Assessment and Management of Patients With Endocrine Disorders. Don Smart, 55 years of age presents to the family physician to follow up on some symptoms he recently developed.
Assessment and Management of Patients With Endocrine Disorders
1. Don Smart, 55 years of age presents to the family physician to follow up on some symptoms he recently developed. The patient states that he is extremely tired and is having trouble concentrating. He states that his skin is dry and flaky. His nails are brittle and his hair is dry, dull, and falls out as he showers.
He is 8 weeks postop after a modified radical neck procedure for laryngeal cancer and has completed the external radiation therapy. He is using a Blom-Singer prosthesis for speech. He states that his appetite is poor, yet he is gaining weight.
The patient’s current medications include metformin (Glucophage) for a history of type 2 diabetes, digoxin 0.25 mg every day for a history of atrial fibrillation, and warfarin therapy being managed by the family physician for thromboembolism prophylaxis related to atrial fibrillation. The physician orders the following lab work: CBC with differential, serum albumin, TSH, FT4, PT, and INR.
a. What is the rationale for the labs ordered, based on the symptoms that the patient is exhibiting?
b. The physician follows up with the patient with the diagnosis of hypothyroidism. What are reasons why the patient developed hypothyroidism?
c. Based on the results of the TSH and FT4, the physician starts the patient on levothyroxine (Synthroid) 0.025 mg/day and to have follow-up TSH and FT4 labs and visit to the oncologist in 4 weeks. The physician informs the patient that he will continue to have lab tests and monthly follow-up until the TSH and FT4 are stable. What is the rationale for this treatment plan?
d. What nursing interventions should the nurse provide the patient?
2. Mrs. Ramirez was admitted to the hospital for wrist surgery secondary to rheumatoid arthritis. Postoperatively, she is stabilized and transferred to the general surgery unit. Mrs. Ramirez’s medications include digoxin, Lasix, captopril, Synthyroid, aspirin, Protonix, and prednisone. When administering morning medications, Mrs. Ramirez refuses her aspirin and prednisone, and the nurse holds the medications. Over the next 3 days, Mrs. Ramirez continues to refuse the prednisone, and the medication is not administered.
On the third postoperative day, Mrs. Ramirez becomes hypotensive, tachycardic, and has a decrease in level of consciousness. STAT labs are sent for a complete blood cell count and chemistry panel, and the physician is notified of the change in patient status.
On review of the patient’s record, the physician notes that Mrs. Ramirez has not received her prednisone for 4 days.
Mrs. Ramirez has been on Prednisone for the past 5 years for her rheumatoid arthritis, and the physician begins to treat the patient for acute adrenal insufficiency.
What other clinical manifestations should the nurse monitor for with suspected adrenal insufficiency?
The physician orders a STAT dose of IV hydrocortisone. What is the rationale for this medication in this situation?
Evaluation of endocrine issues is a sometimes overlooked yet important component of the preoperative medical evaluation. Patients with diabetes, thyroid disease, and hypothalamic-pituitary-adrenal axis suppression are commonly encountered in the surgical setting and require unique consideration to optimize perioperative risk.
For patients with diabetes, perioperative glycemic control has the strongest association with postsurgical outcomes. The preoperative evaluation should include recommendations for adjustment of insulin and noninsulin diabetic medications before surgery.
Recommendations differ based on the type of diabetes, the type of insulin, and the patient’s predisposition to hyperglycemia or hypoglycemia. Generally, patients with thyroid dysfunction can safely undergo operations unless they have untreated hyperthyroidism or severe hypothyroidism. Patients with known primary or secondary adrenal insufficiency require supplemental glucocorticoids to prevent adrenal crisis in the perioperative setting.
Evidence supporting the use of high-dose supplemental corticosteroids for patients undergoing long-term glucocorticoid therapy is sparse. We discuss an approach to these patients based on the dose and duration of ongoing or recent corticosteroid therapy. As with other components of the preoperative medical evaluation, the primary objective is identification and assessment of the severity of endocrine issues before surgery so that the surgeons, anesthesiologists, and internal medicine professionals can optimize management accordingly.