Endocrine Disorders Concept: Fluid and Electrolytes
Acromegaly
"Enlarged extremities" When excessive GH occurs in adulthood Bone and connective tissue continue to grow, but growth plates are closed. Forehead, maxilla grow Voice deepens Hands and feet enlarge Nerve entrapment - pain, carpal tunnel
An IV hydrocortisone infusion is started before a patient is taken to surgery for a bilateral adrenalectomy. Which explanation, if given by the nurse, is most appropriate? "The medication prevents sodium and water retention after surgery." "The drug prevent clots from forming in the legs during your recovery from surgery." "This medicine is given to help your body respond to stress after removal of the adrenal glands." "This drug stimulates your immune system and promotes wound healing."
"This medicine is given to help your body respond to stress after removal of the adrenal glands."
Treatment of Addisonian Crisis
-Correct F & E imbalance Kayexalate enema - releases Na ions in place of K ions Rapid hydration, vasopressors, volume expander (albumin, plasmonate) -Correct hypoglycemia- IV glucose -Replace steroids- hydrocortisone Often IM, self-injected Watch blood sugar Watch for GI disturbances, ulcers Cushing's symptoms
Treatment of Cushing's
-Medications - treat symptoms, normalize hormone secretion Adrenal blocking agents (supress the synthesis and secretion of cortisol from the adrenal gland (medical adrenalectomy)- mitotane (Lysodren), aminoglutethimide (Cytadren), ketoconazole (Nizoral). Hydrocortisone or prednisone may be needed to avoid adrenal insufficiency. ACTH reducing agents- Periactin -Surgery - removal of adrenal tumor or whole gland - adrenalectomy Life-long replacement drugs -If result of a pituitary disease - removal of pituitary gland
Treatment for SIADH
Hypertonic IV fluids- correct hyponatremia Sodium restriction Diuretics - increase plasma osmolality Replace electrolyte loss Demeclocycline to increase free water clearance (allow some water to be excreted and some to be absorbed) Treat underlying cause (CVA, malignancy)
Assessment of SIADH
Hyponatremia -Fatigue, H/A, anorexia, nausea, ↓ mental status, coma, seizure Fluid volume excess -Weight gain, jugular vein distention, tachycardia, tachypnea, rales Think: CONCENTRATED urine DILUTE serum
Causes of Addison's
Autoimmune *** Seen with AIDS, TB, Type 1 diabetes Adrenal mets from lung, breast, GI, melanoma Bilateral adrenalectomy Hemorrhagic infarction from trauma Glucocorticoid use
Fluids and Electrolytes with Dialysis Patients
Calcium and Phosphate - Hyperphosphatemia results from decreased phosphate excretion by the kidneys. Hyperphosphatemia decreases serum calcium levels. A low calcium level can lead to tetany.
Fluids and Electrolytes with Dialysis Patients
Calcium and Phosphate - as kidney function deteriorates, less vitamin D is converted to its active form, resulting in decreased serum levels. Activated vitamin D is needed for absorption of calcium from the GI tract, thus low vitamin D levels results in low calcium levels. Low calcium levels stimulates the parathyroid to release PTH. PTH stimulates the bones to release calcium to try to increase calcium levels in the serum.
Symptoms of Cushing's
Central obesity Muscle weakness an wasting (extremities) Thin skin, abdominal striae, fragile capillaries Steroid diabetes- altered glucose metabolism E-lyte imbalance, dysrhythmias, edema, hypertension (K, NA, water retention) Osteoporosis, compression fractures Increased susceptibility to infection, but few symptoms due to immune supression Hirsutism
Dialysis - Review
Clinically, dialysis is a technique in which substances move from the blood through a semipermeable membrane and into a dialysis solution (dialysate).
Pituitary Gland
Controls many glands, but primary disease is uncommon Can indirectly cause many disease processes Produces Somatotropin (growth hormone) Produces several gland-stimulating hormones
Some Clues
Cushings is over- secretion of glucocorticoids. (Think of UP) Addisons is under-production (need to ADD hormones to fix it)
What did you learn?
Cushings= overactive adrenal cortex -High cortisol levels -Treat high levels with blocking agents, remove adrenals Addisons= DECREASED cortisol, DECREASED aldosterone, DECREASED adrogens -Treat symptoms and replace hormones Pheochromocytoma= excess epinephrine and norepinephrine -Neuro stimulant -Remove adrenals
Treatment of DI
IV fluids, oral fluids if tolerated ADH replacement desmopressin - DDAVP - (nasal, bid) (a synthetic vasopressin - the hormone that reduces urine production) Pressin tannate oil, IM - replaces ADH
Concept: Fluid and Electrolyte Balance
Definition: process of regulating the extracellular fluid volume, body fluid osmolality and plasma concentrations of electrolytes. Fluid is water plus the substances dissolved and suspended in it. Important characteristics of fluid are its volume (amount) and its degree of concentration (osmolality).
Addison's Disease Adrenal insufficiency
Destruction or dysfunction of adrenal cortex Chronic deficiency -Cortisol -Aldosterone -Androgens
Diagnosis Pheochromocytoma
Diagnosed by urinary fractionated metanephrines - catecholamine metabolites, such as VMA (vanillylmandelic acid) CT MRI for tumors
Acromegaly
Diagnosis: MRI CT to detect pituitary tumor Treatment: surgery - transsphenoidal approach, radiation therapy, medication
Cushing's Diagnosis
Diagnosis: elevated plasma cortisol levels, elevated 24 hour urine for free cortisol
General Principles of Dialysis
Diffusion Movement of solutes from an area of greater concentration to an area of lesser concentration
Dialysis - Disequilibrium Syndrome
Disequilibrium Syndrome - caused by too rapid a decrease of BUN and circulating fluid volume. It may result in cerebral edema and increased intracranial pressure. -S&S - nausea, vomiting, change in LOC, seizures, agitation -Risk factors - advanced age, hypotension - related to rapid changes in fluid and electrolytes
Concept: Fluid and Electrolyte Balance
Electrolytes are substances that are charged particles (ions) when they are placed in water. All body fluids contain electrolytes, concentration of electrolytes varies with location in body.
Syndrome of Inappropriate Antidiuretic Hormone (SIADH)
Excessive ADH release from posterior pituitary, not in response to body needs -Too much antidiuretic means hold fluid Due to trauma, CVA, lung or pancreas malignancy, some medications, stress Small cell cancers produce ectopic ADH
Giantism
Excessive GH begins before puberty and closure of epiphyseal plates Abnormal height with proportional body Rare because of good diagnostic tools, and care of children
Concept: Fluid and Electrolyte Balance
Fluid and electrolyte balance is a dynamic interplay between: -Fluid and electrolyte intake and absorption -Fluid and electrolyte distribution - intracellular, extracellular -Fluid and electrolyte output - removal from body
Diabetes Insipidus (DI)
Is not same as Diabetes Mellitus -Although symptoms appear similar (thirst, excess urination) Hyposecretion of ADH, injury to pituitary, surgery to pituitary, infection - meningitis, encephalitis -Not enough antidiuretic leads to diuresis Often caused by CVA's, trauma, especially head injuries Kidney tubules fail to reabsorb water Are several kinds- neurogenic, gestational, nephrogenic, dipsogenic - don't need to know these levels
Addison's Education
Lifelong hormone therapy Recognize need for extra meds with stress Teach signs and symptoms of Cushing's (excess hormone) ID badge Emergency 100mg IM hydrocortisone
Fluids and Electrolytes with Dialysis Patients
Magnesium - primarily excreted by the kidneys. Hypermagnesemia is usually not a problem unless the patient is ingesting magnesium (milk of magnesia, magnesium citrate, antacids that contain magnesium). Clinical signs of hypermagnesemia can include absence of reflexes, decreased mental status, cardiac dysrhythmias, hypotension and respiratory failure.
Adrenal Glands
Medulla - (central) similar to substances produced in sympathetic nervous system Cortex - (peripheral) essential to life Medulla- epinephrine & norepinephrine Cortex- corticosteroids -Mineralocorticoids - aldosterone, controlled by renin -Glucocorticoids - cortisol & cortisone, released when stressed, affect carb metabolism -Androgens
Nursing Issues with Cushing's
Monitor for fractures Monitor blood sugars (steroids) Low calorie, low carbohydrate, high protein diet Daily weight Monitor B/P At risk for infection (steroids) Skin integrity - no tape Activity intolerance Watch for mood swings, change in appearance, depression
Nursing Interventions for SIADH
Monitor urine and serum labs Watch for mental status changes Daily weight, I&O Restrict fluids to prevent further hemodilution (provide comfort measures for thirst - mouth care, ice chips, lozenges)
Nursing Interventions for DI
Monitor vitals, neuro checks, CV status Safe environment for cognitive impairment Monitor lytes, signs of dehydration I&O, ↓ urine specific gravity Daily weight ↑ Plasma osmolality, increased sodium level (volume depletion) Avoid caffeine - produce diuresis Medic Alert Bracelet
Dialysis - Review
Movement of fluid/molecules across a semipermeable membrane from one compartment to another Used to correct fluid/electrolyte imbalances and to remove waste products in renal failure Treat drug overdoses
Dialysis - Disequilibrium Syndrome
Nursing Interventions -Use a slow dialysis exchange rate, especially for older adults and those first starting treatments -Administer anticonvulsants if needed
General Principles of Dialysis
Osmosis Movement of fluid from an area of lesser concentration of solutes to area of greater concentration
Cushing's Syndrome Hypercortisolism (Excess glucocorticoid)
Overactive adrenal cortex Pituitary over stimulation Excessive cortisol or ACTH Women 30-50 yrs Any age, drug induced -Long term steroids -Organ transplant, asthma
Assessment for DI
Polyuria up to 24 L per day Polydipsia Dehydration Decreased skin turgor, dry mucous membranes Inability to concentrate urine Low urine specific gravity (1.006 or less) Fatigue, muscle pain, H/A, tachycardia Postural hypotension Change in LOC, confusion Think DILUTE urine, CONCENTRATED serum
Fluids and Electrolytes with Dialysis Patients
Potassium - Hyperkalemia results from the decreased excretion of potassium by the kidneys, the breakdown of cellular protein, bleeding, and metabolic acidosis. Potassium may also come from the foods consumed, dietary supplements, drugs, and IV infusions. Fatal dysrhythmias if potassium is up to 7-8 mEq/L.
Fluids and Electrolytes with Dialysis Patients
Pruritus - multiple causes with kidney patients - dry skin, calcium-phosphate deposits in the skin, and sensory neuropathy. The itching can be so intense it can lead to bleeding or infection secondary to the scratching.
Cushing Syndrome Nursing Diagnoses
Risk for infection Imbalanced nutrition Disturbed body image Impaired skin integrity
Treatment Pheochromocytoma
Treatment = adrenalectomy (like in Cushings, but more severe) Nursing Interventions: -Avoid palpating abdomen - could cause sudden release of catecholamines and severe hypertension -Rest -Nutrition -Emotional support
Symptoms of Addison's
Slow onset, insidious Fatigue, irritability Weight loss, N & V Postural hypotension Usually 90% loss of both adrenal cortices by diagnosis Diagnosed by hormone levels, lytes, glucose- ↑K, NA, Blood glucose Hyperpigmentation
Fluids and Electrolytes with Dialysis Patients
Sodium - Sodium may be elevated, normal, or low in kidney failure. Because of impaired sodium excretion, sodium along with water is retained. If large quantities of water are retained, dilutional hyponatremia occurs. Sodium retention can contribute to edema, hypertension, and heart failure. Sodium intake must be individually determined but is generally restricted to 2 g/day.
Addisonian Crisis Acute Adrenal Insufficiency
Stress - pregnancy, surgery, infection, without appropriate hormone replacement Sudden penetrating pain in back, abdomen or legs due to severe elyte imbalance Changed mental function Hypovolemia, hypotension, hypoglycemia Loss of consciousness, shock
Symptoms of Pheochromocytoma
Sympathetic hyperactivity INCREASED blood glucose, glucosuria *Hypertension often paroxysmal, H/A INCREASED metabolic rate- diaphoresis, agitation, tachycardia, palpitations Emotional instability- crying, outbursts Acute attacks- profuse sweating, dilated pupils, cold extremities
Multiple Problems with Endocrine Disorders
Testing is exhausting Changing physical appearance and emotional response Permanent lifestyle changes
Increased ACTH causes the striking feature of bronze-colored skin hyperpigmentation. It is seen primarily in sun-exposed areas of the body, at pressure points, over joints, and in the creases, especially palmar creases.
The changes in the skin are most likely due to increased secretion of β-lipotropin (which contains melanocyte-stimulating hormone [MSH]). This tropic hormone is increased because of decreased negative feedback and subsequent low corticosteroid levels. Patients with secondary adrenocortical hypofunction usually do not have hyperpigmented skin because ACTH levels are low.
The nurse administers corticosteroids to a patient with acute adrenal insufficiency. The nurse determines that treatment is effective if what is observed? The patient is alert and oriented. The patient's lung sounds are clear. The patient's urinary output decreases. The patient's potassium level is 5.7 mEq/L.
The patient is alert and oriented.
Pheochromocytoma
Tumors of adrenal medulla (benign) Produce epinephrine or norepinephrine (excess catecholamines) Stimulate sympathetic nervous system Diagnosed by epi and norepi in blood Cause unknown Rare, runs in families
Diagnosis DI
Water deprivation test - fluids withheld and urine concentration and output monitored. Positive for DI if unable to concentrate urine despite increased plasma osmolarity.
Key features of SIADH
Water retention Hyponatremia- dilutional Low serum osmolality (concentration) * Continual release of ADH → water retention from renal tubules; extracellular fluid volume increases; hyponatremia suppresses renin and aldosterone secretion causing ↓ in reabsorption of sodium