ADVANCE NURSING
MANAGEMENT OF
ENDOCRINE DISEASES
OBJECTIVES
At the end of the unit, students will be able to:
Utilize Functional health pattern to identify patients
problems related to endocrine disorders including:
Diabetes Mellitus
Hypothyroidism/Hyperthyroidism
Parathyroid disorder
Integrate pathophysiology and pharmacology
concepts of endocrine disease
Apply nursing process with support on Evidence-
Based Nursing (EBN) to provide to the clients with
endocrine disorders
Discuss the holistic approach for nursing management
of the patient with endocrine diseases
Develop a teaching plan for a client experiencing
disorders of the endocrine disorders.
DIABETES MELLITUS
DIABETES MELLITUS
Definition
Diabetes mellitus is a metabolic disorder
characterized by hyperglycemia and results from
defective insulin production, secretion, or
utilization.
Pathophysiology and Etiology
There is an absolute or relative lack of insulin
produced by the beta cell, resulting in
hyperglycemia.
Defects at the cell level, impaired secretory
response of insulin to rises in glucose, and
increased nocturnal hepatic glucose production
(gluconeogenesis) are seen in type 2 diabetes.
Etiology of type 1 diabetes is not well understood;
viral, autoimmune, and environmental theories are
under review.
Etiology of type 2 diabetes involves heredity,
genetics, and obesity.
Risk factors for type 2 diabetes
Risk factors for type 2 diabetes in adults and
children include family history and ethnicity and
a variety of other factors.
Overweight (BMI ≥ 25 kg/m2)
Family history of diabetes (first-degree relative)
Sedentary lifestyle/habitual inactivity
Race/ethnicity (ie, Black, Hispanic American, Native
American, Alaskan American, and Pacific Islander)
Diagnosis of pre diabetes (either IFG or IGT)
Prior history of GDM or baby weighing > 9 lbs at birth
HTN ≥ 140/90 mm Hg
Risk factors for type 2 diabetes
HDL cholesterol ≤ 35 mg/dL and/or triglyceride level ≥ 250
mg/dL
History of polycystic ovary disease (PCOS)
History of vascular disease
CHILDREN
Family history of type 2 diabetes in first- or second-degree
relative
Race/ethnicity (ie, Native American, Black, Latino, Asian
American, Pacific Islander)
Signs of insulin resistance or conditions associated with
insulin resistance (ie, acanthosis nigricans, hypertension,
dyslipidemia, or PCOS)
Maternal history of GDM
Clinical Manifestations
Onset is abrupt with type 1 and insidious with type
2.
Hyperglycemia
Polyuria, polydipsia, polyphagia
Weight loss, fatigue
Blurred vision
Altered Tissue Response
Poor wound healing
Recurrent infections, particularly of the skin and genitourinary
(GU) tract.
Diagnostic Evaluation
Diabetes can be diagnosed in any of the following
ways (and should be confirmed on a different day
by any of these tests):
FBS of greater than or equal to 126 mg/dL
Random blood glucose of greater than or equal to 200
mg/dL with classic symptoms (polyuria, polydipsia,
polyphagia, weight loss) (Note: This presentation is
diagnostic and does not require retesting.)
OGTT greater than or equal to 200 mg/dL on the 2-hour
sample
Diagnostic Evaluation
Tests for glucose control over time are glycated
hemoglobin and fructosamine assay. These tests
are not used for screening/diagnosis.
Screening for type 2 diabetes:
Nonpregnant adults older than age 45: every 3 years or
every 1 to 2 years with any risk factors
Children: start screening at age 10 or onset of puberty if
overweight and has any type 2 risk factors and
screening every 2 years thereafter (fasting plasma
glucose is the preferred method).
Management
Diet
Dietary control with caloric restriction of carbohydrates
and saturated fats to maintain ideal body weight.
The goal of meal planning is to control blood glucose
and lipid levels.
Weight reduction is a primary treatment for type 2
diabetes.
Exercise
Regularly scheduled, moderate exercise performed 30
to 60 minutes most (ideally all) days of the week
promotes the utilization of carbohydrates, assists with
weight control, enhances the action of insulin, and
improves cardiovascular fitness.
Medication
Oral antidiabetic agents for patients with type 2
diabetes who do not achieve glucose control with
diet and exercise only (see Table 25-3).
Act by a variety of mechanisms, including stimulation of
insulin secretion from functioning beta cells, reduction of
hepatic glucose production, enhancement of peripheral
sensitivity to insulin, reduced absorption of
carbohydrates from the intestine, and suppressed
glucagon release.
Sulfonylureas and meglitinide analogues may cause
hypoglycemic reactions.
Biguanides, alpha-glucosidase inhibitors, incretin
mimetics and meglitinide analogues may cause
significant flatus and GI adverse effects.
Medication
Insulin therapy for patients with type 1 diabetes
who require replacement.
May also be used for type 2 diabetes when unresponsive
to diet, exercise, and oral antidiabetic therapy.
Hypoglycemia may result as well as rebound
hyperglycemia (Somogyi effect).
Commonly results in increased appetite and weight gain.
Complications
Acute
Hypoglycemia occurs as a result of an imbalance in
food, activity, and insulin/oral antidiabetic agent.
Diabetic ketoacidosis (DKA) occurs primarily in type
1 diabetes during times of severe insulin deficiency or
illness, producing severe hyperglycemia, ketonuria,
dehydration, and acidosis.
Hyperosmolar hyperglycemic nonketotic syndrome
(HHNKS) affects patients with type 2 diabetes, causing
severe dehydration, hyperglycemia, hyperosmolarity,
and stupor.
Complications
Chronic
In type 1 diabetes, chronic complications usually appear
about 10 years after the initial diagnosis.
The prevalence of microvascular complications
(retinopathy, nephropathy) and neuropathy is higher in
type 1 diabetes.
Because of its insidious onset, chronic complications can
appear at any point in type 2 diabetes. Approximately
50% will have at least one complication at time of
diagnosis.
Macrovascular complications—in particular
cardiovascular disease, occurring in type 1 and type 2
diabetes—are the leading cause of morbidity and
mortality among persons with diabetes.
Nursing Assessment
Obtain a history of current problems, family
history, and general health history.
Has the patient experienced polyuria, polydipsia,
polyphagia, and any other symptoms?
Number of years since initial diagnosis of diabetes
Family members diagnosed with diabetes, their
subsequent treatment, and complications
Perform a review of systems and physical
examination to assess for signs and symptoms of
diabetes, general health of patient, and presence
of complications.
General: recent weight loss or gain, increased fatigue,
tiredness, anxiety
Nursing Assessment
Skin: skin lesions, infections, dehydration, evidence of poor
wound healing
Eyes: changes in vision—floaters, halos, blurred vision, dry or
burning eyes, cataracts, glaucoma
Mouth: gingivitis, periodontal disease
Cardiovascular: orthostatic hypotension, cold extremities, weak
pedal pulses, leg claudication
GI: diarrhea, constipation, early satiety, bloating, increased
flatulence, hunger or thirst
GU: increased urination, nocturia, impotence, vaginal discharge
Neurologic: numbness and tingling of the extremities,
decreased pain and temperature perception, changes in gait
and balance
Nursing Diagnoses
Imbalanced Nutrition: More than Body Requirements
related to intake in excess of activity expenditures
Fear related to insulin injection
Risk for Injury (hypoglycemia) related to effects of insulin,
inability to eat
Activity Intolerance related to poor glucose control
Deficient Knowledge related to use of oral hypoglycemic
agents and injectable agents
Risk for Impaired Skin Integrity related to decreased
sensation and circulation to lower extremities
Ineffective Coping related to chronic disease and complex
self-care regimen
STANDARDS OF CARE GUIDELINES
Caring for Patients With Diabetes Mellitus
When caring for patients with diabetes mellitus:
Assess level of knowledge of disease and ability to care for
self
Assess adherence to diet therapy, monitoring procedures,
medication treatment, and exercise regimen
Assess for signs of hyperglycemia: polyuria, polydipsia,
polyphagia, weight loss, fatigue, blurred vision
Assess for signs of hypoglycemia: sweating, tremor,
nervousness, tachycardia, light-headedness, confusion
Perform thorough skin and extremity assessment for
peripheral neuropathy or peripheral vascular disease and any
injury to the feet or lower extremities
Assess for trends in blood glucose and other laboratory results
STANDARDS OF CARE GUIDELINES
Caring for Patients With Diabetes Mellitus
Make sure that appropriate insulin dosage is given at the right
time and in relation to meals and exercise
Make sure patient has adequate knowledge of diet, exercise,
and medication treatment
Immediately report to health care provider any signs of skin or
soft tissue infection (redness, swelling, warmth, tenderness,
drainage)
Get help immediately for signs of hypoglycemia that do not
respond to usual glucose replacement
Get help immediately for patient presenting with signs of either
ketoacidosis (nausea and vomiting, Kussmaul's respirations,
fruity breath odor, hypotension, and altered level of
consciousness) or hyperosmolar hyperglycemic nonketotic
syndrome (nausea and vomiting, hypothermia, muscle
weakness, seizures, stupor, coma).
HYPOTHYROIDISM/
HYPERTHYROIDISM
PARATHYROID
DISORDER
References
Bruner, L.S., & Suddarth, D.S. (2001). Text book
of Medical-Surgical Nursing (9th Ed.).
Philadelphia : Lippincott.
