Metabolism

Increased appetite, weight loss, heat intolerance

Cardiovascular

HTN, tachycardia, palpitations

GI

Hyperactive BS, increased peristalsis

Neuromuscular

Nervousness, restlessness, insomnia, tremor

Other

Fine hair, smooth/warm skin

Thyroid antibodies

TSH

T4, T3

3

Radioactive iodine uptake test

Thyroid suppression test

Drugs

Antithyroid

Beta-blockers

Radioactive Therapy

Damage or destroy cells

Surgery

Subtotal or total thyroidectomy

Risk for decreased cardiac output

Altered Nutrition

Body Image Disturbance

Insufficient amount of thyroid hormone

Defect in thyroid gland

Post hyperthyroid treatment

Thyroditis (Hashimoto’s)

Iodine deficiency

Myxedema

Common in females 30-60

Hypothyroidism

Manifestations

Metabolism

Cold, sleepy, weakness, fatigue

Cardiovascular

Hypotension, bradycardia

GI

Constipation, anorexia, vomiting

Neuromuscular

Slow movement and thinking

Other

Goiter, dry skin and hair

Hypothyroid crisis

Hyponatremia, hypoglycemia, lactic acidosis

Hypothermia, cardiovascular collapse

Precipitated by trauma, infection, uncontrolled hypothyroidism

Maintain airway, correct imbalances

Same as hyperthyroid with opposite results

TSH- elevated

T4, T3- decreased

RAI- decreased

Medications

Replacement therapy

Surgery

For goiter that interferes with airway/swallowing

Hypothyroidism

Nursing Care

Decreased cardiac output

Constipation

Risk for impaired skin integrity

Activity intolerance

Altered thought process

Risk factor

Exposure to ionizing radiation during childhood

More common in females

Palpable firm nodule in thyroid

TH usually normal

Subtotal or total thyroidectomy

Thyroid replacement

Hyperparathyroidism

Collaborative Care

May be d/t tumor or hyperplasia

Hypercalcemia & hypophosphatemia

"Bones, stones, abdominal groans"

Bone decalcification

Renal calculi

Abdominal pain, constipation

Labs

Electrolytes, Ca, Phos, Mag

Treatmemt

Decrease Ca levels

Increase fluid intake

Diuretics (Lasix)

Meds to inhibit bone reabsorption (Fosamax)

Removal of gland

Damage or removal of parathyroid glands

Hypocalcemia & hyperphosphatemia

Numbness, tingling around mouth, tetany

Need long term calcium supplements, Vit D

Excessive production of cortisol

Primary

Benign or malignant adrenal tumor

Secondary

Increased release of ACTH

Iatrogenic

Long term glucocorticoid therapy

Central obesity, buffalo hump, rounded face

Hyperglycemia

Sodium retention

Hypokalemia

Thin, bruising skin

Altered immunity, risk for infection 

Depression

Changes in secondary sex characteristics

Cushing's Lab & Diagnostics, Treatment,

Nursing Care

Plasma cortisol and ACTH levels

24-hour urine

Electrolytes

ACTH suppression test

Medications

Suppress activity of adrenal cortex

Inhibit cortisol synthesis

Surgery

Adrenalectomy

hypophysectomy

Fluid volume excess

Risk for injury/infection

Body image disturbance

Deficiency of cortisol, aldosterone, adrenal androgens

Autoimmune destruction most common cause

Abrupt withdrawal from steroids

Manifestations

Hyponatremia, hyperkalemia, hypoglycemia

Hypotension, syncope

Dizziness, confusion

N/V/D, weakness

Hyperpigmentation of skin

Addison’s Disease

Lab & Diagnostics

Treatment

Nursing Care

Serum cortisol levels

Blood glucose

Electrolytes, CBC

Plasma ACTH

Replacement of corticosteroids

May result in Cushing-like syndrome

Increase dietary sodium

Fluid volume deficit

Knowledge deficit

Tumor of adrenal medulla

Overproduction of catecholamines

Paroxysmal severe hypertension with tachycardia

Adrenalectomy

Causes

Tumor of the adrenal cortex

Chronic kidney disease

Manifestations

HTN, HA, muscle weakness, dysrhythmias

Adrenalectomy, aldactone

Disorders of Anterior Pituitary

gigantism and acromegaly

Gigantism

Hypersecretion of GH prior to puberty

Results in excessively tall stature

Acromegaly

Hypersecretion of GH after puberty

Enlargement of face, hands, feet

High levels of ADH, suppression of aldosterone

Hyponatremia and water intoxication

Neuro symptoms

Decreased LOC, confusion, seizures

Treatment

Restrict fluids, treat underlying cause

Growth Hormone

Prolactin

Thyroid-stimulating hormone (TSH)

Adrenocoricotropic hormone (ACTH)

Gonadotropin hormone

Follicle-stimulating hormone (FSH)

Luteinizing hormone (LH)

Antidiuretic hormone (ADH)

Vasopressin

Oxytocin

Thyroid hormone

T4

T3

Calcitonin

Parathyroid hormone

Catecholamines

Epinephrine

Norepinephrine

Mineralocorticoids

Aldosterone

Glucocorticoids

Cortisol & Cortisone

Glucagon

Insulin

Somatostatin

Pancreatic polypeptide

Androgens

Estrogens

Progesterone

Hormones regulate tissue responses

Feedback mechanisms

Negative

Sensors detect changes in hormone level and respond

Positive

Increased level of one hormone causes another gland to release a hormone

Medical history

Family history

Changes in size or function of organs, skin, hair

Changes in thirst, appetite, weight, energy, sleep

Medications

Change in reproductive functioning

Inspection of skin, hair, nails, facial appearance

Palpate thyroid

Motor function

Sensory function

Musculoskeletal structure

Assess for tetany

Normal Older Adult Variations

Endocrine

Hyperpigmentation of forearms and hands

Decreased hair growth

Nails thick, brittle, yellow

Decreased sensation of touch

Decreased DTR

Autoimmune reaction (Grave’s disease)

Excess secretion of TSH from pituitary

Neoplasms

Thyroiditis

Excessive intake of thyroid meds

Extreme state of hyperthyroidism

Infection, trauma, manipulation of thyroid during surgery can precipitate

Excessive metabolic symptoms

Temp elevation to 102-106

HTN, tachycardia, psychosis, delirium, seizure

Formation of stones

One stone or multiple

Stone formation occurs when bile crystallizes

75% cholesterol stones

25% pigment stones

Manifestations

Epigastric pain

Heartburn

Right upper quadrant pain

Jaundice ( with obstruction of the common bile duct)

Intolerance to fat-containing foods

Cholelithiasis

contributing factors/6 F's

Contributing Factors

Stasis of bile in gallbladder

Increased bile concentration

Family history of gallstones

Race or Ethnicity

Female Gender

The Six F’s

Fair

Fat

Female

Fertile

Forty

Flatulent

Inflammation of gallbladder

Stones in the cystic or common bile duct

Acute or chronic

Severe pain from abdominal right quadrant to midline and posteriorly to scapular region

Nausea and vomiting

Fever

Elevated WBC

Elevated serum bilirubin, alkaline phosphatase

Elevated serum amylase

Less severe symptoms

Flatulence

Complications

Infection of biliary system

Peritonitis

Perforation

Pancreatitis

Lab Tests

CBC: elevated WBC due to infection & inflammation

Serum amylase & lipase: to determine presence of pancreatitis

Serum bilirubin levels: to ascertain either obstruction in biliary duct system(elevated direct bilirubin) or hepatic damage (elevated indirect bilirubin)

Diagnostic Tests

X-ray study of abdomen: Flat plate to visualize stones

Oral cholecystogram: to assess the GB’s ability to concentrate and excrete bile

Cholangiogram: to detect stones in biliary duct system

Ultrasonography: to detect stones, edema, or distention of GB

GB scans: Cholescintography (HIDA): nuclear medicine techniques to assess cholecystitis

Pharmacology

Oral bile acids: dissolvers

Ursodeoxycholic acid (UDCA); used for cholesterol stones under 20mm in diameter

Chenodeoxycholic acid (Chenodiol): decreases amount of cholesterol in bile, causing stones to be more soluble

Treatments

Surgery: Cholecystectomy: removal of GB

Laproscope

Open with bile duct exploration and T-tube insertion

Cholecystostomy: permits drainage of GB

Choledochostomy: allows for removal of stones & placement of T-tube in the common bile duct

Lithotripsy

Percutaneous stone dissolution- ERCP

Nursing Care

Pain

Altered nutrition due to N/V, & impaired fat metabolism

Risk for impaired gas exchange

Risk for infection

Rare, primarily affecting people over 65

Women more likely to develop

C/O of intense pain in RUQ of abdomen

A mass may be palpated in the region

Jaundice and weight loss

Metastasize via blood, lymph system, or direct extension

Poor prognosis

Inflammation of liver

Viral or toxic

Acute or chronic

Most common liver disorder

Endemic in underdeveloped countries

Majority are Type A or B

Most frequently affects young adults

Risk factors vary with type

Alcoholic

Necrosis of hepatocytes and inflammation of liver tissue

Toxic

Acetaminophen most common

Hepatobiliary

Caused by cholestasis

Infectious hepatitis

Transmission: fecal-oral route, contaminated food, water

Contagious through stool 2 weeks before symptoms occur

Self-limiting, symptoms last up to 2 months

Transmission: blood and body fluids

Liver cells damaged by immune response

High risk populations

Health care workers

IV drug users

Person’s exposed to blood products

Transmission: blood and body fluids, IV drug use most common

Primary worldwide cause of chronic hepatitis, cirrhosis, and liver cancer

Acute Viral Hepatitis

phases

Incubation phase

Pre-icteric phase

"Flu-like" symptoms, malaise, fatigue

N/V/D, anorexia

HA, muscle aches, polyarthritis

Icteric Phase

Jaundice

Pruritus

Lighter-colored stool

Brown urine

Decrease in pre-icteric phase symptoms (appetite improves, no fever)

Post-icteric/Convalescent Phase

Serum bilirubin and enzymes return to normal levels

Energy level increases

Pain subsides

GI symptoms: minimal to absent

Rare sequela of viral hepatitis

Hepatic encephalopathy

Widespread necrosis of the parenchyma

Liver actually shrinks

Benign, results from either HBV or HCV infections

Low serum transferase levels

Usually does not progress to cirrhosis

Malaise, mild fatigue, hepatomegaly

Diagnosed by liver biopsy

No specific treatment

Life threatening

Progresses to cirrhosis with liver failure

Fatigue is common

Results from hepatotoxic drug administration, HBV or HCV

Liver biopsy plus other dx and lab tests

Hepatitis

Lab & Diagnostic Tests

Anti-HAV

IgM anti-HAV

HBsAG: hepatits B surface antigen

HBeAG

Anti-HBs

Anti-HBe

Anti-HBc-IgM

ADAg

Alkaline phosphatase (ALP)

Gamma-glutamyl transferase (GGT)

Alanine aminotransferase (ALT)

Aspartate aminotransferase (AST)

LDH5

Conjugated & unconjugated bilirubin levels

Prothrombin time

Pre-biopsy preparation

Review the procedure w/ pt

Pt should be NPO for 4-6 hrs before biopsy

Have pt void before biopsy

Record baseline vital signs

Review chart for H&H, platelet count, bleeding & clotting times

Post-procedure

Right after procedure, apply direct pressure

Instruct pt to lie on the right side to keep pressure on the site for two hours

Strict bedrest for at least 6 hours

Monitor vital signs frequently for 4-6 hrs

Notify physician if BP differs markedly from baseline or if pt in severe pain

Keep pt. NPO for two hours. Then resume previous diet

Instruct pt. Not to cough hard or strain for 2-4 hr & avoid lifting or strenuous activities for 1 week

Pre-exposure Prophylaxis

Hep A clinical illness can be avoided in up to 90% of cases when immune globulin is given

Hep B prophylaxis is recommended for people at risk. Nurses & health care workers need to be vaccinated

Post-exposure Prophylaxis

Hep A: single dose of IG as soon as possible after exposure

Hep B: Hepatitis B immune globulin (HBIG) for short-term immunity. HBV vaccine given concurrently for long-term immunity

Bedrest

Clear liquids initially then encourage a high calorie, high protein, high carb, low fat diet

Pruritus-frequent skin cleaning

Vitamin supplements (B-complex, K)

Avoid alcohol and drugs detoxified by liver

Emotional support

Home Care Teaching

During acute phase

No sharing of eating utensils, bath towels

Avoid sexual and close personal contact

Avoid hepatotoxic substances

Diffuse inflammation and fibrosis

Drastic structural changes

Significant loss of function

Complications: Portal hypertension, bleeding, ascites, hepatic encephalopathy, esophageal varices, bacterial peritonitis

Portal hypertension

Elevated B/P within portal vein

Blood rerouted to other veins with normally lower B/P (collateral circulation)

Veins affected become engorged & congested

Esophagus

Rectum

Abdomen

Splenomegly

Ascites

r/t increased hydrostatic pressure in vessel lumen

Hypoalbuminemia

Hyperaldosteronism

Esophageal varices

Hepatic encephalopathy

ETOH causes fatty infiltration

Inflammatory cells cause necrosis, fibrosis and destruction

Liver shrinks and becomes nodular

Clinical symptoms: anorexia, malaise,weight loss, low-grade fever, jaundice, ascites, hemorrhage,encephalopathy

Etiology: chronic right-sided CH

Liver enlarged

Changes reversible if CHF is successfully treated

Fibrosis with long standing CHF

Cirrhosis

Labs and Diagnostic Tests

Serum electrolytes

CBC w/ platelets

Bilirubin measurements

Total protein, serum albumin, and ammonia levels

Coagulation studies

Serum glucose values

Liver enzyme studies

Diagnostics

Ultrasound

Liver biopsy

Esophagoscopy

Cirrhosis

pharmacology/surgical procedures

Pharmacology

Diuretics: Spironolactone (Aldactone), furosemide (Lasix)

Laxatives: Lactulose

Vitamin K

Antacids

Avoid meds metabolized by the liver

Surgical Procedures

Sclerotherapy per endoscopic procedure

Paracentesis for severe ascites

Peritoneovenous shunt: LeVeen shunt

Tranjugular intrahepatic portosytemic shunt (TIPS)

Liver transplant

Sodium intake is restricted to under 2g/day

Fluid needs are calculated based on response to diruetic therapy, urinary, and serum electrolyte values

Dietary protein is adjusted to pt’s ability to handle nitrogenous load

Vitamin and mineral supplements based on lab values

Nursing Care

Fluid volume excess/deficit

Altered thought processes

Risk for injury: bleeding

Risk for impaired gas exchange

Impaired skin integrity

F&E

Ascites, edema, oliguria, hypotension

Hemorrhage

GI bleeding, hypotension, tachycardia

Infection

Fever, tachycardia, abnormal breath sounds, chills, malaise, cloudiness of body fluids

Neuro

Mental status impairment, change in sleep pattern, mood, behavior, perceptual ability, lethargy, slurred speech, poor coordination

Linked with alcoholic cirrhosis and chronic hepatitis B and C

Mets: GI cancers, lung, breast

Poor prognosis

No early S&S

DX: Liver bx & CT scans

Treatment

Resection, Radiation, Chemotherapy

Not a candidate for liver transplant

Often bacterial

Destroys healthy tissue leaving necrosis, inflammatory exudates, and blood

Acute onset with fever, vomiting, abd pain

CT or US

Tx: antibiotics

Release of pancreatic enzymes into pancreatic tissue leading to hemorrhage and necrosis

10% mortality rate

Acute or Chronic

Autodigestion of the pancreas

Obstruction by gallstone

Obstruction of bile ducts

Back up of duodenal contents into pancreatic duct

Excess HCL causing sphincter spasm

Acute Pancreatitis

Assessment Findings

Sudden severe pain in middle upper abdominal region that radiates to back

N/V, fever

Abdominal distension and tenderness

Diminished bowel sounds

Shallow, rapid breathing

Tachycardia, hypotension

Restlessness, confusion

Jaundice

Discoloration of abdomen and flanks

Elevated serum amylase and lipase levels

Elevated WBC and serum bilirubin level

Transient elevation in blood and urine glucose levels

AST/ALT may be elevated

In severe cases, serum calcium levels may drop

Abnormal ultrasound & CT of pancreas

Local

Pseudocyst

Abscess

Fistulas

Systemic

Diabetes

Hemorrhage, DIC

Hypovolemic shock

Sepsis

Renal failure

ARDS

Acute pancreatitis

Collaborative Care

Relief of pain

Meperidine

Prevention or alleviation of shock

Albumin

Reduction of pancreatic secretions

NPO w/ NG tube to suction

Cimetidine (Tagamet) or ranitidine (Zantac) IV

Control of fluid and electrolyte imbalance

Lactated Ringer’s Solution

Prevention or treatment of infection

Peritoneal lavage

Antibiotics

Removal of precipitating cause, if possible

Surgery: Cholescystectomy to remove gallstones

Surgical resection of all or part of pancreas to remove necrotic tissue

For pseudocyst or abscess, percutaneous insertion of tubes placed for external drainage

Monitor vital signs

Observe fluid & electrolyte imbalances

Assess respiratory function

Observe for symptoms of tetany

Measures to relieve pain

Maintain hydration/nutrition

Observe for fever & other signs of infection

Progressive, destructive disease of pancreas

Characterized by remissions & recurrences

Inflammation & fibrosis contribute to pancreatic insufficiency & diminished function

Chronic Pancreatitis

Two major types:

Chronic obstructive pancreatitis

Associated with biliary disease

Chronic calcifying pancreatitis

Also called alcohol-induced pancreatitis

Chronic Pancreatitis

Assessment Findings

Upper abdominal pain radiating to the back

N/V with weight loss

Flatulence

Constipation

Steatorrhea

Manifestations of DM

Elevated serum & urinary amylase levels

Elevated serum bilirubin w/ jaundice

Chronic Pancreatitis

Collaborative Care/Nursing Care 

Prevention of further attacks

Relief of pain

Control of pancreatic exocrine & endocrine insufficiency

Diet

Pancreatic enzyme replacement

Control of diabetes

Surgery

Nursing Care

After pancreatitis

Prevention of further attacks

Avoid alcohol, narcotics

Reporting symptoms

Pain, N/V, abdominal distention, steatorrhea, polyuria, polydipsia, polyphagia, weight loss, fever

Low-fat,low protein, high carbohydrate bland diet

Several small meals, vitamin supplements

Continuing medications

Pancreatic enzymes, bile salts, oral hypoglycemic agents or insulin

Need for continued medical follow up

Seek medical care when ill

Usual site at head of pancreas at ampulla of Vater

Risk factors: Smoking, diabetes, high fat diets

S&S: anorexia, nausea, dull epigastric pain

Poor prognosis, usually mets before diagnosis

Cancer of the Pancreas

Collaborative Care

Whipple procedure

Chemotherapy and radiation

Postoperative Care

Same as for any intestinal surgery

NG tube and suction

Pain management

TCDB

F&E

I&O (IV fluids/blood and monitor drains/tubes, etc)

Assess skin, color, temperature, moisture, turgor

Assess LOC

Vital signs

Monitor labs

Assess for hemorrhage, hyovolemic shock, hepatorenal failure