Endocrine Disorders

ENDOCRINE DISORDERS

·         Diabetes Mellitus (DM)

·         Poly cystic ovarian syndrome (PCOD)

·         Hyperthyroidism

·         Hypothyroidism

1.   Diabetes Mellitus (DM)

Diabetes mellitus is a metabolic disorder characterized by hyperglycemia (raised blood sugar level) and results from the defective insulin production, secretion, or utilization.

Types of DM

·            IDDM: Insulin dependent diabetes mellitus

·            NIDDM: Non-Insulin dependent diabetes mellitus

Causes

·            Lack of insulin produced by the beta cell resulting in hyperglycemia

·            Defects of the cell receptor site, impaired secretary response of insulin (glyconeogenosis)

·            Viral, Autoimmuno, and environmental theories are under review (IDDM)

·            Heredity/genetics and obesity plays a major role (NIDDM)

Signs and Symptoms

Diagnosis

·            Fasting Blood sugar (FBS)

·            Post Prandial Blood sugar (PPBS)

·            HbA1c

Management

·            Diet

·            Exercise

·            Medication.

·            Health education.

Diet:

·           Dietary control with calorie restriction of carbohydrates nd saturated fats are to maintain ideal body weight

·           Advise patient about the importance of an individualized meals plan in meeting weight loss goals

·           Explain the importance of exercise in maintaining / reducing body weight. Calorie expenditure for energy in exercise

·           Strategise with the patient to address the potential social pitfalls of weight reduction

Exercise:

Weight reduction is the primary management for NIDDM regular scheduled exercise to promote the utilization of carbohydrate, assist with weight control, enhance the action of insulin, and improve cardio vascular fitness.

Medication:

·           Oral hypoglycaemic agents for patient where NIDDM do not achieve glucose control with diet and exercise only

·           Insulin therapy for patients with IDM who require replacement. (May also be used for NIDDM when unresponsive to diet, exercise and oral hypoglycaemic agent therapy. Hypoglycemic may result, as well as rebound hyperglycaemic effect

·           Demonstrate and explain thoroughly the procedure for insulin self-injection

·           Help [patient to master technique by taking a step-by-step approach

·           Allow patient time-to-time handle insulin and syringe to become familiar with the equipment

·           Teach self-injection first to alleviate fear from injection

·           Instruct patient in filling the syringe when he or she expresses confidence in self-injection procedure

·            Review dosage and time injections in relation to meals activity, and bedtime based on patient’s individualized insulin regimen

Health Education:

Preventing  injury          secondary to Hypoglycemia:

1.        Closely monitor blood glucose levels to detect hypoglycaemia.

2.        Asses patient for the signs and symptoms of hypoglycaemia.

3.        Sweating, cardiac palpitation and nervousness.

4.        Head ache, light-headedness,. Confusion, irritability, slurred speech, lack of co-ordination staggering gait from depression of central nervous system as glucose level progressively falls.

5.        Treat hypoglycaemia promptly with 10-15 gms of fast acting carbohydrates.

6.        Half-cup juice, 3 glucose tablets, 4 sugar cubes, 5-6 pieces of sugar candy may be taken orally.

7.        Encourage patient to carry a portable management for hypoglycaemia at all times.

8.        Encourage patients to wear an identification bracelet opr card that may assist in prompt management in a hypoglycaemia emergency.

9.        Identification bracelet may be obtained from Medic Alert Foundation.

10.   Identification card may be requested from the Indian Diabetes Association.

11.   Between meal snacks as well as extra food taken before exercise should be encouraged to prevent hypoglycaemia.

Improving activity tolerance:

·           Advice patient to asses blood glucose level before strenuous exercise.

·            Advice patient that prolonged strenuous exercise may require

·            increased food at bedtime to avoid nocturnal hypoglycaemia.

·           Instruct patient to avoid exercise whenever blood glucose levels exceeds 250 mgs per day.

Providing information about oral hypoglycaemic agents:

·           Identify any barriers to learning, such as visual, hearing, low literacy, distractive environment.

·           Teach the action, use and side effects of oral hypoglycemic agents.

Maintain skin integrity:

·           Maintain skin integrity.

·           Use-heal protection, special mattress, foot cradles, for patients on bed rest.

·           Avoid drying agents to skin.(e.g. Alcohol)

·           Apply skin moisturizes to maintain supplement and prevent cracking, fissures.

Improving coping strategies:

·           Encourage patient and family participation is diabetes self care regimen to foster confidence.

Complication

·            Hypoglycemia

·            Diabetic ketoacidocis

·            Hyperglycemic syndrome.

·            Micro vascular complication e.g. Retinopathy, Nephropathy, Neuropathy. 

·            Micro vascular complications in Cardiovascular disease occurring both in NIDDM and IDDM.

2. Poly Cystic Ovarian Syndrome/Disease (PCOD)

Polycystic ovary syndrome (PCOS) is a disorder that includes ovulatory dysfunction, polycystic ovaries, and hyper and rogenism. It most commonly occurs in women under 30 years old and is a cause of infertility.

Causes

·            The causes are unknown.

Signs and Symptoms

·            Hormonal imbalance

·            Ovulation fails and multiple fluids filled cysts

·            Irregular menstrual periods  Amenorrhea

·            Hirsutism and obesity. (80% of women)

·            Oligomenorrhea and infertility

·            Insulin resistance

Management

·            Early diagnosis (pelvic ultrasound)

·            To improve quality of life and decrease the risk of complications

·            OCPs are useful in regulating menstrual cycles

·            Hirsutism may be treated with

·            spironolactone

·            Hyper and rogenism can be treated with flutamide and a GnRH agonist such as leuprolide

·            Metformin (glucophage)    reduces hyperinsulinemia       

·            Improves hyperandrogenism     

·            Restores ovulation  

·            Fertility  drugs may be used to induce ovulation.                        

Nursing Management

·            A woman with PCOD includes teaching about the importance of weight management

·            Exercises to decrease insulin resistance

·            Obesity exacerbates the problems related to

·            PCOD

·            Monitor lipid profile and fasting glucose levels

·            Support the patient as she explores measures to remove unwanted hair

·            Stress the importance of regular follow up care to monitor the affective ness of therapy and to detect any complications.

3. .HYPERTHYROIDISM:

It is defines as sustained increased in synthesis and relaxes of thyroid hormone by the thyroid glands.

It is highly prevented endocrine disorders.

Causes

·            Graves’ disease

·            Toxic, diffuse goiter

·            Toxic adenoma

·            Thyroid carcinoma

Signs and Symptoms

·            Heat intolerance

·            Exophthalmos

·            Loose bowel movements

·            Profuse diaphoresis

·            Tachycardia

·            Hypertrophy of thyroid cells

Investigation

·            History and physical examination  Ophthalmologic examination

·            Laboratory tests such as serum T3, T4, TSH, FT3, FT4, FTSH levels.

·            Thyroid scan

Management

Medical management:

·            Antithyroid drugs which inhibits synthesis of thyroid hormone, e.g. prophylthiouracil and methimazole

·            Iodine e.g. Radioactive iodine  Beta adrenergic blockers

Surgical management:

·            Subtotal thyroidectomy : Removal of one lobe of the thyroid gland.

·            Total thyroidectomy : Removal of thyroid gland.

Complication of thyroidectomy:

·           Hemorrhage or infection

·           Risk of thyroidectomy tetany

·           Respiratory obstruction

·           Laryngeal edema

·           Vocal cord edema

Complications:

The Major complications of graves’ disease are

·           Exophthalmos

·           Thyroid storm

·           Thyroid crisis

·           Thyroid toxicosis

3.  Hypothyroidism

It is a metabolic state resulting from a deficiency of thyroid hormone that may occur at any age. Congenital hypothyroidism results in a condition called cretinism.

Causes

1.     Congenital defects of the thyroid gland

2.     Defective hormone synthesis

3.     Iodine deficiency (prenatal and post natal)

4.     Anti thyroid drugs

5.     Surgery of management with radioactive agents for hyperthyroidism

6.     Chronic inflammatory (acute immune) disease such as hashimoto’s disease, amylodois sarcoidosis

Signs and Symptoms

The manifestation of the hypothyroidism depend on whether it is mild, severe (Myxedema) or complicated (Myxedema coma)

Myxedema:

1.     Respiratory failure

2.     Heart failure

3.     Cerebral vascular accident

4.     Trauma (injury)

5.     Metabolic disturbances

Myxedema coma:

·           Drastic increase in metabolic rate

·           Hypoventilation

·            leading to respiratory acidosis

·           Hypothermia

·           Hypotension

·           Hyponatremia

·           Hypocalcaemia

·           Hypoglycemia

Diagnostic evaluation:

·           History and physical examination

·           Serum TSH and free T4

·           TRH stimulation test

Management

Medical management:

·           Antithyroid drugs such as Propylathiouracil (PTU) which inhibits thyroid hormone synthesis

·           Radioactive iodine offers a more permanent option because it destroys thyroid tissue

·           Client with hypothyroidism must receive lifelong thyroid hormone replacement therapy