chap 19 endocrine system

7/30/2019 Chap 19 Endocrine System

1/14

The Endocrine System

Normal Changes of Aging

Decreased secretion of insulin

Potential for thyroid function problems with systemicsymptoms that may be attributed to normal aging

Decreased sensitivity to insulin resulting in variation of

blood glucose levels Peripheral tissues may become insulin resistant,

especially with obesity

Review of Thyroid

Hormoneso Thyroxine (T4)o Triiodothyronine (T3)

o Thyrotropin-releasing hormone (TRH) producing ofthyroid-stimulating hormone (TSH) [T4 + T3]production + increased carbohydrate, protein, and

lipid metabolism negative feedback decreasedTSH + TRH

Altered Thyroid Function with Agingo Gland atrophyo Nodularity of thyroid gland, especially areas with

low iodine levelso Elevated thyroid antibody levelso Decreased T4 production but serum T4 unchanged

because of diminished use

Decline in lean body masso Decreasing T3 levelso Elevated TSH levels

Impact of age-related changes on endocrine function.

Diabetes Mellitus (DM)

Statistics for older adultso Highest prevalence ages 65 to 74o Second highest, > 75 yearso Thirteen times > than in persons < 45 years oldo Ethnic groups

Higher for African Americans and Hispanicso African American women < 75 years of age

at highest prevalence, except Hispanicmales after age 75


2/14

More likely to develop microvascularcomplications

More lower limb amputations than Caucasians

Statistics for Older Adultso Higher death rates from other illnesses

Pneumonia

Influenza

Heart diseaseo Greater functional disabilityo More coexisting illnesso Greater risk

Depression

Cognitive impairment

Urinary incontinence

Falls

Persistent pain

Pathophysiologyo Defective insulin secretion and/or defective

utilization of insulin abnormally high bloodglucose damage to multiple organs + bloodvessels + nervous system

Type 1

o -cell destruction lack of or underproduction ofinsulin

o Cause Autoimmune disease

Idiopathico Insulin dependento At risk for ketoacidosis

Type 2o Most prevalent in all age groupso Decreased insulin ability to stimulate glucose

uptake by skeletal muscle + failure to inhibit

hepatic glucose production Insulin resistance +insulin secretory defect rising glucose levels +more insulin production

o Symptoms

Visceral/abdominal obesity

Hypertension

Hyperlipidemia

Coronary artery disease


3/14

Others

Rare ketoacidosis

Complications of DM

o Eye disease loss of vision or even blindnesso Kidney failureo Heart disease

o Nerve damage loss of feeling or pain in thehands, feet, legs, or other parts of the body(peripheral neuropathies)

o Strokeo Poor wound healing

Impaired immune response

Poor tissue perfusion in peripheral vasculardisease

Blood Glucose Elevations withoutDMo

Glucocorticoidso Some diureticso Peritoneal dialysiso Infectiono Acute event, such as myocardial infarction

Diagnostics for DMo Physical examination

Especially sites at high risk for micro- andmacrovascular disease

o

Nutritional assessment including weighto Eye examinationo Electrocardiogram if patient has not had one within

10 years

Diagnostics for DM

Laboratory testso Thyroid function tests (TSH)o Urinalysis to test for albuminuria, and serum

creatinine for renal functiono

Fasting lipid profile to assess cardiovascular risko Glycosylated hemoglobin (HbA1c)

Medication review

Psychosocial assessment

Gait and balance evaluationNKHHC

Symptomatic hyperglycemia + inadequate fluid intakeNKHHC

Complication of type 2 DM with high mortality rate


4/14

o Widespread thrombosiso DIC

Symptoms of hyperglycemiao Dry moutho Extreme thirsto Excessive urinationo Fatigueo Blurred visiono Weight losso Nausea and vomitingo Abdominal pain

Laboratory values for NKHHCo Hyperglycemia (> 500 mg/dl)o Hyperosmolarityo Metabolic acidosiso Serum Na and K levels, usually normalo Increased blood urea nitrogen (BUN) and serum

creatinine levels

Prevalence of Thyroid Disease in Older Persons

Hypothyroidismo Women > men of all ageso Higher in institutionalized elderly than in older

community-residing elderly

Hyperthyroidismo Similar general population rates

Hypothyroidism Symptoms

Hypothyroidismnot the classic symptomso Fatigueo Increased need for sleepo Muscle acheso Dry skino Bradycardia, decreased contractility and stroke

volumeo Increased cholesterol levels (elevations in LDL)o Ataxia and balance difficultieso Hearing loss

Hypothyroidismo Depressiono Cold intoleranceo Hair loss


5/14

o Voice changeso Hypothermiao Periorbital swellingo Decreased appetite and weight loss

Other symptomso Neurological

Headache Vertigo

Relaxation of DTRs

Psychiatric disorders

Cognitive deficits

Visual disturbanceso Sensory

Numbness, tingle, and paresthesias

Other symptomso Musculoskeletal

Muscle fatigue

Cramps and myalgias

Joint effusions

Osteoporosis

Pseudogouto GI

Constipation and gaseous distention

o Achlorhydria and pernicious anemia Note: Older patients may have fewer symptoms than

younger patients.Hypothyroidism Diagnosis

Thyroid function testingo Free T4 and TSH

TSH gold standard

Serum T4

High sensitivity for elderlyo T3

Low in only 50% of hypothyroid elders

Nutritional deficiencies can slow peripheralconversion

Thyroid Function Testingo Other tests

T3-resin uptake

Assesses thyroxine and Triiodothyronine


6/14

Thyroglubulin levels

Marker for thyroid cancer

Thyroid antibody levels

Hashimotos thyroiditis

I 131 uptake

Graves disease

Physical examination

Comprehensive health assessment

Hyperthyroidism

Graves disease

Toxic nodular goiters

Medicationo Amiodaroneo Levothyroxine

Hyperthyroidism Signs and Symptoms

Exhibit fewer and different in elderly than in youngeradults

Most common in older adulto Tachycardia, > 90 beats/minute in older adults

Atrial fibrillationo Weight losso Fatigueo

Weakness or apathy

Hyperthyroidism Diagnosis

Comprehensive health history

Physical examinationo Emphasize

Cardiovascular assessment

BP, pulse rate, and rhythm

Thyroid palpation

Neuromuscular examination Eye exam with vision assessment

Laboratory testso TSH levelo Serum T3, T4, and thyroglobulin levels are lower in

elders with hyperthyroidism

Ultrasound

Fine-needle aspiration


7/14

Risk factors to health for the older person with an endocrineproblem

Risk Factors for Diabetes Mellitus

Genetics

Environmental factorsType 2 DM

Overweight (BMI > 25) with higher percentages of bodyfat

Weight may be normal with upper-body obesity increased waist-to-hip ratio (> 1)

Age over 45 risk increases with age African American, Hispanic/Latino American, Asian

American or Pacific Islander, or Native American ethnicgroups

Parent, brother, or sister with DM

Blood pressure above 140/90 Low levels of HDL (< 40 for men and < 50 for women)

(good cholesterol) and high levels of triglycerides (> 250mg/dL).

Gestational diabetes while pregnant or giving birth to alarge baby (more than 9 pounds)

Sedentary lifestyleexercising less than three times perweek

Impaired glucose tolerance

Random blood glucose levels > 160 mg/dL(NDEP, 2003)

Risk Factors for Developing Hypothyroidism

Older age

Female gender

History or diagnosis of thyroid diseaseo Goitero Thyroid noduleso Thyroiditiso Hyperthyroidism

Treatment of head or neck cancero External radiationo Iodine131

Risk Factors for Developing Hypothyroidism

Family history


8/14

Medicationso Lithiumo Amiodaroneo Sulfonylureaso Salicylateso Furosemideo Phenytoino Rifampino Radioactive contrast dyes

Unique presentation of diabetes and thyroid problems in theolder person.

Symptoms of DM in Older Persons

Anorexia

Incontinence

Falls Pain intolerance

Cognitive or behavioral changes

Symptoms of hyperglycemia (usually > 200 mg/dl)o Polydipsia (excessive thirst)o Weight losso Polyuria (excessive urination)o Polyphagia (excessive hunger)o Blurred visiono Fatigueo Nauseao Fungal and bacterial infections

Older womeno Perineal itching as a result of vaginal candidiasiso Frequent urinary tract infections (UTIs)

Type 1 DM in the Elderly

Slower onset of hyperglycemia symptoms Absence of ketoacidosis

Note: Pancreatic cancer should be considered in olderadults with rapid onset weight loss, polyuria, polydypsia,and polyphagia with elevated blood glucose.

Complications of DM are accelerated in the elderly.

Blood glucose levels before breakfast are exaggerated inolder patients with DM.

Euthyroid sick syndrome


9/14

o Body compensates for decreased metabolic rates decreased TSH levels + low T4 levels

Nursing interventions directed toward assisting older adultswith endocrine problems to develop self-care abilities.

High-Risk Diabetic Foot Exam Presence of protective sensation

Vascular status

Skin integrity

Foot structure

Saving the Diabetic Foot

Identification of feet at risk

Prevention of foot ulcers

Treatment of foot ulcers Prevention of recurrence of foot ulcers

Hygieneo Lubricate dry areaso Dry between toes

Protectiono Mirror on or near the flooro Have podiatrist cut toenails

Management Goals of DM in the Older Person

Control of hyperglycemia and its symptoms

Prevention, evaluation, and treatment of macrovascularand microvascular complications

Self-management through education

Maintenance or improvement of general health status

Individualized Goals of DM

Highly functional older persono A fasting blood glucose level between 100 and 120

mg/dLo A postprandial glucose level of less than 180 mg/dLo An HbA1c under 8%

Older person with advanced microvascular complicationso A fasting glucose level of less than 140 mg/dL


10/14

o A postprandial glucose level of less than 200 to 220mg/dL

o An HbA1c under 10%

Controlling DM in the Older Person

Weight managemento Address elevated lipidso Maintain protein and calcium requirementso Maintain sodium restrictionso Control carbohydrate and fat intake at mealtimeso Eat a high-fiber dieto Snack during peak insulin or oral hypoglycemia

actiono Avoid alcohol

Physical exerciseo Avoid strenuous activities because of risk for retinal

detachmento Exercise carefully with peripheral neuropathieso Check blood glucose prior to exercise if taking

insulin

If < 100 mg/dL, eat additional carbohydrateso Avoid exercise if fasting glucose > 250 mg/dLo Obtain medical assessment prior to implementation

of program

Graded exercise test Radionuclide stress test

Physical exerciseo Benefits of walking

Getting more energy

Reducing stress

Improving sleep

Toning muscles

Controlling appetite

Increasing the number of calories burned bybody daily

Preventing complications of diabetes

Appropriate Use of Medications

Monotherapy or combinationo Combinations


11/14

Simplify dosing

May be less expensive

Antihyperglycemic drugs

Biguanides enhanced glucose uptake + muscleutilization increased insulin sensitivity

Metformino Weight losso Improved lipid profileo Rare hypoglycemiao Do not use if > 80 years or renal failure if serum

creatinine > 1.5 for men or > 1.4 for women

-glucosidase inhibitors slow digestion + delayedabsorption of carbohydrates decreased postprandialhypoglycemia

o Good for normal baseline blood glucose buthyperglycemic after eating a meal

o GI with flatulence and bloating

Thiazolidinediones activate intracellular receptors +repress hepatic glucose production enhanced insulinsensitivity

o Contraindicated

Acute liver disease

ALT > 2.5 times upper limit

CHF

AHA class III or IV

Oral Hypoglycemic Drugs

Sulfonylureas

o Second-generation stimulates beta cells increased insulin

hypoglycemia

Glyburide

If low blood sugar, monitor in hospital for 2to 3 days

Weight gain

Check sulfa allergy

Meglitinide stimulates insulin release in response tomeal


12/14

o Rapid onset with short durationo Do not take with a meal

Insulin

Used primarily with type 1

Long actingo Control blood glucose levelso Provide insulin after meal is digested

Short actingo Provide insulin after meal or snacks

Prevention of Complications

Acute illnesso Vaccinations

Annual influenza

Pneumococcal at age 65

Revaccinate if > 5 years and under 65years at initial vaccination

Hypoglycemiao Symptoms

Feeling nervous or shaky

Sweaty

Onset of excessive fatigue

Check blood twice, including after a snack

Hyperglycemiao Tendency for blood glucose level to rise before

breakfast is exaggerated in older patients with DM

Lipidso LDL < 100 mg/dLo HDL

> 45 mg/dL for men

> 55 mg/dL for women

Educate Regarding Acute Illness Acute illness can cause hyperglycemia

Call healthcare provider ifo Unable to keep food or liquids down or eat normally

for more than 6 hourso Occurrence of severe diarrheao Unintentional weight loss of 5 poundso Oral temperature higher than 101 F


13/14

o Blood glucose levels lower than 60 mg/dL or morethan 300 mg/dL

o Presence of large amounts of ketones in the urineo Difficulty breathingo Feeling sleepy or unable to think clearly

Nursing interventions

Six Geriatric Syndromes Associated with DM RequiringCareful Management

Polypharmacy

Depression

Cognitive impairment

Urinary incontinence

Injurious falls

Pain

The Goals of Therapy for Hypothyroidism Relieve symptoms

Provide sufficient thyroid hormone to decrease raisedserum TSH levels to the normal range

o If history of heart disease cardiac stress testingand complete cardiovascular risk assessment beforeinitiating treatment

Tailored to meet the needs of the individual patiento T4 replacement = Levothyroxine sodium

> 65 years 0.075 to 0.1 mg/day

CAD then begin 0.0125 to 0.025 mg/day

Increase gradually (0.025 mg) for 4 weekintervals

o TSH below normal

Decrease dose of levothyroxineo TSH above normal

Slowly increase dose of levothyroxine

Monitor Medications with Levothyroxine Interfere

o Aluminum hydroxideo Calcium preparationso Cholestyramineo Colestipolo Iron preparationso Sucralfate

Accelerate metabolism


14/14

o Rifampino Anticonvulsants

Monitoring Older Persons Receiving Treatment forHyperthyroidism

I131

o Treatment of choice for older adults

Other antithyroid drugso Prophylthiouracilo Methimazoleo Side effects of both drugs dose related

Skin rash, nausea, hepatitis, and arthritis

Careful monitoring for granulocytopenia

Watch for signs and symptoms of illness

Surgery

Beta-blockers for Hashimotos diseaseo Monitor cardiac status

Nursing Diagnoses for Older Patients with EndocrineDisorders

Type 2 DM and obesityo Imbalanced nutrition: more than body requirementso Risk for infectiono Risk for sensory/perceptual alterations: tactile

Thyroid disorderso Sleep deprivationo Fatigueo Risk for activity intoleranceo Ineffective thermoregulationo Risk for imbalanced body temperature

chap 19 endocrine system

Documents