HYPOTHYROIDISM insufficient secretions of thyroid hormnes ASSESSMENT: Subjective data: Weakness, fatigue, lethargy, headache, slow memory, loss

of interest in sexual activity. Objective data: Depressed BMR; intolerance to cold Cardiomegaly, bradycardia, hypotension, anemia Menorrhagia, amenorrhea, infertility Dry skin, brittle nails, coarse hair, hair loss Slow speech, hoarseness, thickened tongue Weight gain: edema, periorbital puffiness Lab data: elevated TRH, TSH; normal-low serum T4 & T3; decreased RAUI. NURSING MANAGEMENT 1. Provide appropriate pacing of activities - Allow patient extra time to think, speak, act - Teaching should be done slowly and in simple terms 2. Promote comfort, rest and sleep - Frequent rest period between activities - Provide patient with extra clothing and beddings 3. Maintain skin integrity 4. Teach appropriate diet - High protein, low calorie (Small frequent feedings) - Prevent constipation - Cathartics and stool softener as ordered - High fiber diet; increase fluid intake HYPERTHYROIDISM *Hypersecretion of the thyroid gland. *Provide adequate rest & administer sedatives as prescribed. *Provide cool & quiet environment. *Obtain daily weight & give high-calorie food. **Administer anti-thyroid meds & avoid giving stimulants. *Prepare the patient for the following: -iodine preparations -antithyroid meds -propanolol (Inderal) -radioactive iodine -for thyroidectomy as px ASSESSMENT: Subjective data: o nervousness, mood swings, palpitations, heat intolerance, dyspnea, weakness. Objective data: o Eyes: exophthalmos, characteristic stare, lid lag. o Skin: warm, moist, velvety; increased sweating; increased melanin pigmentation; pretibial edema with thickened skin & hyperpigmentation o Weight loss despite increased appetite o V/S: increased systolic BP, widened pulse pressure, tachycardia o Goiter: thyroid gland noticeable & palpable o Gyne: abnormal menstruation o GI: frequent bowel movements o Activity pattern: fatigue which leads to depression

Lab data: elevated T3 & T4 level; elevated RAIU; elevated metabolic rate (BMR); decreased WBC caused by decreased granulocytosis (<4500).

NURSING MANAGEMENT: 1. Promote physical & emotional equilibrium: 2. Protect from stress: private room, restrict visitors, quiet environment. a. cool, quiet, cool well ventilated environment. b. eye care: sunglasses to protect from photophobia, protective drops (methylcellulose) to soothe cornea c. diet: high calorie, protein, vit. B; avoid stimulants 3. Prevent complications: give medications as ordered. 4. Monitor for thyroid storm. 5. Health teaching: stress reduction techniques; importance of medications; methods to protect eyes from environment; s/sx of thyroid storm. THYROID STORM Acute & life threatening condition in uncontrolled hyperthyroidism *Risk factors: Infection, surgery, beginning labor to give birth, taking inadequate antithyroid medications before thyroidectomy. *S/Sx: fever, tachycardia, hypotension, marked respiratory distress, pulmonary edema, irritability, apprehension, agitation, restlessness, confusion, seizures *Meds: PTU or Tapazole; Sodium iodide IV or Lugols solution orally; Propranolol (Inderal); Aspirin, Steroids, Diuretics THYROIDECTOMY Removal of thyroid gland & performed for persistent hyperthyroidism *PRE-OPERATIVE CARE: -Assess V/S, weight, electrolyte & glucose level -Teach DBE & coughing as well as how to support neck in post-op period when coughing & moving -Administer antithyroid meds etc. to prevent thyroid storm *POST-OP CARE: -Monitor for respiratory distress & have tracheostomy set, O2 & suction machine at bed side -Maintain semi-Fowlers position to reduce edema -Immobilize head with pillows/sandbags; prevent flexion & hyperextension of neck -Check surgical site for edema & bleeding -Limit client talking & assess for hoarseness -Assess for laryngeal nerve damagehigh-pitched voice, stridor, dysphagia, dysphonia & restlessness -Monitor for signs of hypocalcemia & tetany & have calcium gluconate at bed side THYROID HORMONES Levothyroxine (Synthroid, Levothroid, Levoxyl) Thyroglobulin (Proloid) *Controls the metabolic rate of tissues & accelerates heat production & oxygen consumption *For hypothyroidism, myxedema & cretinism *A/R: cramps, diarrhea, nervousness, tremors, hypertension,

tachycardia, insomnia, seating & heat intolerance *Taken same time every day preferably in the a.m. with food *Teach client to how to take HR *Avoid foods that will inhibit thyroid secretions such as: strawberries, peaches, pears, cabbage, turnips, spinach, Brussels sprouts, cauliflower, peas & radishes *Wear Medic-Alert bracelet SIGNS OF TETANY *Positive Chvosteks Sign *Positive Trousseaus Sign *Wheezing & dyspnea (bronchospasm, laryngospasm) *Numbness & tingling of face & extremities *Carpopedal spasm *Visual disturbances (photophobia) *Muscle & abdominal cramps *Cardiac dysrhythmias *Seizures DIABETES MELLITUS A CHRONIC DISORDER OF IMPAIRED GLUCOSE INTOLERANCE AND CARBOHYDRATE, PROTEIN & LIPID METABOLISM; CAUSED BY A DEFIECIENCYOF INSULIN. 2 MAJOR TYPES OF DM 1.INSULIN-DEPENDENT DIABETES 2.NON-INSULIN DEPENDENT DIABETES Pathophysiology: Deficient insulin production Hyperglycemia Inc. concemtration of blood glucose Glucosuria Excess glucose excreted in urine Excess fluid loss Polyuria / Polydipsia Insulin deficiency Impaired metabolism of CHON and fats Weight loss Decreased storage of calories Polyphagia Assessment POLYPHAGIA

POLYDIPSIA POLYURIA HYPERGLYCEMIA WEIGHT LOSS BLURRED VISION SLOW WOUND HEALING VAGINAL INFECTIONS WEAKNESS & PARESTHESIAS SIGNS OF INADEQUATE FEET CIRCULATION

APPROACH TO DIABETES MELLITUS: =DIET =EXERCISE =ORAL HYPOGLYCEMIC AGENTS/INSULIN= Sulfonylureas Chlorpropamide (Diabinase) Tolbutamide (Orinase) Glimepinide (Solosa) Acetohexamide (Dymelor) Prandial Glucose Regulator Repaglinide (Novonorm) Rosiglitazone (Avandia) Non-sulfonylureas Metphormine (Glucophage) Precose (Acarbose) Rosiglitazone (Avandia Insulin=*Insulin increases glucose transport into cells & promotes conversion of glucose to glycogen, decreasing serum glucose levels *Primarily acts in the liver, muscle, adipose tissue by attaching to receptors on cellular membranes & facilitating transport of glucose, potassium & magnesium glucagons=Hormone secreted by the alpha cells of the islets of Langerhans in the pancreas *Increase blood glucose by stimulating glycogenolysis in the liver *given SC, IM or IV routes *Used to treat insulin-induced hypoglycemia when semiconscious/ unconscious common types of insulin TYPE ONSET PEAK 1 hour DURATION 3 hours

RAPID-ACTING INSULIN Lispro (Humalog) 10-15 mins

SHORT-ACTING INSULIN Humulin Regular 0.5-1 hour 2-3 hours INTERMEDIATE-ACTING INSULIN Humulin NPH 3-4 hours 4-12 hours Humulin Lente 3-4 hours 4-12 hours LONG-ACTING INSULIN Humulin Ultralente 6-8 hours 12-16 hours 2-12 hours

4-6 hours 16-20 hours 16-20 hours 20-30 hours 18-24 hours

PREMIXED INSULIN 0.5-1 hour 70% NPH-30% Regular major complications of DM HYPOGLYCEMIA *DIABETIC KETOACIDOSIS (DKA) *HYPERGLYCEMIC HYPEROSMOLAR NONKETOTIC SYNDROME (HHNS)

Diabetic ketoacidosis Assessment: The three main clinical features of DKA are: Hyperglycemia Dehydration and electrolyte loss Acidosis - frank hypotension with a weak, rapid pulse - GI symptoms such as anorexia, nausea, vomiting, and abdominal pain. - acetone breath (a fruity odor), Hyperventilation (Kussmaul respirations) The three main clinical features of DKA are: Hyperglycemia Dehydration and electrolyte loss Acidosis

DKA
Progressive insulin deficiency Glucogenolysis Gluconeogenesis Contribute to further hyperglycemia Breakdown of fats Increased production of ketones Nursing Management Patients must be taught sick day rules for managing their diabetes when ill

- most important issue to teach patients is not to eliminate insulin doses when nausea and vomiting occur - Take insulin or oral antidiabetic agents as usual. - Test blood glucose and test urine ketones every 3 to 4 hours. - Report elevated glucose levels (greater than 300 mg/dL [16.6 mmol/L] or as otherwise specified) or urine ketones to the physician. - Insulin-requiring patients may need supplemental doses of regular insulin every 3 to 4 hours. - If usual meal plan cannot be followed, substitute soft foods (eg, 13 cup regular gelatin, 1 cup cream soup, 12 cup custard,3 squares graham crackers) six to eight times per day. - If vomiting, diarrhea, or fever persists, take liquids (eg, 12 cup regular cola or orange juice, 12 cup broth, Gatorade) every 12 to 1 hour to prevent dehydration and to provide calories. Treatment - REHYDRATION Normal saline or .045% NAC l - RESTORING ELECTROLYTES K as soon as urine output is satisfactory - REVERSING ACIDOSIS Regular Insulin IV Bicarbonate infusion to correct severe acidosis is avoided during treatment of DKA CHRONIC COMPLICATIONS OF DM DIABETIC RETINOPATHY *DIABETIC NEUROPATHY PREVENTIVE FOOT CARE *Prevent moisture from accumulating between toes *Wear loose socks & well-fitting (not tight) shoes & instruct client not to go barefoot *Change into clean cotton socks daily *Wear socks to keep feet warm *Do not wear the same shoes 2 days in a row *Do not wear open toed shoes or shoes with strap that goes between toes *Check shoes for tears or cracks in lining & for foreign objects before putting them on *Break in new shoes gradually *Cut toenails straight across & smooth nails with an emery board *Do not smoke HEALTH TEACHING Take insulin or oral hypoglycemic agents as prescribed. *Test blood glucose & test the urine for ketones every 3-4 hours *If meal plan cannot be followed, substitute with soft food 6-8 x per day *If vomiting, diarrhea or fever occurs, consume liquids every to 1 hour to prevent dehydration & to provide calories *Notify doctor if vomiting, diarrhea, or fever persists, if blood glucose levels are greater than 250 to 300 mg/dL, when ketonuria is present for more than 24 hours, when unable to take food or

fluids for a period of 4 hours, when illness persists for more than 2 days