into the cell…DKA no insulin
 Liver and glucagon- body attempts to use glucose stores in
the liver
 Ketones- a byproduct of fat breakdown- body decides to use
fats- metabolic acidosis
 Kidneys- reabsorption of glucose of kidney- leakage of
glucose in urine- osmotic diuresis- polyuria and Na, K, and Cl.
 KDA mainly occurs in Type 1 DM
Acute Complications: Diabetic
Ketoacidosis
 Thislife-threatening complication develops when severe
insulin deficiency= burning of fats and ketones breakdown.
 Hyperglycemia, Ketones, Acidosis
 Cause: decreased or missed dose of insulin, illness or
infection, or undiagnosed or untreated diabetes mellitus.
(Type I)
 Thecondition proceeds rapidly and must be treated
promptly.
Diabetic Ketoacidosis cont.
 Assessment findings include:
 Polyuria- osmotic diuresis
 Polydipsia
 Dry skin
 Nausea
 Abdominal pain
 Acetone breath (fruity odor)
 Ketones in blood
 Kussmaul respirations
 Lethargy that progresses to coma
 Blood glucose concentration greater than 300 mg/dL
Nursing Considerations
 Dehydration is treated with an IV infusion of 0.9% or
0.45% normal saline solution; dextrose is added to IV
fluids when the blood glucose concentration reaches an
appropriate level as a means of preventing hypoglycemia.
 Hyperglycemia is treated with IV regular insulin.
 Electrolyte
imbalances are treated; the potassium level
may be increased as a result of dehydration and acidosis.
 Monitorthe potassium level closely; when the client
receives treatment for dehydration and acidosis, the
serum potassium level will decrease, and potassium
replacement may be required.
Key player: HHNS seen in
Type 2
 Blood sugar more than 600 mg/dl- causes the blood to become
hyperosmolar- fluids shift to the intravascular
 No breakdown of fats= no ketones
 Glucose- fuels the cell with energy body resistant to insulin
 Insulin-takes glucose in the cells, body has enough of this.
 Kidneys-reabsorb glucose in the renal tubules- leaks to the
urine- osmotic diuresis- polyuria- dehydration
 Cause: illness, infection in older adults
 Happens gradually- warning signs (high BS, polyuria,
polydipsia
Acute Complications: Hyperglycemic Hyperosmolar
Nonketotic Syndrome (HHNS)
 Thiscomplication is like diabetic ketoacidosis except that
ketosis or acidosis is not present. (no breakdown of ketones)
 It
occurs most often in individuals with type 2 diabetes
mellitus.
 S/sx:
 Hyperglycemia (more than 600)
 Polyuria
 Polydipsia
 Dehydration
 Mental status changes
Nursing Considerations
 Treatment is like that for diabetic ketoacidosis.
 Insulinplays a less critical role in treatment than for
the treatment of diabetic ketoacidosis because enough
insulin is present to prevent the breakdown of fats for
energy, preventing ketosis.
 Isotonic
solution (0.9 Saline), progress to hypotonic
(hydrate the cells)
 Insulin drip (Regular insulin IV)- causes K to move to cells
K solution
Self-Check Question 6
 The school nurse receives a telephone call from a physical
education teacher, who says that a student with diabetes
mellitus is feeling shaky and weak. Which action should the
nurse tell the teacher to take immediately?
 1. Laying the student on the floor
 2. Staying with the student until the nurse arrives
 3.Giving the student a glass of orange juice or non-diet
soda
 4.Calling for an ambulance to bring the student to the
emergency department
Answer: 3
 RATIONALE: Exercise can cause the blood glucose level to drop.
Shakiness and weakness are signs of a hypoglycemic reaction in a
diabetic client. A hypoglycemic reaction is treated promptly with a
substance that contains 10 to 15 g of carbohydrates — for instance,
commercially prepared glucose tablets, six to 10 Life Savers or other
hard candies, 4 teaspoons of sugar, four sugar cubes, 1 tablespoon of
honey or syrup, a half-cup of fruit juice or regular (non-diet) soft drink,
8 oz of low-fat milk, six saltines, or three graham crackers. If the
symptoms are not relieved in 15 minutes, the treatment is repeated.
Laying the student on the floor, staying with the student until the nurse
arrives, and calling for an ambulance would each delay necessary
interventions. There is no need to call an ambulance at this time.
Chronic Complications: Diabetic
Retinopathy
 Chronic, progressive noninflammatory impairment of retinal
circulation may eventually cause hemorrhage and result in
blindness.
 Vision
impairment makes it difficult for the client to perform
blood glucose testing and administer insulin injections.
 Assessment findings in the client with diabetic retinopathy
include changes in vision (resulting from ruptured vessels),
blurred vision (macular edema), sudden loss of vision
(resulting from retinal detachment), and cataracts.
Nursing Considerations
 Take steps to maintain the client’s safety.
 Early
prevention involves controlling hypertension
and blood glucose levels.
 Surgical
procedures may be performed to remove
hemorrhagic tissue as a means of reducing scarring
and decreasing tension on the retina, preventing
detachment.
 Cataract removal may be performed.
Chronic Complications: Diabetic
Nephropathy
Diabetes results in a progressive decrease in kidney
function.
 Assessment findings include:
 Microalbuminuria

 Thirst

 Fatigue

 Weight loss
 Anemia

 Signs of malnutrition
 Frequent urinary tract infections
 Signs of neurogenic bladder
Nursing Considerations
 Early prevention measures—control of hypertension and
the blood glucose level—are crucial.
 Monitor the blood urea nitrogen and creatinine levels and
watch for albuminuria.
 Implement measures to limit dietary protein, sodium, and
potassium.
 Nephrotoxic medications should be avoided.
 Ifthe condition becomes severe, the client may require
dialysis.
Chronic Complications: Diabetic
Neuropathy
 Diabetesleads to general deterioration of the nervous
system, with such complications as the development of
nonhealing ulcers of the feet, gastric paresis, and erectile
dysfunction.
 Symptoms vary, depending on the body system involved,
but include paresthesias, diminution or absence of
peripheral pulses, vomiting after meals, diarrhea or
constipation, incontinence, impotence, dyspareuria, skin
breakdown and signs of infection.
Nursing Considerations
 Earlyprevention measures—control of hypertension and
the blood glucose level—are crucial.
 Foot care is also important.
A bladder training program may be prescribed.
 Estrogen-containing lubricants may be prescribed for
female clients with dyspareunia.
 Penileinjections or implantable devices may be prescribed
for the impotent male client.
 Prepare for surgical decompression of compression lesions
related to cranial nerves as prescribed.
Preventive Foot Care Measures
 Inspect the feet daily and be alert for redness, swelling, and skin
breakdown.
 Notify the health care provider if redness or a break in the skin
occurs.
 Avoid thermal injuries from hot water, heating pads, and baths.
 Wash the feet with warm (not hot) water and a mild soap, then dry
thoroughly (avoid foot soaks).
 Refrain from self-treating corns, blisters, or ingrown toenails.
 Avoid crossing the legs or wearing tight garments that might
constrict blood flow.
 Apply moisturizing lotion to feet (but not between the toes).
Preventive Foot Care Measures
 Keep moisture from accumulating between the toes.
 Wearloose socks and well-fitting (not tight) shoes, and
avoid going barefoot; check shoes for foreign objects or
cracks or tears in the lining before putting them on.
 Wearclean cotton socks daily to keep the feet warm and
change socks daily.
 Avoid
open-toed shoes and any shoe with a strap that goes
between the toes.
 Break in new shoes gradually.
 Trim
toenails straight across and smooth nails with an
emery board.
Diabetes Mellitus
Nursing Considerations: During
Illness
 The client should take insulin or oral antidiabetic
medications as prescribed.
 Instructthe client to test the blood glucose every 3 to 4
hours and test the urine for ketones at each voiding.
 Ifthe usual meal plan cannot be followed, the client should
instead eat soft foods six to eight times a day.
 Diabetes Mellitus
Nursing Considerations: During Illness
 Ifvomiting, diarrhea, or fever occurs, the client should
consume liquids every half-hour to an hour to prevent
dehydration and provide calories.
 Instruct the client to notify the health care provider if
vomiting, diarrhea, and fever persist; if the blood glucose
level is consistently higher than 250 to 300 mg/dL (13.9 to
16.7 mmol/L); if ketonuria is present for more than 24 hours;
if food or fluids cannot be taken for 4 hours; or when illness
persists for more than 2 days.
Pediatric Considerations
 The parent should always give insulin even if the child
does not have an appetite or contact the health care
provider for specific instructions.
 The blood glucose level should be tested at least every 4
hours.
 The urine should be tested for ketones with each voiding.
 Instruct the parents to follow the child's usual meal plan.
 Liquids should be given to help prevent dehydration and
clear ketones.
Pediatric Considerations
 The child should rest, especially if urine ketones are
present.
 Instruct the parents to notify the health care provider if the
child is vomiting; has fruity-smelling breath; exhibits deep,
rapid respirations or a decreasing level of consciousness;
moderate or large amounts of urinary ketones are present;
or persistent hyperglycemia occurs.
Nursing Considerations: Surgical
Care
Before Surgery
 Check with the surgeon regarding the need to withhold
oral antidiabetic medications or insulin; some long-acting
oral antidiabetic medications are discontinued 24 to 48
hours before surgery, and the insulin dose may be
adjusted or withheld if intravenous (IV) insulin
administration during surgery is planned.
 Check the blood glucose level.
 Administer IV fluids as prescribed.
 After Surgery
 Check the blood glucose level frequently.
 Administer IV infusions and insulin as prescribed
until the client can tolerate oral feedings.
 Remember that the diabetic client is at risk for
cardiovascular and renal complications and
impaired wound healing.
Self-Check Question 7
 The nurse provides instructions to a client with type 1
diabetes mellitus with regard to foot care. The nurse
determines there is a need for further teaching if the
client makes which statement?
 1. I will inspect my feet daily
 2. I will walk barefoot only at home
 3. I will wash my feet with warm water and a mild soap
 4.I will check my shoes for foreign objects before putting
them on
Answer: 2
 RATIONALE: In clients with diabetes mellitus, minor foot problems
may progress to major problems, in some cases severe enough
to necessitate amputation. Many foot problems can be prevented
with proper foot care. The client is instructed not to walk
barefoot, even at home. Inspecting the feet daily, using warm
water and a mild soap to wash the feet, and checking shoes for
foreign objects before putting them on are all appropriate foot
care measures for the diabetic client. The client should also avoid
thermal injuries from hot water, heating pads, and baths; prevent
moisture from accumulating between the toes; wear socks to
keep the feet warm and change them daily; and trim toenails
straight across and smooth nails with an emery board.
 Metabolic and
Endocrine Disorders
Fever
 abnormally high body temperature.
A child's temperature may vary with activity, emotional
stress, type and amount of clothing being worn, and
environmental temperature.
 Assessment findings associated with fever provide
important indications of its seriousness; findings include:
A temperature of 100.4° F (38.0° C) or higher
 Flushed skin
 Diaphoresis

 Chills

 Restlessness or lethargy
 temp 100.4F (38.0° C)
Nursing Considerations
 Monitor the child’s temperature per agency policy.
 Administer antipyretics (e.g., acetaminophen or ibuprofen) as prescribed.
 Do not administer aspirin (acetylsalicylic acid, ASA) unless prescribed,
because it may precipitate the development of Reye syndrome.
 Retake the temperature 30 to 60 minutes after an antipyretic is
administered.
 Provide adequate fluid intake as tolerated and as prescribed.
 Monitor the child for dehydration and fluid and electrolyte imbalances.
 Instruct the parents in how to take the temperature, how to safely
medicate the child, and when it is necessary to call the health care
provider.
Dehydration
 Infantsand children are more vulnerable to fluid-
volume deficit than are adults because more of a
child’s body water is in the extracellular fluid
compartment and because the organs that conserve
water are immature.
 Causesinclude decreased fluid intake, diaphoresis,
vomiting, diarrhea, diabetic ketoacidosis, and
extensive burns or other serious injuries.
 Assessment findings depend on the severity of
dehydration:
 Dry skin and mucous membranes
 Loss of skin elasticity and turgor
 Tachycardia

 Sunken eyeballs and fontanels

 Weight loss
 Decreased urine output and increased urine specific gravity
 Thirst

 Absence of tears
 Changes in the level of consciousness
Nursing Considerations
 Monitor the child for signs of dehydration.
 Provideoral rehydration therapy with solutions, as
prescribed, if the child is able to tolerate fluids orally.
 Administerintravenous fluids and electrolyte replacements,
as prescribed, if the child is unable to take sufficient fluids
orally.
 Introduce
a regular diet as prescribed when the child is
rehydrated.
 Provide instructions to the parents about the types and
amounts of fluid to be encouraged, signs of dehydration, and
indications of the need to notify the health care provider.
Growth Hormone (GH)
Deficiency
 Growth hormone (GH) deficiency results from inadequate
production or secretion of GH, causing poor growth and
short stature.
 Hypoglycemia may be a manifestation of GH deficiency.
 Signs/symptoms typical of GH deficiency include height
less than 5th percentile for age and gender, diminished
growth rate (less than 2 standard deviations below the
mean for age and gender), immature or cherubic facies
and delayed puberty.
Nursing Considerations
 Administerreplacement therapy; synthetic growth
hormone comes in a powdered form that must be diluted
for administration or a premixed liquid form.
 Adminster synthetic growth hormone as a subcutaneous
injection six or seven times per week, usually at bedtime.
 Educatechildren and families about the proper dilution and
administration of the growth hormone.
 Remind the child and parents that growth hormone therapy
is continued until the child reaches an acceptable adult
height or radiographic evidence shows growth plate fusion.
Phenylketonuria
 This genetic disorder, also known as PKU, causes central
nervous system damage, the result of accumulation of a
toxic level of phenylalanine in the blood (normal level is
1.2 to 3.4 mg/dL (72.6 to 205.8 mcmol/L) in newborns
and 0.8 to 1.8 mg/dL (48.4 to 109.0 mcmol/L)
thereafter).
 All50 U.S. states require routine screening of newborn
infants for PKU (PKU testing is universally offered but not
required in any Canadian province or territory except
Saskatchewan.)
 Assessment findings vary with the age of the child.
Nursing Considerations

 The newborn should be screened for PKU (formula or

breast feeding should be started before specimen
collection).
 Theinfant is rescreened by 14 days of age if the initial
specimen was collected before 48 hours of age.
If PKU Is Diagnosed

 Restrictphenylalanine intake; high-protein foods (meats

and dairy products) and grains are avoided.
 Monitorphysical, neurological, and intellectual
development.
 Stressthe importance of follow-up treatment to the
parents.
Self-Check Question
 The nurse provides instructions to the parent of a child
who is restricted to a low-phenylalanine diet. Which foods
should the nurse tell the parent are acceptable to give the
child? Select all that apply.
 1. Meat
 2. Eggs
 3. Pears
 4. Pasta
 5. Apples
 6. Cheese
Answer: 3, 4, 5

 RATIONALE; In a low-phenylalanine diet, the child

must avoid high-protein foods such as meats, fish,
eggs, cheese, milk, and legumes. Because protein
is also present in grains, low-protein breads,
cereals, and pasta are used. Vegetables and fruits
are also acceptable foods to consume.
CNS DRUGS
Endocrine Medications: Nursing
Considerations
 Growth hormones may increase the blood glucose level.
 Provideteaching to the client who has been prescribed
thyroid hormones for hypothyroidism.
 Instructthe client to take the medication with a full glass of water
1 hour before consuming any other fluid or food.
 Teach the client how to monitor the pulse rate.
 Advise the client to report symptoms of hyperthyroidism (e.g.,
chest pain, palpitations or tachycardia, excessive sweating).
 Instruct the client to avoid foods that can inhibit thyroid secretion
(e.g., peaches, pears, strawberries, Brussels sprouts, cabbage,
cauliflower, kale, peas, radishes, spinach, turnips).
Endocrine Medications: Nursing
Considerations
 Provide teaching, including information on THYROID STORM.
 Instruct the client to take the medication with meals to avoid GI upset.
 Advise the client to contact the health care provider in the event of a
fever or sore throat, which may be a sign of agranulocytosis, an
adverse effect of the medication.
 Instructthe client to be alert for signs of iodism: vomiting, abdominal
pain, metallic taste in the mouth, rash, and sore salivary glands.
 Advise the client to avoid foods and substances that contain iodine
(e.g., seafood, acetylsalicylic acid).
 Tellthe client that abruptly stopping the medication could cause
thyroid storm and discuss the signs (e.g., fever, flushed skin,
tachycardia, confusion, behavioral changes).
Endocrine Medications: Nursing
Considerations
 Hyperparathyroidism results in a high serum calcium level and
bone demineralization; medication is used to decrease serum
calcium.
 Hypoparathyroidism results in a low serum calcium level, which
increases neuromuscular excitability; treatment includes calcium and
vitamin D supplements.
 Instruct the client receiving oral calcium to maintain adequate intake of
vitamin D, which enhances the absorption of calcium.
 Glucocorticoids and corticosteroids alter the normal immune response
and suppress inflammation, promote sodium and water retention and
potassium excretion, can mask the signs and symptoms of infection,
and are used with caution in clients with diabetes mellitus because
they increase blood glucose. Client teaching tips are found here.
Endocrine Medications: Nursing
Considerations
 Androgens can cause bleeding (if the client is taking an oral
anticoagulant), hepatotoxicity, and a reduced serum glucose
level, thereby reducing insulin requirements in the client with
diabetes mellitus.
 Educate
the client on the formulation and use of
hormonal contraceptives.
 The nurse should provide the client taking fertility medication
with information about the increased potential for multiple
births and tell her to notify the health care provider if she
experiences signs of ovarian stimulation (e.g., abdominal
pain, distention).
Client Teaching for Hormonal
Contraceptives
 Hormonal contraceptives contain a combination of
estrogen and a progestin or a progestin alone.
 Contraceptivesare contraindicated in women with
hypertension, thromboembolic disease, cerebrovascular or
coronary artery disease, estrogen-dependent cancers, and
pregnancy and are to be avoided with the use of
hepatotoxic medications.
 Informthe client that if she decides to become pregnant,
an alternative form of birth control should be used for 2
months after discontinuation to ensure more complete
excretion of hormonal agents before conception.
Client Teaching for Hormonal
Contraceptives
 Tellthe client to follow the directions for use of the
prescribed contraceptive.
 Inform the client (as appropriate) that certain antibiotics
and anticonvulsants decrease the absorption and
effectiveness of the contraceptive.
 Instruct
the client not to smoke while taking contraceptives
because of the risk for thrombosis.
Self-Check Question
A client has been prescribed levothyroxine. The
nurse should instruct the client to take the
medication by which procedure?
 1. With food
 2. At bedtime
 3. With a snack at 3 p.m.
 4. In the morning, on an empty stomach
ANSWER: 4

 RATIONALE: Levothyroxine should be taken on an

empty stomach to enhance its absorption. The daily
dose should be taken in the morning, 1 hour before
breakfast. Therefore, the remaining options are
incorrect.
Self-Check Question
 Oral prednisone, 10 mg/day, has been prescribed for a
hospitalized client with a history of type 1 diabetes
mellitus for the treatment of an acute exacerbation of
asthma. The nurse should monitor the client closely for
which occurrence?
 1. Signs of hypoglycemia
 2. Signs of hyperglycemia
 3. The need to decrease the prescribed daily insulin dose
 4.The need to change the prescribed daily insulin to an
oral hypoglycemic medication
ANSWER: 2
 RATIONALE: Because of their effect on glucose production
and utilization, glucocorticoids can increase the plasma
glucose level, causing hyperglycemia and glycosuria.
Clients with diabetes mellitus may need to increase the
dosage of insulin or oral hypoglycemic medications
during treatment with a glucocorticoid. Decreasing the
prescribed insulin dose, needing to change the prescribed
insulin to an oral hypoglycemic medication, and watching
for signs of hypoglycemia are all therefore incorrect.
Blood Glucose Regulators
 Insulin
increases glucose transport into cells and promotes
conversion of glucose to glycogen, lowering the serum
glucose level.
 Oralhypoglycemic agents stimulate the pancreas to
produce more insulin and increase the sensitivity of
peripheral receptors to insulin, thereby decreasing the
serum glucose level.
 Useof hypoglycemic medications together with ß-
adrenergic blocking agents masks signs and symptoms of
HYPOGLYCEMIA
 Sulfonylureas,used to treat diabetes mellitus, can affect
cardiac function and oxygen consumption and lead to
cardiac dysrhythmias; they can also cause the type of
reaction triggered by disulfiram when the client ingests
alcohol.
 Glucagon, which increases blood glucose by stimulating
glycogenolysis in the liver, is used to treat insulin-induced
hypoglycemia in the client who is semiconscious or
unconscious and unable to ingest liquids; the blood
glucose level begins to increase within 5 to 20 minutes of
administration.
Oral Hypoglycemic
Medications
 Thesemedications are prescribed for clients with
type 2 diabetes mellitus.
 Hypoglycemia may occur if an excessive dose is
administered or if meals are omitted or delayed,
food intake is decreased, or activity is increased.
Nursing Considerations

Inform the client taking an oral hypoglycemic

agent that insulin may be needed during
times of stress, surgery, or infection.
Educate the client about the signs of
hypoglycemia and hyperglycemia
Insulin
 Insulin is prescribed for clients with type 1 diabetes mellitus.
 Nursing Considerations
 The client must be taught how to store insulin (insulin vials and
insulin pens).
 Discuss injection-site protocol with the client.
 Tohelp prevent dosing errors, be certain that the insulin
concentration noted on the vial matches the calibration of units
on the insulin syringe; the usual concentration of insulin is Units
100 (100 units/mL).
 Most insulin syringes have a 27- to 29-gauge needle,
approximately 0.5 inch (1.3 cm) long.
Nursing Considerations
 Roll (never shake, which produces bubbles) the insulin bottle to ensure that
the insulin and other ingredients are mixed well; otherwise, an inaccurate
dose will be drawn.
 Administer a mixed dose of insulin within 5 to 15 minutes of preparation;
after this time the rapid/short-acting insulin binds with the NPH insulin and
its action is reduced.
 Aspiration is generally not recommended with self-injection of insulin.
 Administer insulin with the needle at a 45- to 90-degree angle (45- to 60-
degree angle in thin persons) to the skin.
 Regular insulin may be administered intravenously.
 The client must be taught about all aspects of self-administration of insulin.
 The client and family should be taught how to administer glucagon if a
hypoglycemic reaction occurs.
Storing Insulin
 Exposure to extremes in temperature is avoided; insulin
should not be frozen or kept in direct sunlight.
 Before injection, insulin should be room temperature.
 Ifa vial of insulin will be used up in a month, it may be kept
at room temperature; otherwise, the vial should be
refrigerated.
 Unopened insulin vials or insulin pens must be kept
refrigerated; once the vial or pen is opened, it may be kept
at room temperature (with the date and time of the vial's or
pen's opening noted).
Storing Insulin cont.
A 3-week supply of insulin may be prepared in
syringes for those clients who have difficulty
drawing up an accurate dose of insulin and kept in
the refrigerator; prefilled syringes should be kept
flat or with the needle in an upright position to
help prevent clogging.
Injection Sites
 The main areas for injection are the abdomen, arms (posterior
surface), thighs (anterior surface), and hips.
 Insulin injected into the abdomen may be absorbed more evenly
and rapidly than it is at other sites.
 Systematic rotation within one anatomical area is recommended to
prevent lipodystrophy; the client should be instructed not to use
the same site more than once in a 2- to 3-week period.
 Injections should be made 1.5 inches apart.
 Heat, massage, and exercise of the injected area may increase the
rate of absorption, resulting in hypoglycemia.
 Injection into scar tissue may delay absorption.
Mixing NPH and Rapid/Short-Acting
(Regular) Insulin in the Same Syringe
Step 1: Verify the health care provider’s prescription and be certain
that the insulin concentration noted on the insulin bottle matches the
calibration of units on the insulin syringe. Clean the rubber stopper on
the NPH insulin bottle with alcohol or other agency-approved solution.
Inject a volume of air equal to the prescribed amount of insulin into the
NPH insulin bottle. (A vacuum makes it difficult to draw up the insulin.)

Step 2: Clean the rubber stopper on the rapid/short-acting (regular)

insulin bottle and inject a volume of air equal to the prescribed amount
of insulin into the regular insulin bottle.
Mixing NPH and Rapid/Short-Acting
(Regular) Insulin in the Same Syringe
cont.
 Step 3: Invert the regular insulin bottle and draw
up the prescribed amount of insulin.

Step 4: Clean the rubber stopper on the NPH

insulin bottle with alcohol or other agency-
approved solution. Invert the NPH insulin bottle and
draw the prescribed amount into the syringe
Self-Check Question
A nurse has taught a client with type 1 diabetes mellitus
how to draw up and mix the prescribed dose of NPH insulin
20 units and regular insulin 6 units. Which action should
the client take first to perform this procedure correctly?
 1. Drawing up the NPH insulin
 2. Drawing up the regular insulin
 3. Putting 20 units of air into the NPH insulin bottle
 4. Putting 6 units of air into the regular insulin bottle
Answer: 3
 RATIONALE: When the prescribed treatment calls for the
administration of both NPH and regular insulin, it is
desirable to mix the two types rather than inject them
separately, because this eliminates the need for a second
injection. To prepare a mixture of NPH and regular insulin,
the client should first add the air to the NPH insulin bottle,
then add air to the regular insulin bottle, invert the bottle,
and draw up the dose of regular insulin. The client would
draw up the NPH insulin second.