■ Encourage the patient to express his feelings.
■ Evaluate laboratory tests for hormonal deficiencies.
■ Record calorie intake.
■ Check and evaluate daily weight.
■ Monitor vital signs.
■ Assess neurologic status.
■ Assess for signs and symptoms of pituitary apoplexy, a medical emer-gency (sudden, severe headache, vomiting, and visual changes)
■ Assess for signs and symptoms of hypoglycemia.
PAT I E N T T E A C H I N G Be sure to cover:
■ the disorder, diagnosis, and treatment
■ long-term hormonal replacement therapy and adverse reactions
■ when to notify the physician
■ regular follow-up appointments
■ energy-conservation techniques
■ need for adequate rest
■ need for a balanced diet.
CA U S E S
■ Amyloidosis
■ Antithyroid medications
■ Autoimmune thyroiditis (Hashimoto’s) (most common cause)
■ Congenital defects
■ Endemic iodine deficiency
■ External radiation to the neck
■ Hypothalamic failure to produce thyrotropin-releasing hormone
■ Idiopathic
■ Inflammatory conditions
■ Medications, such as iodides and lithium
■ Pituitary failure to produce TSH
■ Pituitary tumor
■ Postpartum pituitary necrosis
■ Radioactive iodine therapy
■ Sarcoidosis
■ Thyroid gland surgery
A S S E S S M E N T F I N D I N G S
■ Vague and varied symptoms that developed slowly over time
■ Energy loss, fatigue
■ Forgetfulness
■ Sensitivity to cold
■ Unexplained weight gain
■ Constipation
■ Anorexia
■ Decreased libido
■ Menorrhagia
■ Paresthesia
■ Joint stiffness
■ Muscle cramping
■ Slight mental slowing to severe obtundation
■ Thick, dry tongue
■ Hoarseness; slow, slurred speech
■ Dry, flaky, inelastic skin
■ Puffy face, hands, and feet
■ Periorbital edema; drooping upper eyelids
■ Dry, sparse hair with patchy hair loss
■ Loss of outer third of eyebrow
■ Thick, brittle nails with transverse and longitudinal grooves
■ Ataxia, intention tremor, nystagmus
H Y P O T H Y R O I D I S M 161
■ Doughy skin that feels cool
■ Weak pulse and bradycardia
■ Muscle weakness
■ Sacral or peripheral edema
■ Delayed reflex relaxation time
■ Possible goiter
■ Absent or decreased bowel sounds
■ Hypotension
■ A gallop or distant heart sounds
■ Adventitious breath sounds
■ Abdominal distention or ascites
T E S T R E S U LT S
■ Radioimmunoassay shows decreased serum levels of T3and T4.
■ Serum TSH level is increased with thyroid insufficiency and decreased with hypothalamic or pituitary insufficiency.
■ Serum cholesterol, alkaline phosphatase, and triglycerides levels are ele-vated.
■ Serum electrolytes show low serum sodium levels in myxedema coma.
■ Arterial blood gases show decreased pH and increased partial pressure of carbon dioxide in myxedema coma.
■ Skull X-rays, computed tomography scan, and magnetic resonance imag-ing may show pituitary or hypothalamic lesions.
T R E AT M E N T
■ Long-term thyroid replacement
■ Low-fat, low-cholesterol, high-fiber, low-sodium diet
■ Possibly fluid restriction
■ Activity, as tolerated
■ Synthetic hormone levothyroxine (Levothroid)
■ Synthetic liothyronine (Cytomel)
■ Surgery for underlying cause such as pituitary tumor
K E Y PAT I E N T O U T C O M E S The patient will:
■ maintain adequate cardiac output
■ maintain stable vital signs
■ demonstrate normal laboratory values
■ maintain balanced fluid volume status
■ consume adequate daily calorie requirements
■ express positive feelings about self.
N U R S I N G I N T E R V E N T I O N S
■ Administer prescribed medications.
■ Provide adequate rest periods.
■ Apply antiembolism stockings.
■ Encourage coughing and deep-breathing exercises.
■ Maintain fluid restrictions and a low-sodium diet.
■ Provide a high-bulk, low-calorie diet.
■ Reorient the patient, as needed.
■ Offer support and encouragement.
■ Provide meticulous skin care.
■ Keep the patient warm, as needed.
■ Encourage the patient to express his feelings.
■ Help the patient develop effective coping strategies.
■ Monitor vital signs.
■ Record and evaluate intake and output.
■ Check daily weight.
■ Assess the patient’s cardiovascular status.
■ Assess the patient’s pulmonary status.
■ Assess for the presence of edema.
■ Monitor the patient’s bowel sounds, abdominal distention, and frequency of bowel movements.
■ Monitor the patient’s mental and neurologic status.
■ Observe for signs and symptoms of hyperthyroidism.
PAT I E N T T E A C H I N G Be sure to cover:
■ the disorder, diagnosis, and treatment
■ prescribed medications and possible adverse effects
■ when to notify the physician
■ physical and mental changes
■ signs and symptoms of myxedema
■ need for life-long hormone replacement therapy
■ need to wear a medical identification bracelet
■ importance of keeping accurate records of daily weight
■ need to adhere to a well-balanced, high-fiber, low-sodium diet
■ energy-conservation techniques.
I N T E S T I N A L O B S T R U C T I O N 163
Intestinal obstruction
D E S C R I P T I O N
■ Partial or complete blockage of the lumen of the small or large bowel
■ Commonly a medical emergency
■ Most likely after abdominal surgery or with congenital bowel deformities
■ Without treatment, may cause death within hours from shock and vascu-lar collapse
PAT H O P H YS I O L O G Y
■ Mechanical or nonmechanical (neurogenic) blockage of the lumen occurs.
■ Fluid, air, or gas collects near the site.
■ Peristalsis increases temporarily in an attempt to break through the block-age.
■ Intestinal mucosa is injured, and distention at and above the site of ob-struction occurs.
■ Venous blood flow is impaired, and normal absorptive processes cease.
■ Water, sodium, and potassium are secreted by the bowel into the fluid pooled in the lumen.
CA U S E S Mechanical obstruction
■ Adhesions
■ Carcinomas
■ Compression of the bowel wall from stenosis, intussusception, volvulus of the sigmoid or cecum, tumors, and atresia
■ Foreign bodies
■ Strangulated hernias Nonmechanical obstruction
■ Electrolyte imbalances
■ Neurogenic abnormalities
■ Paralytic ileus
■ Thrombosis or embolism of mesenteric vessels
■ Toxicity, such as that associated with uremia or generalized infection
A S S E S S M E N T F I N D I N G S
■ Recent change in bowel habits
■ Hiccups
Mechanical obstruction
■ Colicky pain
■ Nausea, vomiting
■ Constipation
■ Distended abdomen
■ Borborygmi and rushes (occasionally loud enough to be heard without a stethoscope)
■ Abdominal tenderness
■ Rebound tenderness Nonmechanical obstruction
■ Diffuse abdominal discomfort
■ Frequent vomiting
■ Severe abdominal pain (if obstruction results from vascular insufficiency or infarction)
■ Abdominal distention
■ Decreased bowel sounds (early), then absent bowel sounds
T E S T R E S U LT S
■ Serum sodium, chloride, and potassium levels are decreased.
■ White blood cell count is elevated.
■ Serum amylase level is increased if pancreas is irritated by a bowel loop.
■ Blood urea nitrogen is increased with dehydration.
■ Abdominal X-rays reveal the presence and location of intestinal gas or flu-id. (In small-bowel obstruction, a typical “stepladder” pattern emerges, with alternating fluid and gas levels apparent in 3 to 4 hours.)
■ Barium enema reveals a distended, air-filled colon or a closed loop of sig-moid with extreme distention (in sigsig-moid volvulus).
T R E AT M E N T
■ Correction of fluid and electrolyte imbalances
■ Decompression of the bowel to relieve vomiting and distention
■ Treatment of shock and peritonitis
■ Nothing by mouth if surgery scheduled
■ Parenteral nutrition until bowel is functioning
■ High-fiber diet when obstruction is relieved and peristalsis returns
■ Bed rest during acute phase
■ Postoperatively, avoidance of lifting and contact sports
■ Broad-spectrum antibiotics
■ Analgesics
I N T E S T I N A L O B S T R U C T I O N 165
■ Blood replacement
■ Surgery is usually the treatment of choice (exception is paralytic ileus in which nonoperative therapy usually attempted first)
■ Type of surgery dependent on cause of blockage
K E Y PAT I E N T O U T C O M E S The patient will:
■ express feelings of increased comfort
■ maintain normal fluid volume
■ return to normal bowel function
■ maintain caloric requirement
■ maintain stable vital signs.
N U R S I N G I N T E R V E N T I O N S
■ Insert a nasogastric (NG) tube and attach to low-pressure, intermittent suction.
■ Maintain the patient in semi-Fowler’s position.
■ Provide mouth and nose care.
■ Begin and maintain I.V. therapy, as ordered.
■ Administer prescribed medications.
■ Monitor vital signs.
■ Assess for signs and symptoms of shock.
■ Assess bowel sounds and signs of returning peristalsis.
■ Monitor NG tube function and drainage.
■ Assess pain control and provide comfort measures.
■ Measure the abdominal girth to detect progressive distention.
■ Assess hydration and nutritional status.
■ Monitor electrolytes and signs and symptoms of metabolic derange-ments.
■ Assess the wound site (postoperatively) and provide wound care.
■ Refer the patient to an enterostomal therapist, if indicated, and home health care services.
PAT I E N T T E A C H I N G Be sure to cover:
■ the disorder (focusing on the patient’s type of intestinal obstruction), diagnosis, and treatment
■ techniques for coughing and deep breathing and incentive spirometry
■ colostomy or ileostomy care, if appropriate
■ incision care
■ postoperative activity limitations and why these are necessary
■ proper use of prescribed medications, focusing on their correct adminis-tration, desired effects, and possible adverse reactions
■ importance of following a structured bowel regimen, particularly if the patient had a mechanical obstruction from fecal impaction.