NCLEX: Care of the Client with Endocrine Disorders

Care of the Client with Endocrine Disorders: Diabetes Mellitus

Focus topic: Care of the Client with Endocrine Disorders

There are two types of diabetes: type 1 and type 2. Type 1, also called insulin-dependent diabetes mellitus (IDDM) or juvenile-onset diabetes, is a condition where the islets of Langerhans in the pancreas do not produce needed insulin. Insulin is necessary for food to be metabolized. Antibodies have been found in the majority of clients with type 1 diabetes. These antibodies are proteins in the blood that are part of the client’s immune system. It is believed that type 1 diabetes is in part genetically transmitted from parent to child.

At stressful times in life, such as when infection is present, pregnancy or environmental toxins might trigger abnormal antibody responses that result in this autoim- mune response. When this happens, the client’s body stops producing insulin. Type 1 diabetes tends to occur in young, lean individuals, usually before 30 years of age; however, it can occur in older individuals. These individuals are referred to as latent autoimmune diabetes in adults (LADA). Diabetes occurs in about 6% of Caucasians, 10% of African Americans, 20–50% of Native Americans, and 15% of Hispanics.

Type 2 diabetes was referred to as non–insulin-dependent, adult-onset diabetes mellitus (ADDM). However, in recent years, more and more children have been diagnosed with ADDM. This trend can be attributed to obesity and sedentary lifestyle. In ADDM, the cells of the body, particularly fat and muscle cells, become resistant to insulin. This leads to increased insulin production with increased insulin resistance.

Tests have also shown that this increased insulin resistance leads to a steady decline in beta cell production further worsening glucose control. This problem along with gluconeogenesis, a process in which the liver continues to produce glucose, leads to further hyperglycemia, metabolic acidosis, and deterioration of the client’s health.

Signs and symptoms associated with diabetes mellitus include

  • Weight loss: Insulin is required for carbohydrates to be converted into useable glucose; a lack of insulin results in a lack of glucose with cellular starvation.
  • Ketonuria: The breakdown of fats leads to the production of ketones that causes characteristic fruity breath.
  • Polyphagia: Cellular starvation causes the diabetic to increase food consumption.
  • Polyuria: The kidneys attempt to regulate pH by increasing urinary output of ketones and glucose.
  • Polydipsia: The loss of large amounts of fluid leads to metabolic acidosis and dehydration. To compensate for the fluid loss, the client drinks large amounts of water.
  • Delayed wound healing: Increased blood sugar contributes to poor wound healing.
  • Elevated blood glucose: Normal is 70–110 mg/dl. Uncorrected or improperly managed diabetes mellitus leads to coma and death.

Diagnosis of diabetes mellitus is made by checking blood glucose levels. Several diagnostic tests that can be performed to determine the presence and extent of diabetes are as follows:

  • Glucose tolerance test: The glucose tolerance test is the most reliable diagnostic test for diabetes. Prior to the glucose tolerance test, the client should be instructed to eat a diet high in carbohydrates for three days and remain NPO after midnight the day of the test. The client should come to the office for a fasting blood glucose level, drink a solution high in glucose, and have the blood tested at one and two hours after drinking the glucose solution (glucola) for a test of glucose in the serum. A diagnosis of diabetes is made when the venous blood glucose is greater than 200 mg/dl two hours after the test.
  • Fasting blood glucose levels: The normal fasting blood glucose is 70–110 mg/dl. A diagnosis of diabetes can be made if the fasting blood glucose level is above 140 mg/dl or above on two occasions. A blood glucose level of 800 mg/dl or more, especially if ketones are present, indicates a diagnosis of hyperosmolar hyperglycemic nonketoic syndrome (HHNKS).
  • Two-hour post-prandial: Blood testing for glucose two hours after a meal.
  • Dextrostix: Blood testing for glucose.
  • Glycosylated hemoglobin assays (HbA1c): The best indicator of the average blood glucose for approximately 90–120 days. A finding greater than 7% indicates non-compliance.
  • Glycosylated serum proteins and albumin levels: Become elevated in the same way that HbA1c does. Because serum proteins and albumin turn over in 14 days, however, glycosylated serum albumin (GSA) can be used to indicate blood glucose control over a shorter time.
  • Urine checks for glucose: Ketonuria occurs if blood glucose levels exceed 240 mg/dl.
  • Antibodies: Checked to determine risk factors for the development of type 1 diabetes. Measurement of the cells’ antibodies can also determine the rate of progression to diabetes.

Management of the client with diabetes mellitus includes the following:

  • Diet: The diet should contain a proper balance of carbohydrates, fats, and proteins.
  • Exercise: The client should follow a regular exercise program. He should not exercise if his blood glucose is above 240 mg/dl. He should wait until his blood glucose level returns to normal.
  • Medications: Oral antidiabetic agents or insulin. Medications used to treat diabetes mellitus include sulfanylurea agents, alpha-glucosidase inhibitors, nonsulfanylurea agents, D-phenylalanine derivatives, and thiazolidinediones. Insulins are also used to treat clients with type 1 diabetes. Insulin can be administered subcutaneously, intravenously, or by insulin pump. An insulin pump administers a metered dose of insulin and can provide a bolus of insulin as needed. Byetta is an injectable medicine used to improve blood sugar control in adults with type 2 diabetes. This drug can be used with metformin (Glucophage) or other sulfonylureas.
Care of the Client with Endocrine Disorders

Care of the Client with Endocrine Disorders: Hyperglycemia

Focus topic: Care of the Client with Endocrine Disorders

When there is lack of the hormone insulin, the glucose can’t move from the outside of the cell to the inside of the cell where it can be used. It is very important that the nurse be aware of the signs of hyperglycemia to teach the client and family. Signs and symptoms of hyperglycemia are as follows:

  • Headache
  • Nausea/vomiting
  • Coma
  • Flushed, dry skin
  • Glucose and acetone in urine
Care of the Client with Endocrine Disorders

Care of the Client with Endocrine Disorders: Hypoglycemia

Focus topic: Care of the Client with Endocrine Disorders

When there is a lack of glucose, cell starvation occurs. This results in hypoxemia and cell death. Signs and symptoms of hypoglycemia are as follows:

  • Headache
  • Irritability
  • Disorientation
  • Nausea/vomiting .
  • Diaphoresis
  • Pallor
  • Weakness
  • Convulsions
Care of the Client with Endocrine Disorders

Care of the Client with Endocrine Disorders: Managing Hyperglycemia and Hypoglycemia

Focus topic: Care of the Client with Endocrine Disorders

Management of hypoglycemia includes giving glucose. Glucagon, a 50% glucose solution, is an injectable form of glucose given in emergency. Cake icing, orange juice, or a similar carbohydrate can be administered if the client is still conscious. The best bedtime snack is milk and a protein source, such as peanut butter and crackers. Fluid and electrolyte regulation is also a part of the treatment of both hyperglycemia and hypoglycemia.

Unchecked hyperglycemia leads to microangiopathic and macroangiopathic changes. These lead to retinopathies, nephropathy, renal failure, cardiovascular changes, and peripheral vascular problems.

 Care of the Client with Endocrine Disorders: Adrenal Gland

Focus topic: Care of the Client with Endocrine Disorders

The adrenal gland is a vascular gland located at the top of the kidney. It comprises the cortex (outer portion) and the medulla (inner portion). The action of the adrenal gland consists of production of mineralocorticoids that help control the body’s levels of minerals such as sodium and potassium. Glucocorticoids, androgens, and estrogens are made in the zona fasciculata and zona reticularis. The cortex produces the adrenal steroids and corticosteroids.

The major mineralocorticoid produced in the cortex is aldosterone. As previously discussed, this mineralcorticoid helps to control reabsorption of sodium and potassium that the kidneys excrete. Other regulatory mechanisms controlled by the cortex are renin and adrenocorticotropic hormone (ACTH). The most prominent glucocorticoid secreted by the adrenal cortex is cortisol. This hormone helps to regulate the body’s stress response, metabolism of food, emotional stability, and the immune response. Small amounts of androgens and estrogen are secreted by the adrenal cortex.

Care of the Client with Endocrine Disorders

Adrenal Gland

The adrenal medulla is a sympathetic nerve ganglion that stimulates the sympathetic nervous system. This stimulation results in elevations in catecholamines such as norepinephrine and epinephrine. These chemicals help to control response to stress. The “fight or flight” response results in changes in pulse rate, blood pressure, and central nervous system response.

Care of the Client with Endocrine Disorders: Adrenal Gland Disorders

Focus topic: Care of the Client with Endocrine Disorders

Adrenal disorders result in many problems. Some of these include fatigue, weakness, suppression of the immune response, muscle and bone loss, and many others. This section covers some of the most common types of adrenal disorders along with their causes and treatments.

Care of the Client with Endocrine Disorders: Primary Aldosteronism (Conn’s Syndrome)

Focus topic: Care of the Client with Endocrine Disorders

Conn’s syndrome is a disease of the adrenal glands that involves an excessive production of aldosterone. The most common reasons for development of Conn’s syndrome are a tumor of the adrenal gland or benign hyperplasia of the adrenal gland, but the syndrome can also be related to use of thiazide diuretics or high levels of angiotensin II caused by poor renal perfusion.

Signs and symptoms of Conn’s syndrome include an elevated serum sodium level, decreased potassium serum levels, and hypertension with a related headache. Positive Trousseau’s and Chvostek’s signs might be present. Diagnosis of Conn’s is made by checking the serum levels for sodium and potassium and aldosterone levels. X-rays, CT scans, and an MRI confirm the presence of tumors.

Treatment includes a low-sodium diet, potassium supplementation, and control of hypertension. Spironolactone (Aldactone)—a potassium-sparing diuretic—is prescribed to lower aldos- terone levels and lower blood pressure. Surgical intervention is done when tumors are identified. Prognosis is good if the client is accurately diagnosed. If the client fails to receive an accurate diagnosis, the disease can lead to a stroke, heart attack, or renal disease.

Pheochromocytoma is a catecholamine-producing adrenal tumor that leads to a marked elevated blood pressure. Treatment includes treatment of malignant hypertension with drugs such as sodium nitroprusside (Nipride) or clonidine (Catapres). Removal of the tumor primarily corrects the hypertension. The client’s blood pressure must be stabilized prior to surgery. This is usually done by administration of an alpha- adrenergic–blocking agent such as phenoxybenzamine hydrochloride (Dibenzyline).

Care of the Client with Endocrine Disorders: Adrenocortical Insuffiency (Addison’s Disease)

Focus topic: Care of the Client with Endocrine Disorders

Addison’s disease can occur as a result of long-term use of steroids or the rapid cessation of corticosteroids. It can also be caused by sepsis, surgical stress, or hemorrhage of the adrenal glands (Waterhouse-Friderichsen syndrome).

Signs and symptoms associated with Addison’s disease include

  • Weakness.
  • Bronze-like pigmentation of the skin.
  • Decreased glucose levels.
  • Decreased blood pressure.
  • Anorexia.
  • Sparse axillary hair.
  • Urinary frequency.
  • Depression.
  • Addisonian crises. The symptoms of Addisonian crises are severe hypotension, cyanosis, and shock. This constitutes an emergency situation. The nurse should call the doctor immediately to obtain orders for medications to treat shock.

Diagnosis of Addison’s disease involves an evaluation of serum sodium and chloride levels. Evaluation of ketosteroids and 17-hydroxycorticoids is also done. Adrenal func- tion is evaluated by administering adrenocorticoid-stimulating hormone (ACTH) and checking for changes in cortisol levels.

Management of the client with Addison’s disease includes the use of intravenous cortisone and plasma expanders to achieve and maintain the blood pressure. When stable, the client can be given intramuscular cortisol in the form of dexamethasone (Decadron) or orally in the form of prednisolone (Prednisone). The client with Addison’s disease requires lifelong maintenance with cortisone. The client should be instructed to take the medication exactly as prescribed and to avoid sudden cessation of the drug.

Care of the Client with Endocrine Disorders: Adrenocortical Hypersecretion (Cushing’s Disease)

Focus topic: Care of the Client with Endocrine Disorders

The terms Cushing’s disease and Cushing’s syndrome are often used interchangeably although they are not the same. Cushing’s syndrome or primary Cushing’s syndrome can be caused by tumors of the adrenal cortex. Secondary Cushing’s syndrome (Cushing’s disease) often is caused by pituitary hypothalamus or adrenal cortex problems that result in an increased ACTH (adrenocorticotropic hormone). Long-term administration of glucocortidoids or iatrogenic Cushing’s syndrome will also produce elevated levels of cortisole and symptoms associated with hypersecretion.

Diagnosis is made by checking serum cortisole, calcium, potassium, sodium, and glucose levels. Altered ACTH and 17 ketosteroid levels are also seen with Cushing’s. A positive ACTH suppression test can be performed to check for changes in cortisole levels when ACTH is administrated.

Signs and symptoms associated with Cushing’s disease include

  • Pendulous abdomen
  • Buffalo hump
  • Moon faces
  • Hirsutism (facial hair)
  • Ruddy complexion (dark red)
  • Increased BP
  • Hyperglycemia
  • Osteoporosis
  •  Decreased serum potassium and decreased serum chloride
  •  Increased 17-hydroxycorticoids
  •  Decreased eosinophils and decreased lymphocytes

Management of the client with Cushing’s is accomplished by removing the cause— hyperplasia of the gland. Surgery can be required. A low-sodium diet, regulation of fluid and electrolytes, and administration of a potassium-sparing diuretic such as aldactone (Spironalactone) help to decrease the symptoms. Because elevated glucose levels are common in the client with Cushing’s syndrome, the client often requires frequent checks of glucose levels and administration of insulin or oral antidiabetic medications.

Care of the Client with Endocrine Disorders
Care of the Client with Endocrine Disorders
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