Anatomy and Physiology of the Endocrine

System

 
 

Endocrine Gland Hormone Functions

Hypothalamus
Corticotropin-releasing hormone Activates the synthesis and release of adrenocorticotropic
(CRH) hormone (ACTH) from the pituitary gland.

Gonadotropin-releasing hormone Controls the synthesis and release of luteinizing hormone and
(GnRH) follicle-stimulating hormone in the anterior pituitary.

Plays an inhibitory role in the normal regulation of several organ

Growth hormone-inhibiting systems including the CNS, hypothalamus and anterior pituitary
hormone (GHIH) gland, the GI tract, the exocrine and endocrine pancreas , and
the immune system.

Growth hormone-releasing Stimulate the pituitary gland to produce and release growth
hormone (GHRH) hormone into the bloodstream.

Thyrotropin-releasing hormone Regulator of thyroid gland growth and function, including the
(TRH) secretion of the thyroid hormones thyroxine and triiodothyronine.

Melanocyte-inhibiting hormone Inhibits the release of melanocyte-stimulating hormones.

(MIH)
 Prolactin-inhibiting hormone (PIH) Inhibits prolactin and thereby milk production.

Adrenocorticotropic hormone Controls functions of the adrenal glands. Promotes release of

(ACTH) glucocorticoids and androgens from adrenal cortex.

Stimulates follicle maturation and production of estrogen;

Follicle-stimulating hormone (FSH)
stimulates sperm production

Concerned with growth of cells, bones and soft tissues. It affects

Growth hormone (GH)
carbohydrate, protein and fat metabolism.
Anterior Pituitary
Gland
Triggers ovulation and production of estrogen and progesterone
Luteinizing Hormone (LH)
by ovary; promotes sperm production.

Melanocyte-stimulating hormone
Necessary for pigmentation.
(MSH)

Prolactin Necessary for breast development and lactation.

Thyroid-stimulating hormone (TSH) Controls the production of the thyroid hormones.

Promotes “let-down” reflex in a lactating breast and causes

Oxytocin
increased uterine contraction after labor has begun.
Posterior Pituitary
Gland
Major control of osmolality and body water volume. It increases
Antidiuretic hormone (ADH)
water reabsorption in the collecting ducts of the kidneys.

Triiodothyronine (T3) Regulate metabolic rate of cells and stimulate sympathetic

Thyroxine (T4) nervous system (SNS) activity.
Thyroid glands

Thyrocalcitonin (Calcitonin) Inhibits osteoclastic activity and lowers serum calcium levels.

Regulates calcium and phosphorous balance. Elevates serum

Parathyroid glands Parathormone
calcium levels by withdrawal of calcium from the bones.

Adrenal glands Epinephrine Short-term stress response; increase blood sugar levels,
(Medulla) Norepinephrine vasoconstriction, increase heart rate, blood diversion.

Long-term stress response; increase blood glucose levels, blood

Glucocorticoids (Cortisol)
volume maintenance, immune suppression

Adrenal glands
Long-term stress response; blood volume and blood pressure
Mineralocorticoids (Aldosterone)
(Cortex) maintenance, sodium and water retention by kidneys.

Sex hormones
Responsible for some secondary sex characteristics in females.
(Androgen and Estrogen)
 Glucagon Enhances gluconeogenesis and elevates blood glucose levels.
Pancreas

Insulin Increase glycogenesis and fatty acid synthesis.

Hypopituitarism
 Loss of function in an endocrine gland due to failure of the pituitary gland to secrete hormones which stimulate that
gland’s function.

 Causes:
1. Tumors
2. Trauma
3. Encephalitis
4. Autoimmunity
5. Stroke
6. Surgery or radiation of the pituitary gland

 Dwarfism – hyposecretion of growth hormone. It is characterized by failure to grow in height.

 Panhypopituitarism – this condition represents the loss of all hormones released by the anterior pituitary gland. This is
also known as complete pituitary failure.

1. In this condition, the thyroid gland, the adrenal cortex, and the gonads atrophy because of loss of the trophic-
stimulating hormones.

 
 

 Interventions:

1. Hormone replacement for the specific deficient hormone.

2. Provide client education regarding the signs and symptoms of hypofunction and hyperfunction related to insufficient
or excess hormone replacement.
3. Provide emotional support to the client and family.
4. Encourage the client and family to express feelings related to disturbed body image or sexual dysfunction.

Hyperpituitarism
 Hyperfunction of the anterior pituitary hormone.
 Frequently caused by benign pituitary adenoma or may result also from hyperplasia of pituitary tissue.

 Clinical manifestations:

1. Overproduction of growth hormone results in acromegaly in adults and gigantism in children.

 2. Hormonal imbalances
3. Neurologic manifestations:
1. Hemianopsia or scotomas
2. Headache
3. Somnolence
4. Sign and symptoms of increased intracranial pressure
5. Behavioral changes, seizures
6. Disturbance in appetite, sleep, temperature regulation and emotional balance due to hypothalamic involvement.
4. Endocrine manifestations:

1. Irregular menses, anovulatory periods, oligomenorrhea and amenorrhea

2. Infertility
3. Galactorrhea
4. Dyspareunia, vaginal mucosa atrophy, decreased vaginal lubrication, decreased libido due to ovarian steroid
effect
5. Decreased libido and impotence, reduced sperm count, infertility and gynecomastia in males.

 Interventions:
1. Surgery: Transsphenoidal hypophysectomy
1.
1. Surgical removal of the pituitary gland through a transsphenoidal approach.
2. Post-operative interventions:
1. Elevate head of the bed at least 2 weeks to promote venous drainage and drainage from the surgical site.
2. Maintain nasal packing in place and reinforce as needed.
3. Provide frequent oral care with toothettes. To prevent trauma to the incision.
4. Instruct the client to avoid blowing the nose and activities that increase intracranial pressure (ICP).
5. Monitor for any postnasal drip or nasal drainage which might indicate leakage of cerebrospinal fluid (CSF).
Check nasal drainage for glucose. CSF is (+) for glucose.
6. Monitor for and report signs of temporary diabetes insipidus; monitor intake and output, and report
excessive urinary output.
7. Administer glucocorticoids and other hormone replacement as prescribed.
2. Radiation therapy or stereotactic radiosurgery.
3. Drugs:

1.
1.
1. Parlodel (Bromocriptine)
2. Somatuline Depot (Octreotide and Lanreotide)

DIABETES INSIPIDUS

 A disorder of water metabolism caused by deficiency of anti-diuretic hormone (Vasopressin) or by inability of the kidneys
to respond to ADH.
 Etiology:
1. Genetic problems
2. Head injury
3. Infection
4. Problem with the ADH-producing cells due to an autoimmune disease
5. Loss of blood supply to the pituitary gland
6. Surgery
7. Tumor in or near the pituitary gland

 Nephrogenic Diabetes Insipidus – involves a defect in the kidneys due to certain drugs, such as Lithium, genetic
problems, hypercalcemia, kidney diseases.
 Clinical manifestations:

1. Excretion of large amounts of dilute urine

2. Polydipsia
3. Dehydration
4. Inability to concentrate urine
5. Low urinary specific gravity
6. Fatigue
7. Muscle pain and weakness
8. Headache
9. Postural hypotension that may progress to vascular collapse without rehydration
10. Tachycardia

 Diagnostics:

1.

1. Fluid Deprivation Test

2. Plasma level measurement of ADH and urine osmolality

 Interventions:

1. Drugs:

 Desmopressin (DDAVP), a synthetic vasopressin administered intranasally

 Intramuscular administration of ADH, vasopressin tannate in oil
 For nephrogenic DI: Thiazide diuretics, mild salt depletion and prostaglandin inhibitors

2. Teach the patient and family about follow-up care and emergency measures and provide specific verbal and written
instructions, including the actions and side effects of all medications.
3. Provide information regarding the signs and symptoms of hyponatremia.
4. Instruct the client to wear a MedicAlert bracelet.

Syndrome of Inappropriate Antidiuretic

Hormone
 Excessive ADH secretion from the pituitary gland even in the face of subnormal osmolality. It is a disorder of impaired
water excretion caused by the inability to suppress the secretion of antidiuretic hormone.
 It may result in impaired water excretion and subsequently hyponatremia and hypo-osmolality.
 Etiology:

1. Trauma
2. Stroke
 3. Malignancies (often in the lungs or pancreas)
4. Medications
5. Stress

 Clinical manifestations:

1. Signs of fluid volume overload

2. Anorexia
3. Nausea and vomiting
4. Irritability
5. Abdominal cramps
6. Low urinary output and concentrated urine
7. Cerebral edema manifesting as headache, generalized weakness, hyporeflexia, confusion, seizures, muscle cramps

 Interventions:

1. Eliminate underlying cause, if possible.

2. Restrict fluid intake.
3. Closely monitor fluid intake and output, daily weight, urine and blood chemistries and neurologic status.
4. Implement seizure precautions.
5. Administer IV fluids (usually normal saline [NS] or hypertonic saline) as prescribed.
6. Drugs:

1.

 Demeclocycline (Declomycin) – inhibits ADH-induced water reabsorption and produces water diuresis.
 Diuretics such as furosemide (Lasix) may be used along with fluid restriction if severe hyponatremia is
present.

Hyperthyroidism  

Definition: Increased synthesis of thyroid hormone from overactivity (Graves’ disease) or change in thyroid gland (toxic
nodular goiter)
Causes: 

 Autoimmune disease
 Genetic
 Psychological or physiologic stress
 Thyroid adenomas
 Pituitary tumors
 Infection

Assessment findings: 

 Anxiety
 Flushed, smooth skin
 Heat intolerance
 Mood swings
 Diaphoresis
 Tachycardia
 Palpitations
 Dyspnea
 Weakness
 Increased hunger
 Increased systolic blood pressure
 Tachypnea
 Fine hand tremors
 Exophthalmos
 Weight loss
 Diarrhea
 Hyperhidrosis
 Bruit or thrill over thyroid

Diagnostic test findings: 

 Thyroid scan: nodules

 Blood chemistry: increased T3, T4, protein-bound iodine, radioactive iodine (131); decreased TSH, cholesterol
 ECG: atrial fibrillation
 RAIU: increased

Medical Management: 

1. Diet: high-protein, high-carbohydrate, high-calorie; restrict stimulants, such as coffee and caffeine
2. IV therapy: saline lock
3. Activity: bed rest
4. Monitoring: vital signs and I/O
5. Laboratory studies: T3, T4
6. Sedative: lorazepam (Ativan)
7. Radiation therapy
8. Antihyperthyroids: methimazole (Tapazole), propylthiouracil (Propyl-Thyracil)
9. Iodine preparations: potassium iodide, radioactive iodine
10. Beta-adrenergic blocking agents: propranolol (Inderal)
11. Vitamins: thiamine (vitamin B,), ascorbic acid (vitamin C)
12. Cardiac glycoside: digoxin (Lanoxin)
13. Glucocorticoids: prednisone (Deltasone); IV hydrocortisone (Solu-Cortef) for thyroid storm
14. IV glucose

Nursing interventions: 

1. Maintain the patient's diet

2. Avoid stimulants, such as drugs and foods that contain caffeine
3. Administer IV fluids
4. Assess fluid balance
5. Assess cardiovascular status
6. Monitor and record vital signs, I/O, and laboratory studies
7. Administer medications, as prescribed
8. Weigh the patient daily
9. Provide rest periods
10. Provide a quiet, cool environment
11. Provide eye care
12. Allay the patient’s anxiety
13. Encourage the patient to express his feelings about changes in his body image
14. Provide post-radiation nursing care

o
 Provide prophylactic skin, mouth, and perineal care
 Monitor dietary intake
 Provide rest periods
15. Individualize home care instructions (for teaching tips, see Patients with endocrine disorders)

1.

 Stop smoking
 Recognize the signs and symptoms of thyroid storm
 Adhere to activity limitations
 Avoid exposure to people with infections
 Monitor self for infection

Hypothyroidism
Definition: Underactive state of thyroid gland, resulting in absence or decreased secretion of thyroid hormone
Causes: 

 Autoimmune disease: Hashimoto's thyroiditis

 Thyroidectomy
 Overuse of antithyroid drugs
 Malfunction of pituitary gland
 Use of radioactive iodine

Assessment findings: 

 Fatigue
 Weight gain
 Dry, flaky, “doughy” skin
 Edema
 Cold intolerance
 Coarse hair
 Alopecia
 Thick tongue, swollen lips
 Mental sluggishness
 Menstrual disorders
 Constipation
 Hypersensitivity to narcotics, barbiturates, and anesthetics
 Anorexia
 Decreased diaphoresis
 Hypothermia

 
Diagnostic test findings: 

 Blood chemistry: decreased T3, T4, protein-bound iodine, sodium; increased TSH, cholesterol
 RAIU: decreased
 ECG: sinus bradycardia

Medical Management: 

1. Diet: high-fiber, high-protein, low-calorie with increased fluid intake

2. Activity: as tolerated
3. Monitoring: vital signs and I/O
4. Laboratory studies: T3, T4, and sodium
5. Stool softener: docusate (Colace)
6. Thyroid hormone replacements: levothyroxine (Synthroid), liothyronine (Cytomel), thyroglobulin (Proloid), liotrix
(Thyrolar)

Nursing Interventions: 
1. Maintain the patient's diet
2. Encourage fluids
3. Monitor and record vital signs, 1/O, and laboratory studies
4. Administer medications, as prescribed
5. Encourage the patient to express his feelings of depression
6. Encourage physical activity and mental stimulation
7. Provide a warm environment
8. Avoid sedation: administer one-third to one-half the normal dose of sedatives or narcotics
9. Check for constipation and edema
10. Prevent skin breakdown
11. Provide frequent rest periods
12. Individualize home care instructions
13. Exercise regularly
14. Recognize the signs and symptoms of myxedema coma (see understanding myxedema coma)
15. Monitor self for constipation
16. Use additional protection in cold weather
17. Limit activity in cold weather
18. Avoid using sedatives
19. Complete skin care daily

Hyperparathyroidism
Definition: Overactivity of one or more parathyroid glands, resulting in increased PTH secretion
Causes: 

 Chronic renal failure

 Bone disease
 Benign adenomas
 Hypertrophy of parathyroid gland
 Malignant tumors of parathyroid gland
 Vitamin D deficiency
 Malabsorption

 
Assessment findings: 

 Renal colic
 Renal calculi
 Arrhythmias
 Constipation
 Bowel obstruction
 Anorexia
 Weight loss
 Nausea and vomiting
 Depression
 Mental dullness
 Fatigue
 Osteoporosis
 Muscle weakness
 Mood swings
 Deep bone pain
 Hematuria
 Paresthesia
 Thick nails
 Pathologic fractures
Diagnostic test findings: 

 ECG: shortened QT interval

 Urine chemistry: decreased phosphorus; increased calcium
 Blood chemistry: increased calcium, BUN, creatinine, chloride, alkaline phosphatase; decreased phosphorus
 X-ray: osteoporosis

Medical Management: 

1. Diet: low-calcium, high-fiber, high-phosphorus in small frequent feedings; increase fluid intake to 3,000 ml/day
2. IV therapy: saline lock
3. Activity: as tolerated
4. Monitoring: vital signs and I/O
5. Laboratory studies: calcium, phosphorus, BUN, creatinine, potassium, and sodium
6. Radiation therapy
7. Treatments: strain urine, bed cradle
8. Analgesic: oxycodone (Vicodin)
9. Diuretics: furosemide (Lasix), ethacrynic acid (Edecrin)
10. Antacid: aluminum hydroxide gel (AlternaGEL)
11. Estrogen: estrogen (Premarin)
12. Antineoplastic: plicamycin (Mithracin)
13. Phosphate salts: K-Phos, Neutra-Phos
14. Dialysis using calcium-free dialysate
15. IV saline

Nursing Interventions: 

1. Maintain the patient's diet

2. Encourage fluids with acidifying solutions: cranberry juice
3. Administer IV fluids
4. Assess urinary status
5. Monitor and record vital signs, 1/O, and laboratory studies
6. Administer medications, as prescribed
7. Encourage the patient to express his feelings about chronic illness
8. Encourage the patient to walk
9. Prevent falls
10. Strain urine
11. Assess bone and flank pain
12. Move the patient carefully to prevent pathologic fractures
13. Limit strenuous activity
14. Assess the patient for constipation
15. Provide postradiation nursing care
16. Provide skin and mouth care
17. Monitor dietary intake
18. Provide rest periods
19. Individualize home care instructions
20. Recognize the signs and symptoms of renal calculi
21. Strain urine
22. Prevent falls
23. Prevent constipation

Hypoparathyroidism
Definition: Decrease in PTH secretion
Causes: 

 Thyroidectomy
 Autoimmune disease
 Parathyroidectomy
 Radiation
 Use of radioactive iodine
 Parathyroid tumor

 
 
 
Assessment findings: 

 Lethargy
 Calcification of ocular lens
 Muscle and abdominal spasms
 Trousseau’s sign: positive
 Chvostek’s sign: positive
 Tingling in fingers
 Arrythmias
 Seizures
 Vision disturbances: diplopia, photophobia, blurring
 Dyspnea
 Laryngeal stridor
 Personality changes
 Brittle nails
 Alopecia
 Deep tendon reflexes: increased

 
Diagnostic test findings: 

 Blood chemistry: decreased PTH, calcium; increased phosphorus

 Urine chemistry: decreased calcium
 X-ray: calcification of basal ganglia; increased bone density
 ECG: prolonged QT interval
Medical management: 

1. Diet: high-calcium, low-phosphorus, low-sodium with spinach restriction

2. Activity: as tolerated
3. IV therapy: saline lock
4. Monitoring: vital signs and I/O
5. Laboratory studies: PTH, calcium, and phosphorus
6. Precautions: seizure
7. Antacid: aluminum hydroxide gel (AlternaGGEL)
8. Sedative: zolpidem (Ambien)
9. Anticonvulsants: phenytoin (Dilantin), magnesium sulfate (Epsom salt)
10. Vitamins: ergocalciferol (vitamin D), dihydrotachysterol (Hytakerol)
11. Oral calcium salts: calcium gluconate (Kalcinate), calcium Carbonate (Os-Cal)
12. Diuretic: furosemide (Lasix)
13. Hormone replacement: parathyroid extract (PTH)
14. IV calcium salts: calcium chloride or calcium gluconate

Nursing interventions: 

1. Maintain the patient's diet

2. Assess neurologic status
3. Maintain seizure precautions
4. Monitor and record vital signs, I/O, and laboratory studies
5. Administer medications, as prescribed
6. Allay the patient's anxiety
7. Keep tracheostomy tray and LV. calcium gluconate available
8. Maintain a calm environment
9. Individualize home care instruction
10. Recognize the signs and symptoms of seizure activity
11. Follow dietary recommendations

Cushing's Syndrome
Definition: Hyperactivity of the adrenal cortex that results in excessive secretion of glucocorticoids, particularly
cortisol. Possible increase in mineralocorticoids and sex hormones
Causes:  

 Hyperplasia of the adrenal glands

 Hypothalamic stimulation of the pituitary gland
 Adenoma or carcinoma of the pituitary gland
 Exogenous secretion of corticotropin by malignant neoplasms in the lungs or gallbladder
 Excessive or prolonged administration of glucocorticoids or corticotropin
 Adenoma or carcinoma of the adrenal cortex

Assessment findings: 

 Weight gain 
 Hirsutism
 Amenorrhea
 Weakness and fatigue
 Pain in joints
 Ecchymosis
 Edema
 Hypertension
 Mood swings
 Fragile skin Girdle
 Purple striae on abdomen
 Poor wound healing
 Truncal obesity
 Buffalo hump
 Moon face
 Gynecomastia
 Enlarged clitoris
 Decreased libido
 Muscle wasting
 Recurrent infections
 Acne

 
Diagnostic test findings: 

 Dexamethasone suppression test: no decrease in 17-OHCS

 X-ray: pituitary or adrenal tumor; osteoporosis
 Angiography: pituitary or adrenal tumors
 CT scan: pituitary or adrenal tumors
 Urine chemistry: increased 17-OHCS and 17-K5; decreased specific gravity; glycosuria
 Blood chemistry: increased cortisol, aldosterone, sodium, corticotropin, glucose; decreased potassium
 Ultrasonography: pituitary or adrenal tumors
 Hematology: increased WECs, RBCs; decreased eosinophils
 GTT: hyperglycemia

Medical Management: 

1. Diet: low-sodium, low-carbohydrate, low-calorie, high-potassium, and high-protein

2. Activity: as tolerated
3. Monitoring: vital signs, I/O, urine glucose and ketones, and specific gravity
4. Laboratory studies: sodium, potassium, cortisol, BUN, glucose, WBCs, and RBCs
5. Radiation therapy
6. Diuretics: furosemide (Lasix), ethacrynic acid (Edecrin)
7. Potassium supplements: potassium chloride (K-Lor), potassium gluconate (Kaon)
8. Adrenal suppressants: metyrapone (Metopirone), aminoglutethimide (Cytadren)
9. Hypoglycemics: rapid-acting (Lispro); short-acting (regular); intermediate-acting (NPH); long-acting (Lente, Lantus-insulin
glargine); glyburide (DiaBeta, Micronase, Amaryl); glipizide (Glucotrol, Glucotrol XL)

Nursing Interventions: 

1. Maintain the patient's diet

2. Assess fluid balance
3. Monitor and record vital signs, I/O, specific gravity, blood glucose levels, urine glucose and ketones, and laboratory
studies
4. Assess edema
5. Check for infections of skin, respiratory, and urinary tracts
6. Protect the patient from falls and bruising
7. Protect from infection
8. Provide meticulous skin care
9. Limit water intake
10. Weigh the patient daily
11. Administer medications, as prescribed
12. Encourage the patient to express his feelings about changes in his body
13. image and sexual function
14. Provide rest periods
15. Minimize environmental stress
16. Provide post-radiation nursing care

1.

 Provide prophylactic skin care

 Monitor dietary intake
 Provide rest periods
 Assess for hypoglycemia

17. Individualize home care instructions

o
 Recognize the signs and symptoms of infection and fluid retention
 Avoid exposure to people with infections
 Monitor self for infection

Addison's Disease
Definition: Chronic hypoactivity of the adrenal cortex, resulting in insufficient secretion of glucocorticoids (cortisol) and
mineralocorticoids (aldosterone)
Causes: 

 Idiopathic atrophy of adrenal glands

 Surgical removal of adrenal glands
 Autoimmune disease
 Tuberculosis
 Metastatic lesions from lung cancer
 Pituitary hypofunction
 Histoplasmosis
 Trauma

Assessment findings: 

 Hypoglycemia
 Weakness and lethargy
 Bronzed skin pigmentation of nipples, scars, and buccal mucosa
 Dehydration
 Anorexia
 Thirst
 Decreased pubic and axillary hair
 Orthostatic hypotension
 Diarrhea
 Nausea
 Weight loss
 Depression

 
Diagnostic test findings: 

 Blood chemistry: decreased HCT, Hb, cortisol, glucose, sodium, chloride, aldosterone; increased BUN, potassium
 Urine chemistry: decreased 17-KS and 17-OHCS
 Basal metabolic rate (EMR): decreased
 Fasting serum glucose: hypoglycemia
 ECC: prolonged PR and OT intervals

Medical Management: 
1. Diet: high-carbohydrate, high-protein, high-sodium, low-potassium in small, frequent feedings before steroid therapy;
high-potassium and low sodium when on steroid therapy
2. IV therapy: hydration, electrolyte replacement: saline lock
3. Activity: bed rest
4. Monitoring: vital signs, I/O, and specific gravity
5. Laboratory studies: sodium, potassium, osmolality, cortisol, chloride, glucose, BUN, creatinine, Hb, and HCT
6. IV saline
7. Vasopressors: phenylephrine (Neo-Synephrine), norepinephrine (Levophed), dopamine (Intropin)
8. Antacids: magnesium and aluminum hydroxide (Maalox), aluminum hydroxide gel (Gelusil)
9. Mineralocorticoid (aldosterone): fludrocortisone (Florinef)
10. Glucocorticoids: cortisone (Cortone), hydrocortisone (Solu-Cortef)

Nursing Interventions: 

1. Maintain the patient's diet

2. Administer IV fluids
3. Monitor and record vital signs, I/O, specific gravity, and laboratory studies
4. Weigh the patient daily
5. Administer medications, as prescribed
6. Allay the patient's anxiety
7. Protect the patient from falls
8. Encourage fluid intake
9. Assist with activities of daily living
10. Maintain a quiet environment
11. Individualize home care instructions

1.

 Avoid strenuous exercise, particularly in hot weather

 Recognize the signs and symptoms of adrenal crisis
 Increase fluid intake in hot weather
 Carry injectable dexamethasone (Decadron)
 Avoid using OTC drugs

Pheochromocytoma
Definition: Catecholamine-secreting neoplasm associated with hyperfunctioning adrenal medulla
Causes: 

 Genetics
 Pregnancy
 Trauma

Assessment findings: 

 Labile malignant hypertension

 Throbbing headaches
 Diaphoresis
 Palpitations
 Tachycardia
 Excessive anxiety
 Hyperactivity
 Dilated pupils
 Cold extremities
 Weakness
 Weight loss
 Dyspnea
 Vertigo
 Angina
 Nausea
 Vomiting
 Anorexia
 Visual disturbances
 Polyuria
 Diarrhea
 Tinnitus
 Tremors

 
Diagnostic test findings: 

 CT scan: adrenal tumor

 Angiography: adrenal tumor
 Magnetic resonance imaging: adrenal tumor
 VMA: increased
 BOG: tachycardia
 Blood chemistries: increased BUN, creatinine, glucose, and catecholamines
 Urine chemistries: increased glucose and catecholamines

Medical Management: 

1. Diet: high-calorie, high-vitamin, and high-mineral with restricted use of stimulants such as caffeine beverage
2. Activity: as tolerated
3. Monitoring: vital signs, I/O, and urine glucose and ketones
4. Position: semi-Fowlers
5. Laboratory studies: BUN, creatinine, and glucose
6. Sedative: lorazepam (Ativan)
7. Alpha-adrenergic blockers: prazosin (Minipress), doxazosin (Cardura), terazosin (Hytrin)
8. Beta-adrenergic blocker: propranolol (Inderal)
9. Vasodilator: clonidine (Catapres), IV nitroglycerine
10. Catecholamine inhibitor: metyrosine (Demser)

Nursing Interventions: 

1. Maintain the patient's diet

2. Assess cardiovascular status
3. Keep the patient in semi-Fowler’s position
4. Monitor and record vital signs, I/O, orthostatic blood pressure, specific gravity, urine glucose and ketones, neurovital
signs, and laboratory studies
5. Weigh the patient daily
6. Administer medications, as prescribed
7. Encourage the patient to express his feelings about fear of dying
8. Protect the patient from falls
9. Minimize environmental stress
10. Provide rest periods
11. Keep phentolamine (Regitine) available
12. Provide post-radiation nursing care

o
 Provide skin and mouth care
 Monitor dietary intake
 Provide rest periods
13. Individualize home care instructions

1.

 Stop smoking
 Recognize the signs and symptoms of renal failure
 Monitor blood pressure, urine glucose, and ketones daily

Hyperaldosteronism
Definition: Hypersecretion of aldosterone (mineralocorticoids) from adrenal cortex
Causes:  

 Adenoma of adrenal cortex

 Adrenal hyperplasia
 Adrenal carcinoma

Assessment findings: 

 Muscle weakness
 Polyuria
 Polydipsia
 Metabolic alkalosis
 Hypertension
 Postural hypotension
 Headache
 Paresthesia
 Pyelonephritis
 Nocturia
 Chvostek's sign: positive
 Trousseau's sign: positive

 
Medical Management: 

1. Diet: high-potassium, low-sodium

2. Activity: as tolerated
3. Monitoring: vital signs and I/O
4. Laboratory studies: potassium, sodium, calcium, and ABG analysis
5. Potassium salts: potassium chloride (KCI), potassium gluconate (Kaon)
6. Diuretics: spironolactone (Aldactone), acetazolamide (Diamox)
7. Calcium salts: calcium gluconate (Kalcinate), calcium carbonate (Os-Cal)

Nursing Interventions: 

1. Maintain the patient's diet, as tolerated

2. Monitor and record vital signs, I/O, orthostatic blood pressure, specific gravity, and laboratory studies
3. Monitor laboratory results: ABG analysis, sodium, potassium, and calcium
4. Administer medications, as prescribed
5. Allay the patient's anxiety
6. Weigh the patient daily
7. Provide a quiet environment
8. Individualize home care instructions cells

1.
  Recognize the signs and symptoms of fluid overload and muscle irritability
 Comply with medical follow-up

Diabetes Mellitus
Definition: Chronic disorder of carbohydrate metabolism with subsequent alteration of protein and fat metabolism. Results
from a disturbance in the production, action, and rate of insulin use
Five types of diabetes mellitus: 

1. Type 1 (insulin-dependent diabetes mellitus or ketosis-prone): usually develops in childhood

2. Type 2 (non-insulin-dependent diabetes mellitus or ketosis-resistant): usually develops after age 30
3. Gestational diabetes mellitus: occurs with pregnancy
4. Secondary diabetes: induced by trauma, surgery, pancreatic disease or medications; can be treated as type 1 or type 2
5. Maturity-onset diabetes: type 2 that develops in teens and young adults under age 30

Causes: 

 Failure of body to produce insulin

 Blockage of insulin supply
 Autoimmune disease
 Receptor defect in normally insulin-responsive cells
 Genetics
 Exposure to chemicals
 Hyperpituitarism
 Cushing’s syndrome
 Hyperthyroidism
 Infection
 Surgery
 Stress
 Medications
 Pregnancy
 Trauma

Assessment findings: 

 Weight loss
 Anorexia
 Polyphagia
 Acetone breath
 Weakness
 Fatigue
 Dehydration
 Pain
 Paresthesia
 Polyuria
 Polydipsia
 Kussmaul's respirations
 Multiple infections and boils
 Flushed, warm, smooth, shiny skin
 Atrophic muscles
 Poor wound healing
 Mottled extremities
 Peripheral and visceral neuropathies
 Retinopathy
 Sexual dysfunction
 Blurred vision

 
Diagnostic test findings: 
 Blood chemistry: increased glucose, potassium, chloride, ketones, cholesterol, and triglycerides; decreased carbon
dioxide; pH less than 7.4
 Urine chemistry: increased glucose, ketones
 Fasting serum glucose: increased
 GIT: hyperglycemia
 Postprandial blood glucose: hyperglycemia
 Glycosylated Hb assay: increased

Medical Management: 

1. Diet: individually prescribed diet based on ideal weight, metabolic activity, and personal activity levels
2. Use the American Diabetes Association's exchange list for meal planning to design a diet that will distribute an
individual’s caloric needs, carbohydrate, fat, and protein intake over 24 hours
3. Avoid refined and simple sugars and saturated fats
4. Limit cholesterol
5. Include high fiber and high complex carbohydrates
6. Activity: as tolerated
7. Monitoring: vital signs and I/O
8. Laboratory studies: glucose, potassium, glycosylated Hb, and pH, and liver and renal function tests
9. Hypoglycemics: rapid-acting (Lispro), short-acting (regular), intermediate- acting (NPH), long-acting (Ultralente, Lantus-
insulin glargine); glyburide (DiaBeta, Micronase, Amaryl); glipizide (Glucotrol, Glucotrol XL); metformin (Glucophage);
pioglitazone (Actos); rosiglitazone (Avandia); repaglinide (Prandin)
10. Vitamin and mineral supplements

Nursing Interventions: 

 Maintain the patient's diet

 Encourage fluids
 Assess acid-base balance
 Monitor and record vital signs, I/O, blood glucose levels, and laboratory studies
 Administer medications, as prescribed
 Encourage the patient to express his feelings about diet, medication regimen, and body image changes
 Encourage activity, as tolerated
 Weigh the patient weekly
 Provide meticulous skin and foot care
 Monitor the patient for infection
 Maintain a warm and quiet environment
 Monitor wound healing
 Observe for Somogyi phenomena and Sjögren’s syndrome
 Provide information about the American Diabetes Association
 Foster independence
 Determine the patient's compliance to diet, exercise, and medication regimens
 Individualize home care instructions

o
 Exercise regularly
 Stop smoking
 Recognize the signs and symptoms of hyperglycemia and hypoglycemia
 Monitor self for infection, skin breakdown, changes in peripheral circulation, poor wound healing, and numbness
in extremities
 Know and use proper dietary substitutions if unable to take prescribed diet because of illness
 Adjust diet and insulin for changes in work, exercise, trauma, infection, fever, and stress
 Demonstrate administration of hypoglycemics
 Demonstrate home blood glucose monitoring technique
 Complete daily skin and foot care
 Carry an emergency supply of glucose
 Seek counseling for sexual dysfunction and feelings about body image changes
 Avoid use of OTC medication
Anatomy and Physiology:
Musculoskeletal System
SKELETON

 Consists of 206 bones (long, short, flat, or irregular)

 Stores calcium, magnesium, and phosphorus; marrow produces red blood cells (RBCs)
 Works with muscles to provide support, locomotion, and protection of internal organs

SKELETAL MUSCLE

 Provide body movement and posture by tightening and shortening

 Attach to bones by tendons
 Begin contracting with the stimulus of a muscle fiber by a motor neuron
 Derive energy for muscle contraction from hydrolysis of adenosine triphosphate to adenosine diphosphate and
phosphate
 Retain some contraction to maintain muscle tone
 Relax with the breakdown of acetylcholine by cholinesterase

LIGAMENTS

 Tough bands of collagen fibers that connect bones

 Encircle a joint to add strength and stability

TENDONS

 Nonelastic collagen cords

 Connect muscles to bones

JOINTS

 Articulation of two bone surfaces

 Provide stabilization and permit locomotion; degree of joint movement is called range of motion (ROM)

SYNOVIUM

 Membrane that lines a joint’s inner surfaces

 Secretes synovial fluid and antibodies
 Reduces friction in joints (in conjunction with cartilage)

CARTILAGE

 Serves as a smooth surface for articulating bones

 Absorbs shock to joints

 Atrophies with limited ROM or in the absence of weight bearing

BURSA

 Fluid-filled sac

 Serves as padding to reduce friction

 Facilitates the motion of body structures that rub against each other

Fracture
 
 Definition: Break in the continuity of bone

 
 

 Causes: 

1. Trauma
2. Osteoporosis
3. Multiple myeloma
4. Bone tumors
5. Immobility
6. Malnutrition
7. Cushing's syndrome
8. Osteomyelitis
9. Steroid therapy
10. Aging

 Assessment findings: 
 1. Pain aggravated by motion
2. Tenderness over the fracture site
3. Loss of function or motion
4. Edema
5. Crepitus
6. Ecchymosis
7. Deformity
8. False motion
9. Paresthesia
10. Affected leg that appears shorter (fractured hip)

 Diagnostic test findings

1. X-ray: break in continuity of bone

2. Hematology: decreased Hb and HCT

 Medical management: 

1. Diet: high-protein, high-vitamin, and low-calcium; increase fluid intake

2. Position: elevate a fractured leg; keep the patient flat with the leg abducted for a fractured hip
3. Activity: as tolerated for extremity fractures; active and passive ROM exercises for unaffected limbs for fractured hip;
isometric exercises
4. Monitoring: vital signs, 1/O, and neurovascular checks
5. Laboratory studies: Hb, HCT, phosphorus, and calcium
6. Cast care, pin cate, ice packs, incentive spirometry, abductor pillow (fractured hip)
7. Analgesic: oxycodone and acetaminophen (Tylox)
8. Skin traction: Buck's, Bryant's, or Russell
9. Skeletal traction: Thomas splint with Pearson attachment, Steinmann pin, Kirschner wire, or Crutchfield tongs
(fractured neck)
10. Closed reduction with hip-spica cast (fractured hip)
11. Cast or closed reduction (fracture)

 Nursing interventions: 

1. Maintain the patient's diet; increase fluid intake

2. Assess neurovascular and respiratory status
3. Keep the patient in a flat position with the foot of the bed elevated 25 degrees (fractured hip)
4. Keep the legs abducted (fractured hip)
5. Elevate a fractured extremity
6. Monitor and record vital signs, I/O, and laboratory studies
7. Administer medications as prescribed
8. Allay the patient's anxiety
9. Provide skin, pin, and cast care
10. Turn the patient to the affected or unaffected side every 2 hours as ordered (fractured hip)
11. Keep the hip extended (fractured hip)
12. Maintain activity as tolerated (fractures)
13. Promote independence in ADLs
14. Provide active and passive ROM and isometric exercises for unaffected limbs
15. Provide a trapeze
16. Maintain traction to ensure proper body alignment and promote healing
17. Keep side rails up
18. Provide appropriate sensory stimulation with frequent reorientation
 19. Provide turning, coughing, and deep breathing and incentive spirometry
20. Prevent constipation as prescribed
21. Maintain proper body alignment
22. Inspect pin sites for infection
23. Provide diversional activities
24. Provide heel and elbow protectors and sheepskin
25. Apply antiembolism stockings
26. Use the logrolling technique to tum the patient
27. Individualize home care instructions

 Complete cast care (fracture)

 Attend physical therapy sessions
 Avoid weight bearing on affected limb 
 Complete skin and foot care daily 

Rheumatoid Arthritis
 Definition: Systemic inflammatory disease that affects the synovial lining of the joints
 Causes: 
1. Unknown
2. Autoimmune disease
3. Genetic transmission (increases susceptibility to the disease)

 Assessment findings:

1. Fatigue
2. Anorexia
3. Malaise
4. Elevated body temperature
5. Painful, swollen joints
6. Limited ROM
7. Subcutaneous nodules
8. Symmetrical joint swelling (mirror image of affected joints)
9. Morning stiffness
10. Paresthesia of the hands and the feet
11. Crepitus
12. Pericarditis
13. Splenomegaly
14. Leukopenia
15. Enlarged lymph nodes

 Diagnostic test findings: 

1. X-rays: joint space narrowing, bone erosions

2. Hematology: increased ESR, WBCs, platelets
3. Gamma globulin: increased immunoglobulin (Ig) M, IgG
4. Synovial fluid analysis: increased WBCs, decreased viscosity, opaque
5. Latex fixation test: positive rheumatoid factor
6. Tumor necrosis factor: elevated
7. ANA test: positive
 Medical management: 

1. Activity: as tolerated
2. Monitoring: vital signs and I/O
3. Analgesic: aspirin
4. Nonsteroidal anti-inflammatory drugs (NSAIDs): indomethacin (Indocin), ibuprofen (Motrin), sulindac (Clinoril),
piroxicam (Feldene), flurbiprofen (Ansaid), diclofenac (Voltaren), naproxen (Naprosyn), diflunisal (Dolobid), celecoxib
(Celebrex)
5. Biologic response modifiers: infliximab (Remicade), etanercept (Enbrel)
6. Glucocorticoids: prednisone (Deltasone), hydrocortisone (Cortef)
7. Antacids: magnesium and aluminum hydroxide (Maalox), aluminum hydroxide gel (Gelusil)
8. Gold therapy: gold sodium thiomalate (Aurolate)
9. Physical therapy
10. Heat therapy
11. Cold therapy
12. Plasmapheresis
13. Laboratory studies: ESR, WBCs
14. Antirheumatic: hydroxychloroquine (Plaquenil)
15. Antimetabolite: methotrexate (Rheumatrex)

 Nursing interventions: 

1. Assess neuromuscular status

2. Keep joints extended
3. Monitor and record vital signs, I/O, and laboratory studies
4. Administer medications as prescribed
5. Encourage the patient to express his feelings about changes in his body image and self-esteem
6. Provide skin care
7. Minimize environmental stress
8. Check joints for swelling, pain, and redness
9. Provide passive ROM exercises
10. Provide warm compresses and paraffin dips (heat therapy) as prescribed
11. Individualize home care instructions (for teaching tips, see Patients with musculoskeletal disorders)

 Provide information about the Arthritis Foundation

 Identify ways to reduce stress
 Avoid cold, stress, and infection
 Avoid unproven remedies
 Promote a quiet environment
 Complete skin and foot care daily

Osteoarthritis
 Definition: Degeneration of articular cartilage, usually affecting the weight-bearing joints (spine, knees, hips)
 Causes:
1. Aging
2. Obesity
3. Joint trauma
4. Congenital abnormalities

 Assessment findings: 

1. Pain relieved by resting joints

2. Joint stiffness
 3. Heberden’s nodes and Bouchard’s nodes
4. Limited ROM
5. Crepitation (a grating sensation associated with degenerative joint disease that can be heard or felt; it’s best detected
by palpation of the affected joint)
6. Increased pain in damp, cold weather
7. Enlarged, edematous joints
8. Smooth, taut, shiny skin

 Diagnostic test findings: 

1. X-rays: joint deformity, narrowing of joint space, bone spurs

2. Arthroscopy: bone spurs, harrowing of joint space
3. Hematology: increased ESE

 Medical management: 

1. Diet: low-calorie if not at optimal weight

2. Activity: as tolerated
3. Monitoring: vital signs and [/O
4. Heat therapy
5. Cold therapy
6. Isometric exercises, strengthening exercises, aerobic exercises
7. Weight reduction
8. Canes, walkers
9. Analgesic: aspirin
10. NSAIDs: indomethacin (Indocin), ibuprofen (Motrin), sulindac (Clinoril), piroxicam (Feldene), flurbiprofen (Ansaid),
diclofenac (Voltaren), naproxen (Naprosyn), diflunisal (Dolobid), rofecoxib (Vioxx)

 Nursing interventions: 

1. Maintain the patient's diet

2. Assess musculoskeletal status
3. Keep joints extended
4. Monitor and record vital signs and I/O
5. Administer medications as prescribed
6. Assess for increased bleeding or bruising
7. Urge the patient to express his feelings about changes in his body image
8. Provide skin care
9. Provide rest periods
10. Determine degree of joint mobility
11. Maintain calorie count
12. Assess pain and provide analgesics, as indicated
13. Provide moist compresses and paraffin baths (heat therapy) as prescribed
14. leach proper body mechanics
15. Provide passive ROM exercises
16. Individualize home care instructions

 Provide information about the Arthritis Foundation

 Avoid jogging, jumping, and lifting
 Identify ways to reduce stress
 Complete skin and foot care daily
Gouty Arthritis
 Definition: Inflammatory joint disease caused by the deposit of uric acid crystals
 Causes: 
1. Genetics
2. Decreased uric acid excretion
3. Chronic renal failure
4. Myxedema
5. Polycythemia vera
6. Hyperparathyroidism
 Assessment findings: 

1. Joint pain
2. Redness and swelling in joints
3. Tophi in great toe, ankle, and outer ear (see Gouty deposits)
4. Malaise
5. Tachycardia
6. Elevated skin temperature

 Diagnostic test findings: 

1. Hematology: increased ESR

2. Blood chemistry: increased uric acid
3. Synovial fluid analysis: sodium urate crystals

 Medical management: 

1. Diet: low-purine, alkaline-ash

2. Dietary recommendations: increase fluid intake to 3 qt (3 L)/day
3. Dietary restrictions: no shellfish, liver, sardines, anchovies, and kidneys; limited alcohol
4. Activity: as tolerated
5. Monitoring: vital signs and I/O
6. Laboratory studies: uric acid, ESR
7. Exercise program, including passive and active ROM exercises and ambulation as tolerated
8. Uricosuric agents: probenecid (Probalan), sulfinpyrazone (Anturane)
9. Xanthine-oxidase inhibitor: allopurinol (Zyloprim)
10. Antigout: colchicine
11. Analgesic: aspirin
12. NSAIDs: indomethacin (Indocin), ibuprofen (Motrin), sulindac (Clinoril), piroxicam (Feldene), flurbiprofen (Ansaid),
diclofenac (Voltaren), naproxen (Naprosyn), diflunisal (Dolobid)

 Nursing interventions: 

1. Maintain the patient’s diet

2. Encourage fluids to 3 qt (3 L)/day
3. Assess integumentary status
4. Monitor and record vital signs, I/O, and laboratory studies
5. Administer medications as prescribed
6. Allay the patient's anxiety
7. Provide skin care
8. Check joints for pain, edema, and ROM
 9. Provide a bed cradle
10. Reinforce exercise of joints; show the patient how to perform the exercises
11. Individualize home care instructions

 Provide information about the Arthritis Foundation

 Recognize signs and symptoms of gout
 Limit alcohol intake
 Avoid fasting
 Identify ways to reduce stress
 Complete skin and foot care daily

Osteomyelitis
 Definition: Bacterial infection of bone and soft tissue
 Causes: 
1. Staphylococcus aureus
2. Hemolytic streptococcus
3. Open trauma
4. Infection
 Assessment findings: 

1. Malaise
2. Elevated body temperature
3. Bone pain
4. Tachycardia
5. Localized edema and redness
6. Muscle spasms
7. Increased pain with movement

 Diagnostic test findings: 

1. Blood cultures: positive identification of organism

2. Hematology: increased WBCs, ESR
3. Wound culture: positive identification of organism
4. Bone biopsy: positive
5. Bone scan: positive

 Medical management: 

1. Diet: high-calorie, high-vitamin C and D, high-protein, and high-calcium

2. IV therapy: saline lock
3. Activity: bed rest
4. Monitoring: vital signs, I/O, and neurovascular checks
5. Laboratory studies: WBCs, ESR
6. Nutritional support: total parenteral nutrition (TPN)
7. Special care: wound and skin
8. Antibiotic: ciprofloxacin (Cipro)
9. Analgesic: oxycodone (Tylox)
10. Continuous wound irrigation
11. Heat therapy
12. Cast or splint for the affected body part
13. Antipyretic: aspirin
 Nursing interventions: 

1. Maintain the patient's diet

2. Encourage fluids to 3 qt (3 L)/day
3. Administer LV. fluids
4. Assess integumentary status
5. Maintain the patency of wound irrigation
6. Change dressings and irrigate wound using strict sterile technique
7. Monitor and record vital signs, 1/O, and laboratory studies
8. Administer TPN
9. Administer medications as prescribed
10. Encourage the patient to express his feelings about changes in his body image
11. Provide skin care
12. Turn the patient every 2 hours
13. Immobilize the affected body part
14. Maintain proper body alignment
15. Maintain bed rest
16. Provide cast and splint care
17. Assess pain
18. Individualize home care instructions

 Recognize the signs and symptoms of fractures

 Avoid exposure to people with infections
 Monitor self for infection
 Practice health routines that prevent infection
 Avoid weight bearing on the affected part

Osteoporosis
 Definition: A metabolic bone dysfunction that results in reduced bone mass and increased porosity. Metabolic illnesses
or medications that cause osteoporosis increase the risk of skeletal fracture
 Causes: 
1. Lowered estrogen levels
2. Immobility
3. Liver disease
4. Calcium deficiency
5. Vitamin D deficiency
6. Protein deficiency
7. Bone marrow disorders
8. Lack of exercise
9. Increased phosphorus
10. Cushing's syndrome
11. Hyperthyroidism

 Assessment findings:

1. Dowager’s hump (kyphosis)

2. Back pain: thoracic and lumbar
3. Loss of height
4. Unsteady gait
5. Joint pain
6. Weakness

 Diagnostic test findings: 

 1. X-ray: thin, porous bone; increased vertebral curvature
2. Dual energy X-ray absorptiometry scan: decreased bone mineral density

 Medical management: 

1. Diet: high in calcium, protein, vitamins, minerals, and boron

2. Dietary restrictions: limit caffeine and alcohol
3. Activity: as tolerated
4. Monitoring: vital signs and I/O
5. Laboratory studies: calcium, phosphorus
6. Estrogen: estradiol (Estrace)
7. Calcium supplement: calcium carbonate (Os-Cal)
8. Vitamin and mineral supplements
9. Exercise program
10. Thiazide diuretic: hydrochlorothiazide (Aldactazide, Dyazide)
11. NSAIDs: indomethacin (Indocin), ibuprofen (Motrin), sulindac (Clinoril), piroxicam (Feldene), flurbiprofen (Ansaid),
diclofenac (Voltaren), naproxen (Naprosyn), diflunisal (Dolobid

 Nursing interventions: 

1. Maintain the patient's diet

2. Assess musculoskeletal status
3. Monitor and record vital signs, 1/O, and laboratory studies
4. Administer medications as prescribed
5. Encourage the patient to express his feelings about changes in his body image
6. Individualize home care instructions

 Reinforce the importance of following an exercise program

 Teach proper body mechanics and posture
 Provide information about the Osteoporosis Foundation

7. Assess pain and administer analgesics, as indicated

Osteosarcoma
 Definition: Malignant bone tumor that invades the ends of long bones
 Causes: 
1. Osteoblastic activity
2. Osteolytic activity
 Assessment findings: 

1. Pain
2. Limited movement
3. Pathologic fractures
4. Soft tissue mass over the tumor site
5. Warm tissue over the tumor site
6. Elevated body temperature

 Diagnostic test findings: 

1. Bone scan: mass

2. Biopsy: cytology positive for cancer cells
 3. Computed tomography scan: mass
4. Blood chemistry: increased alkaline phosphatase
5. Bone marrow aspiration: cancer cells

 Medical management: 

1. Diet: high-protein
2. IV therapy: saline lock
3. Activity: as tolerated
4. Monitoring: vital signs and I/O
5. Laboratory studies: calcium, phosphorus
6. Antiemetics: prochlorperazine (Compazine), ondansetron (Zofran)
7. Nutritional support: TPN
8. Radiation therapy
9. Analgesics: oxycodone (Tylox), meperidine (Demerol)
10. Antineoplastics: cyclophosphamide (Cytoxan), vincristine (Oncovin)
11. Antidiarrheals: attapulgite (Kaopectate), loperamide (Imodium)

 Nursing interventions: 

1. Maintain the patient's diet

2. Assess integumentary and musculoskeletal status
3. Monitor and record vital signs, I/O, and laboratory studies
4. Administer TPN
5. Administer medications as prescribed
6. Encourage the patient to express his feelings about changes in his body image and a fear of dying
7. Provide postchemotherapeutic nursing care
8. Provide prophylactic skin, mouth, and perineal care

 Monitor dietary intake

 Administer antiemetics and antidiarrheals as prescribed
 Monitor for bleeding, infection, and electrolyte imbalance
 Provide rest periods

9. Assess pain
10. Individualize home care instructions

 Provide information about the American Cancer Society

 Recognize signs and symptoms of a fracture
 Avoid exposure to people with infections
 Monitor self for infections
 Monitor pain control interventions

Carpal Tunnel Syndrome

 Definition: Chronic compression neuropathy of the median nerve at the wrist
 Causes: 
1. Strenuous and repetitive use of the hands
2. Fractures and dislocations of the wrist
3. Bruising of the wrist
4. Menopause
5. Genetics
6. Pregnancy
 7. Tenosynovitis
8. Rheumatoid arthritis
9. Acromegaly
10. Hyperparathyroidism
11. Obesity
12. Gout
13. Amyloidosis

 Assessment findings: 

1. Nocturnal pain and paresthesia in the thumb and first three fingers, relieved by shaking the hand
2. Burning and tingling of the hand
3. Impaired sensation in the hand
4. Pain radiating to forearm, shoulder, neck, and chest
5. Thenar atrophy (mound on palm of hand at the base of the thumb)
6. Loss of fine motor movement of the hand
7. Weakness

 Diagnostic test findings: 

1. Tinel's sign: positive (tingling over median nerve on light percussion)

2. Motor nerve velocity studies: segmental, distal, median, and motor conduction delay, and conduction block at wrist

 Medical management: 

1. Diet: low-sodium
2. Dietary restrictions: limit fluids
3. Position: avoid flexion of the wrist; elevate the hand
4. Activity: avoid using the hand
5. Monitoring: vital signs, L/O, and neurovascular checks
6. Hand splint
7. Analgesic: acetaminophen (Tylenol)
8. Diuretic: furosemide (Lasix)
9. Glucocorticoid: cortisone (Cortone)
10. NSAIDs: indomethacin (Indocin), ibuprofen (Motrin), sulindac (Clinoril), piroxicam (Feldene), flurbiprofen (Ansaid),
diclofenac (Voltaren), naproxen (Naprosyn), diflunisal (Dolobid)
11. Vitamin: pyridoxine (Vitamin B6)

 Nursing interventions: 

1. Maintain the patient's diet

2. Assess neurovascular status
3. Elevate the patient's hand
4. Monitor and record vital signs
5. Administer medications as prescribed
6. Encourage the patient to express his feelings about inability to use the hand and to perform job requirements
7. Provide skin care
8. Provide ROM exercises to the splinted hand
9. Protect the hand from cold, burns, abrasions, local trauma, and chemical irritations
10. Avoid manual activity that includes dorsiflexion and volar flexion of the wrist
11. Individualize home care instructions
  Maintain ROM exercises for the hand
 Avoid activities that increase pain
 Alternate rest periods with activities involving the hand
 Protect the hand from trauma
 Splint the hand
 Consider vocational retraining, if appropriate
 Complete skin care daily

Herniated Nucleus Pulposa

 Definition: Rupture of intervertebral disk
 Two types of ruptured disk:
1. Lumbosacral (L4, L5)
2. Cervical (C5, C6, C7)
 Causes:

1. Accidents
2. Back or neck strain
3. Congenital bone deformity
4. Degeneration of disk
5. Weakness of ligaments
6. Heavy lifting
7. Trauma

 Assessment findings: 

Lumbosacral

1. Acute pain in the lower back radiating across the buttock and down the leg
2. Weakness, numbness, and tingling of the tnot and leg
3. Pain on ambulation

Cervical

1. Neck stiffness
2. Weakness, numbness, and tingling of the hand
3. Neck pain that radiates down the arm to the hand
4. Weakness of affected upper extremities
5. Atrophy of biceps and triceps
6. Straightening of normal lumbar curve with scoliosis away from the affected side

 Diagnostic test findings: 

1. Laségue’s sign: positive (pain radiating to the leg when hips and knees are flexed and knee is extended)
2. CSP analysis: increased protein
3. Myelogram: compression of spinal cord
4. EMG: spinal nerve involvement
5. X-ray: narrowing of disk space
6. Deep tendon reflexes: depressed or absent upper extremity reflexes or Achilles reflex

 
 Medical management: 

1. Diet: calories according to metabolic needs; increase fiber; force fluids

2. Keep the patient in semi-Fowler’s position
3. Activity: bed rest; active and passive ROM and isometric exercises
4. Monitoring: vital signs, I/O, neurovascular checks, and laboratory studies
5. Heating pad; moist, hot compresses
6. Orthopedic devices: back brace, cervical collar
7. Analgesic: oxycodone (Tylox)
8. Antacids: magnesium and aluminum hydroxide (Maalox), aluminum hydroxide gel (Gelusil)
9. Stool softener: docusate (Colace)
10. Pelvic traction
11. Cervical traction
12. Muscle relaxants: diazepam (Valium), cyclobenzaprine (Flexeril)
13. Chemonucleolysis using chymopapain (Chymodiactin)
14. NSAIDs: indomethacin (Indocin), ibuprofen (Motrin), sulindac (Chnoril) piroxicam (Feldene), flurbiprofen (Ansaid),
diclofenac (Voltaren), naproxen (Naprosyn), diflunisal (Dolobid)
15. Corticosteroid: cortisone (Cortone
16. Transcutaneous electrical nerve stimulation

 Nursing interventions: 

1. Maintain the patient's diet; increase fluid intake

2. Assess neurovascular status
3. Keep the patient in semi-Fowler’s position with moderate hip and knee
4. Monitor and record vital signs, I/O, and laboratory studies
5. Administer medications as prescribed
6. Encourage the patient to express his feelings about changes in his body image and about fears of disability
7. Provide skin and back care
8. Turn the patient every 2 hours using the logrolling technique
9. Maintain bed rest and body alignment
10. Maintain traction, braces, and cervical collar
11. Promote independence in ADLs
12. Apply bed boards
13. Individualize home care instructions

 Exercise regularly with special attention to exercises that strengthen and stretch the muscles
 Avoid lifting, sleeping in a prone position, climbing stairs, and riding in a car as prescribed
 Avoid flexion, extension, or rotation of the neck
 Use one pillow
 Use a back brace or cervical collar

Cataract
 Definition: Opacification of the normally clear, transparent crystalline lens
 Causes: 
1. Aging
2. Blunt or penetrating trauma
3. Long-term steroid treatment
4. Diabetes mellitus
5. Hypoparathyroidism
6. Radiation exposure
7. Anterior uveitis
 8. Ultraviolet light and sunlight exposure
9. Congenital

 Assessment findings: 

1. Disabling glare
2. Dimmed or blurred vision
3. Distorted images
4. Poor night vision
5. Yellow, gray, or white pupil
6. Loss of red reflex

 Diagnostic test findings: 

1. Endothelial cell counter: 2,000 cells/mL

2. A-scan ultrasound: areas of increased density around the nucleus of the lens
3. Ophthalmoscopy or slit lamp: reveals a dark area in the normally homogenous red reflex

 Nursing Interventions: 

1. Assess vision status

2. Allay the patient's anxiety
3. Encourage the patient to express his feelings about changes in his body image and effect on ADLs
4. Provide information about preventing cataracts, cataract progression, and surgery
5. Provide for the patient's safety
6. Individualize home care instructions (for more information about teaching, see Patients with a sensory disorder)

 Complications: 

7. Glaucoma
8. Blindness
9. Severe vision loss

 Possible surgical intervention: Cataract extraction

Glaucoma
 Definition: 
1. A group of diseases that differ in pathophysiology, clinical presentation, and treatment
2. Characterized by visual field loss because of damage to the optic nerve caused by increased IOP
3. The increased IOP results from pathologic changes that prevent normal circulation and outflow of aqueous humor
 Causes: 

1. Diabetes mellitus
2. Black race (increases risk)
3. Family history of glaucoma
4. Previous eye trauma or surgery
5. Long-term steroid treatment
6. Uveitis
 7. Congenital defects

 Possible assessment findings: 

1. Open-angle glaucoma

1. Initially asymptomatic
2. Usually bilateral
3. Narrowed field of vision
4. Atrophy and cupping of optic nerve head
5. Increased IOP
6. Mild headaches
7. Halos around lights

2. Acute angle-closure glaucoma

1. Typically unilateral
2. Acute eye or facial pain
3. Halo vision
4. Blurted vision
5. Redness in eye
6. Increased IOP
7. Atrophy and cupping of optic nerve head
8. Dilated pupil
9. Abrupt decrease in visual acuity

 Diagnostic test findings: 

1. Tonometry: increased IOP

2. Perimetry: decreased field of vision
3. Gonioscopy: angle open or closed
4. Ophthalmoscopy: atrophy and cupping of optic nerve head

 Medical management: 

1. Dietary restrictions: sodium and fluid

2. Activity: as tolerated
3. Monitoring: vital signs and I/O
4. Laboratory studies: tonometry, perimetry, ophthalmoscopy
5. Primary open-angle glaucoma

 Beta-adrenergic blocker: timolol (Timoptic)

 Adrenergic agonist: epinephrine (Epifrin)
 Carbonic anhydrase inhibitor: acetazolamide (Diamox)

6. Acute angle-closure glaucoma

 Cholinergic agent: pilocarpine (lopidine)

 Carbonic anhydrase inhibitor: acetazolamide (Diamox)
  Avoid such drugs as atropine, anticholinergics, or others with pupil dilating effects

 Nursing interventions: 

1. Maintain the patient's diet restrictions

2. Limit fluid intake
3. Assess vision status
4. Monitor and record vital signs, [I/O, and laboratory studies
5. Administer medications, as prescribed
6. Allay the patient's anxiety
7. Encourage the patient to express his feelings about changes in his body image
8. Assess eye pain
9. Individualize home care instructions

 Avoid rubbing eye

 Use hypoallergenic cosmetics
 Wear goggles while swimming
 Wear protective glasses while playing sports and working
 Monitor eye for redness, discharge, watering, blurred or cloudy vision, halos, flashes of light, and floaters
 Administer eyedrops according to instructions

 Complication: Blindness
 Surgical interventions: 

1. Primary open-angle glaucoma

 Laser or incisional trabeculoplasty with continued medication

 Laser or incisional trabeculectomy with continued medication
 Laser or incisional peripheral iridectomy

2. Acute angle-closure glaucoma

 Laser or incisional iridectomy

Retinal Detachment
 Definition: Separation of the sensory layers of the retina from the underlying retinal pigment epithelium
 Causes: 
1. Aging
2. Diabetic neovascularization
3. Familial tendency
4. Hemorrhage
5. Inflammatory process
6. Myopia
7. Trauma
8. Tumor
9. Intraocular surgery
 Assessment findings: 

1. Floating spots
2. Recurrent flashes of light (photopsia)
3. With progression of detachment, painless vision loss may be described as veil, curtain, or cobweb that eliminates
part of the visual field

 Diagnostic tests: 
 1. Ophthalmoscopy: gray or opaque retina; in severe detachment, retinal folds and ballooning out of the area
2. Indirect ophthalmoscopy: reveals retinal tear or detachment
3. Ultrasound: retinal tear or detachment in presence of cataract

 Medical management: 

1. Diet: no restrictions
2. Activity: complete bed rest with retinal hole or tear at lowest point of eye
3. Restrict eye movement until surgical reattachment

 Nursing interventions: 

1. Maintain the patient's diet

2. Monitor and record vital signs, I/O, and laboratory studies
3. Allay the patient's anxiety
4. Provide preoperative care

 Maintain bed rest with retinal hole or tear in lowest position

 Apply an eye patch
 Provide emotional support
 Explain procedure and what to expect postoperatively
 Administer preoperative antibiotics, as ordered
 Wash face with no-tear shampoo
 Administer cycloplegic-mydriatic eyedrops, as ordered

5. Provide postoperative care

 Position the patient according to the surgical procedure

 Tell the patient to avoid activities that increase IOP, such as coughing, sneezing, vomiting, lifting, straining during
bowel movements, bending from the waist, and rapidly moving the head
 Administer antiemetics, as indicated
 Protect the eye with a shield or glasses
 Apply cold compresses, as ordered
 Assess for pain and administer analgesics, as needed
 Administer cycloplegic and steroid-antibiotic eyedrops, as ordered

6. Individualize home care instructions

Instill eyedrops, as prescribed

Notify the physician if experiencing floaters, flashes of light, blurred vision, or pain unrelieved by analgesics
Report fever, yellow or green eye discharge, increased redness or puffiness of the eye, or reduced vision
Perform dressing changes
Wear an eye shield at might
Follow activity restrictions and head positioning
 Complications: Blindness
 Surgical interventions: 

1. Cryothermy
2. Laser therapy
3. Scleral buckling procedure

Anatomy and Physiology of the Ears

  
 

 External ear: 

 Portion of ear that includes the pinna (auricle) and external auditory canal
 Separated from the middle ear by the tympanic membrane
 Structures: External auditory canal Auricle, Helix, Anthelix, Concha, Antiragus, Lobule

 Middle ear: 

 Air-filled cavity in the temporal bone

 Contains three small bones (malleus, incus, and stapes)
 Opens to the eustachian tube or auditory tube, which connects to the nasopharynx
 Structures: Tympanic membrane malleus, incus, and stapes

 Inner ear: 

 Portion of the ear that consists of the cochlea, vestibule, and semicircular canals
 Also known as the labyrinth
 Structures: Vestibule, cochlea, semicircular canals, eustachian tube, acoustic nerve branches

 Sound transmission — airborne vibrations are transformed to sound through mechanical stimulation of the
endolymphatic fluids
 Equilibrium — Position changes of the head are detected by maculae or cristae

Meniere's Disease
 Definition: Condition of the inner ear characterized by recurrent and usually progressive symptoms, including vertigo,
tinnitus, a sensation of pressure in the ears, and neurosensory hearing loss
 Causes: 
1. Exact mechanism unknown
2. Possible causes:
 1. Abnormal hormonal influence on blood flow to the labyrinth
2. Excess labyrinth fluid (endolymph)
3. Allergic response
4. Autoimmune disorder
5.
Abnormal metabolites
 Assessment findings: 

1. Paroxysmal whirling vertigo with nausea and vomiting

2. Tinnitus
3. Fluctuating unilateral neurosensory hearing loss of low tones
4. Sense of pressure in the ear
5. Nystagmus
6. Ataxia

 Diagnostic test findings: 



1. Audiogram: hearing loss

2. Magnetic resonance imaging, X-ray, computed tomography scan: negative
3. Electronystagmography: labyrinth dysfunction
4. Auditory dehydration test: positive audiometric fluctuation

 Medical management: 

1. Dietary restrictions: fluid, sodium, caffeine

2. Activity: as tolerated
3. Monitoring: vital signs and I/O
4. Glucocorticoid: dexamethasone (Decadron)
5. Benzodiazepine: oxazepam (Serax)
6. Anticholinergic: atropine (Atropine)
7. Antihistamine: diphenhydramine (Benadryl)
8. Diuretic: spironolactone (Aldactone)
9. Antiemetic: prochlorperazine (Compazine)
10. Vasodilators: nicotinic acid (Nicobid), tolazoline (Priscoline), methantheline (Banthine)

 Nursing interventions: 

1. Maintain the patient's diet

2. Limit fluid intake
3. Assess hearing status
4. Monitor and record vital signs, 1/Q, and laboratory studies
5. Administer medications, as prescribed
6. Allay the patient's anxiety
7. Provide for the patient's safety
8. Individualize home care instructions

 Have the patient lie down to relieve dizziness

 Learn to read lips
 Use hearing aid
 Use sign language and gestures to communicate


Complication: Deafness 
 


Possible surgical interventions: 

1. Endolymphatic subarachnoid shunt

2. Endolymphatic system— mastoid shunt
3. Ultrasonic surgery
4. Total labyrinthectomy

Hearing Loss
 Definition: 
1. A mechanical or nervous impediment to the transmission of sound waves
2. Major forms are classified as conductive loss, sensorineural loss, or mixed loss
 Causes: 

1. Conductive hearing loss

1. Obstruction of the external ear canal, such as from impacted cerumen, edema of the ear canal, neoplasms, or
stenosis
2. Congenital malformations
3. Disruption or fixation of the middle ear ossicles
4. Fluid behind eardrum or within middle ear
5. Perforated tympanic membrane
6. Scar tissue in ear canal or eardrum
7. Trauma to tympanic membrane or inner eat
8. Tumors of the tympanic membrane

2. Sensorineural hearing loss

1. Congenital factors
2. Hereditary factors
3. Noise trauma
4. Aging (presbycusis)
5. Méniére’s disease
6. Ototoxicity
7. Systemic disease, such as certain collagen diseases, diabetes, syphilis, and Paget's disease

 Assessment findings: 

1. Congenital hearing loss

2. Lack of response to auditory stimulation
3. Impaired speech development
4. Gradual hearing loss or following acute infection
5. Altered hearing at all frequencies and decibel levels
6. Presbycusis
7. Tinnitus
8. Inability to understand the spoken word
9. Hearing loss caused by neoplasm or fluid
10. Feeling of fullness in the ear
 Diagnostic test findings: 

1. Whisper test: reduced ability or inability to hear

2. Rinne test: air conduction greater than bone conduction in sensorineural hearing loss; bone conduction greater than
air conduction suggests conductive loss
3. Weber's test: sound lateralizes to the better functioning ear in sensorineural hearing loss; sound lateralizes to the ear
with the poorest hearing in conductive hearing loss
4. Audiometry: hearing loss
5. Tympanometry: impaired compliance

 
 

 Medical management:

1. Diet no restrictions
2. Activity: no restrictions
3. Rehabilitation: speech and hearing
4. Sound amplification: hearing aid, pocket talker

 Nursing interventions: 

1. Maintain the patient's diet

2. Maintain and use hearing aid or another assistive device
3. Assess the patient's degree of hearing loss
4. Stand in front of the patient when speaking
5. Speak slowly and distinctly
6. Avoid shouting
7. Approach within the patient's visual range
8. Develop alternative means of communication
9. Provide emotional support and encourage verbalization of fears
10. Prevent isolation
11. Individualize home care instructions

 Maintain hearing aid or assistive device

 Replace batteries when appropriate
 Use alternative means of communication
 Engage in social activities

 Possible surgical interventions: 

1. Stapedectomy
2. Tympanoplasty

 Complications: 

1. Deafness
2. Speech impairment
3. Developmental delays