Endocrine System
Content
disorders of the endocrine system
duke trillanes iii, rn, map
endocrine system endocrine glands endocrine system
o endocrine glands o secrete their products directly into the bloodstream o different from exocrine glands o exocrine glands: secrete through ducts onto epithelial surfaces or into the gastrointestinal tract
hormones
o are chemical substances that are secreted by the endocrine glands. o can travel moderate to long distances or very short distances. o acts only on cells or tissues that have receptors for the specific
hormone. o target organ: the cell or tissue that responds to a particular hormone.
hypothalamus and pituitary gland regulation of hormones: negative feedback mechanism
o if the client is healthy, the concentration or hormones is maintained at
a constant level.
o when the hormone concentration rises, further production of that
hormone is inhibited.
o when the hormone concentration falls, the rate of production of that
hormone increases.
diseases of the endocrine system
o “primary” disease – problem in target gland; autonomous o “secondary” disease – problem outside the target gland; most often
due to a problem in the pituitary gland
disorders of the anterior pituitary gland
hypopituitarism hyperpituitarism
hypopituitarism
o caused by low levels of one or more anterior pituitary hormones. o lack of the hormone leads to loss of function in the gland or organ
that it controls.
causes of primary hypopituitarism
o pituitary tumors o inadequate blood supply to pituitary gland o sheehan syndrome o infections and/or inflammatory diseases o sarcoidosis o amyloidosis o radiation therapy o surgical removal of pituitary tissue o autoimmune diseases o congenital absence
causes of secondary hypopituitarism (affecting the hypothalamus):
o o o o
tumors of the hypothalamus inflammatory disease head injuries surgical damage to the pituitary and/or blood vessels or nerves leading to it
signs and symptoms signs and symptoms
o gonadotropin deficiency
o congenital onset o delayed or absent secondary sexual characteristics o may have micropenis, cryptorchidism o acquired o loss of body hair o infertility, decreased libido, impotence in males, amenorrhea in females o osteopenia, muscle atrophy o prolactin deficiency o failure to lactate
signs and symptoms
o thyroid-stimulating (tsh) deficiency o causes hypothyroidism with manifestations such as fatigue, weakness, weight change, and hyperlipidemia o adrenocorticotropic hormone (acth) deficiency o results in diminished cortisol secretion o symptoms include weakness, fatigue, weight loss, and hypotension
signs and symptoms diagnostics treatment
o surgery for tumors: transsphenoidal hypophysectomy o radiation therapy for tumors o hormonal substitution: maybe for life o corticosteroids o levothyroxine o androgen for males o estrogen for females o growth hormone
hyperpituitarism
o hyperfunction of the anterior pituitary gland → oversecretion of one or
more of the anterior pituitary hormones o usually caused by a benign pituitary adenoma o most common hormones affected:
o prolactin o growth hormone
pituitary tumor: prolactinoma
growth hormone hypersecretion
0 early onset late onset acromegaly epiphyseal closure occur at normal times gigantism acromegalic gigantism 25 50 years
gigantism vs. acromegaly gigantism vs. acromegaly
growth hormone hypersecretion: signs and symptoms
o o o o o o o o o
enlarged hand and feet; carpal tunnel syndrome common coarsening of features esp. in acromegaly; prominent mandible, tooth spacing widens macroglossia hypertension, cardiomegaly, heart failure insulin resistance → dm visual fields defect: bitemporal hemianopsia → complete blindness headaches arthritis hypogonadism
treatment
o medication o bromocriptine and cabergoline (dopamine agonist) for prolactinoma and gh hypersecretion o octreotide (somatostatin) for gh hypersecretion o surgery o transsphenoidal hypophysectomy o radiation therapy for large tumors o diet
nursing interventions
o provide emotional support → striking body change can cause
psychological stress o perform or assist with range of motion exercises to promote maximum joint mobility and prevent injury o evaluate muscle weakness
nursing interventions
o keep the skin dry o be aware that pituitary tumor may cause visual problems.
o warn relatives that hyperpituitarism can cause inexplicable mood
changes
nursing interventions
o if the patient is a child, explain to the parents that surgery prevents
permanent soft-tissue deformities but won’t correct bone changes that have already occurred.
o emphasize the importance of continuing hormonal replacement
therapy.
question
o what is the medication of choice in the treatment of gh hypersecretion and prolactinoma? o o o o
bromocriptine cabergoline octreotide vasopressin
question
o as a nurse which of the following is the most important nursing consideration? o o o o
ensuring a safe environment giving the medications as prescribed providing emotional support and counseling assisting in rom exercises to prevent contractures
question
o the hypothalamus has direct control over which of the
following organs?
o o o o o
adrenal gland thyroid gland kidneys ovaries prostate
disorders of the posterior pituitary gland
diabetes insipidus siadh
vasopressin or antidiuretic hormone
diabetes insipidus diabetes insipidus
o central diabetes insipidus: deficiency of vasopressin o primary diabetes insipidus o maybe familial, occurring as a dominant trait, or sporadic (“idiopathic”) o secondary diabetes insipidus o due to damage to the hypothalamus or pituitary stalk by tumor, surgical or accidental
trauma, infection
diabetes insipidus diabetes insipidus
signs and symptoms o polyuria o intense thirst o dehydration o inadequate water replacement
o hyperosmolality o hypovolemia
diabetes insipidus
diagnostics o fluid deprivation test o administration of desmopressin o 24 hour urine collection for volume, glucose, and creatinine o serum for glucose, urea nitrogen, calcium, uric acid, potassium, sodium
diabetes insipidus
medications o for central di o desmopressin; intranasal
o lypressin; intranasal o vasopressin tannate in oil; im o for nephrogenic di o indomethacin-hydrochlorothiazide o indomethacin-desmopressin o indomethacin-amiloride o clofibrate, chlorpropamide o psychotherapy
diabetes insipidus: nursing management
o maintain fluid and sodium balance o record i and o. weigh patient daily. o maintain fluid intake to prevent severe dehydration o wof: dehydration and shock o keep the side rails up and assist with walking if the patient is dizzy or has muscle
weakness o monitor urine specific gravity between doses. watch for decreased specific gravity with increased urine output. o add more bulk food and fruit juices to diet
diabetes insipidus: nursing management
o provide meticulous skin and mouth care, an apply a lubricant to cracked or sore lips o diet: low in sodium o carry out drug therapy o caution with vasopressin if coronary disease is present → vasoconstriction o assist in searching for the underlying pathology
syndrome of inappropriate antidiuretic hormone (siadh)
o disorder due to excessive adh release o signs and symptoms: o persistent excretion of concentrated urine o signs of fluid overload o change in level of consciousness o hyponatremia o no edema
syndrome of inappropriate antidiuretic hormone (siadh): causes of siadh
o tumors o bronchogenic ca o lymphoma
o o
pancreatic cancer mesothelioma
o pulmonary o tb o pneumonia o lung abscess o copd o pneumothorax o p. carinii pneumonia
syndrome of inappropriate antidiuretic hormone (siadh): causes of siadh o cns
o meningitis o subdural hematoma o subarachnoid hemorrhage o drugs o vincristine o phenothiazines o tricyclic antidepressants
syndrome of inappropriate antidiuretic hormone (siadh): diagnostic tests
o low serum sodium < 135 meq/lo o low serum osmolality o high urine osmolality ( >100 mosmol/kg) o high urine sodium excretion ( >20 mmol/l) o normal renal function (low bun <10 mg/dl)
syndrome of inappropriate antidiuretic hormone (siadh): management
o maintain fluid balance o restriction of water intake o if the patient has evidence of fluid overload – loop diuretics (furosemide) is added. o chronic treatment: lithium or demeclocycline o monitoring of body weight
syndrome of inappropriate antidiuretic hormone (siadh): management
o maintain sodium balance o increase sodium intake o if the serum sodium is below 120 or if the patient is seizing, emergency treatment of 3% nacl followed by furosemide o excessive rapid correction of hyponatremia may cause central pontine myelinolysis
disorders of the thyroid gland
hyperthyroidism hypothyroidism
the thyroid gland function of thyroid hormones function of thyroid hormones tests of thyroid function
thyroid stimulating hormone o single best screening test because of high sensitivity o values should range 0.38 to 6.15 uu/ml o if tsh normal – free thyroxine (ft4) is normal o used for monitoring thyroid hormone replacement therapy
tests of thyroid function
serum free thyroxine
o test used to confirm an abnormal tsh is ft4 o ft4 is a direct measurement of free thyroxine, the only metabolic fraction of t4 o normal levels 0.9 to 1.7 ng/l (11.5 to 21.8 pmol/l).
tests of thyroid function
serum t3 and t4
o normal range for t4 is 4.5 and 11.5 ug/dl (58.5 to 150 nmol/l) o the t3 level appears to be more accurate indicator of hyperthyroidism o normal range for serum t3 is 70 to 220 ng/dl (1.15 to 3.10 nmol/l)
tests of thyroid function
thyroid scan, radioscan, or scintiscan
o in a thyroid scan, a scintillation detector or gamma camera moves back and forth across the area to be studied and a visual image is made of the distribution of radioactivity in the area being scanned o isotopes used o ¹²³i – most commonly used isotope o technetium-99m pertechnetate, thallium, americium
tests of thyroid function
radioactive iodine uptake o measures the rate of iodine uptake by the thyroid gland o the patient is administered a tracer dose of iodine-123 o measures the proportion of the administered dose present in the thyroid gland at a specific
time after administration o hyperthyroidism → high uptake of ¹²³i o hypothyroidism → very low uptake
tests of thyroid function tests of thyroid function
nursing implications of thyroid tests
o it is necessary to determine whether the patient has taken medications or agents that contain iodine because these alter the results of some of the scheduled tests. o assess for allergy to iodine or shellfish o for the scans, tell patient that radiation is minimal
hyperthyroidism
hyperthyroidism:signs and symptoms
o o o o o o o o o o o o o
enlarged thyroid gland tachycardia hypertension heat intolerance, diaphoresis smooth, soft, warm skin fine soft hair diarrhea, weight loss inspite of increased appetite nervousness and fine tremors of hands hyperactive reflexes, body weakness personality changes, mood swings osteoporosis clubbing and swelling of fingers, plummer’s nails menstrual disturbances, decreased infertility
signs and symptoms of grave’s disease
thyroid storm
o a medical emergency: high mortality o marked delirium, severe tachycardia, vomiting, diarrhea, dehydration, high fever o occurs in patients with existing but unrecognizable thyrotoxicosis, stressful illness, thyroid surgery, rai o increased systemic adrenergic activity – epinephrine overproduction and severe hypermetabolism
hyperthyroidism: diagnostics
o o o o o
radioimmunoassay test shows elevated t4 and t3 thyroid scan reveals increased radioactive iodine (¹²³i) uptake ↓ tsh in primary hyperthyroidism ↑ tsh in secondary hyperthyroidism orbital sonography and computed scan confirm subclinical ophthalmopathy
hyperthyroidism: management
antithyroid drug therapy o propylthiouracil (ptu) and methimazole o used for pregnant women and patient who refused surgery or rai treatment o during pregnancy ptu – preferred therapy o a few (1%) of the infants born to mothers receiving antithyroid medication will be
hypothyroid
o mechanism of action: blocks thyroid hormone synthesis o wof: agranulocytosis
hyperthyroidism: management
o radioactive iodine (¹³¹i), potassium or sodium iodide, strong iodine solution (lugol’s solution) o adjunct with other antithyroid drugs in preparation for thyroidectomy o treatment for thyrotoxic crisis o mechanism of action o inhibits the release and synthesis of thyroid hormones o decreases vascularity of the thyroid gland o decreases thyroidal uptake of rai
hyperthyroidism: nursing management
potassium or sodium iodide, strong iodine solution o dilute oral doses in water or fruit juice and give with meals to prevent gastric irritation, to o o o o
hydrate the patient, and to mask the very salty taste warn the patient that sudden withdrawal may precipitate thyrotoxicosis store in light resistant container give iodides through a straw to avoid teeth discoloration force fluids to prevent fluid volume deficit
hyperthyroidism: nursing management of rai treatment
o radioactive iodine o food may delay absorption. the patient should fast overnight before administration o after dose for hyperthyroidism, the patients urine and saliva are slightly radioactive for 24
hours; vomitus is highly radioactive for 6 to 8 hours o institute full radiation precautions during this time o instruct the patient to use appropriate disposal methods when coughing and expectorating
hyperthyroidism: nursing management of rai treatment
o after dose for thyroid cancer, isolate the patient and observe the following precautions: o pregnant personnel shouldn’t take care of the patient o disposable eating utensils and linens should be used o instruct the patient to save all urine in lead containers for 24 to 48 hours so amount of
radioactive material excreted can be determined o or flush the toilet twice after urination
hyperthyroidism: nursing management of rai treatment
o the patient should drink as much fluid as possible for 48 hours after
drug administration to facilitate excretion o limit contact with the patient to 30 minutes per shift per person the 1st day; may increase time to 1 hour on 2nd day and longer on 3rd day
hyperthyroidism: nursing management of rai treatment
o if the patient is discharged less than 7 days after ¹³¹i dose for thyroid
cancer, warn patient
o to avoid close, prolonged contact with small children o not to sleep in the same room with his spouse for 7 days after treatment → increase risk of thyroid cancer in persons exposed to ¹³¹i.
hyperthyroidism: management
o b-blockers, digoxin, anticoagulation o prednisone for ophthalmopathy o treatment for thyroid storm o ptu o i.v. propanolol to block sympathetic effects o corticosteroids to replace depleted cortisol levels o iodide to block release of thyroid hormone
hyperthyroidism: management
o surgery: thyroidectomy o preop: give lugol’s iodide to prevent thyroid storm o care of post-thyroidectomy client o monitor for respiratory distress o have tracheotomy set, oxygen, and suction at bedside o semi-fowlers position
o monitor for laryngeal nerve damage o monitor for signs of hypocalcemia and tetany o monitor for thyroid storm
hyperthyroidism: nursing management
o o o o o o
record vital signs and weight monitor serum electrolyte levels, and check periodically for hyperglycemia and glycosuria monitor cardiac function check levels of consciousness and urine output if patient is in her 1st trimester of pregnancy: report for signs of spontaneous abortion diet
o o o
high protein, high calorie, vitamin supplements low sodium diet for patients with edema no stimulants like coffee, tea
hyperthyroidism: nursing management
o for exophthalmos o suggest sunglasses or eye patches to protect eyes from light o moisten the conjunctivae with artificial tears o warm the patient with severe lid retraction to avoid sudden physical movement that might cause the
lid to slip behind the eyeball
o o
elevate the head of the bed to reduce periorbital edema
o stress the importance of regular medical follow-up after discharge because hypothyroidism may
develop drug therapy and rai therapy require careful monitoring and comprehensive teaching
hypothyroidism hypothyroidism
o a state of low serum thyroid hormone levels or cellular resistance to thyroid hormone o causes: o may result from thyroidectomy o radiation therapy o chronic autoimmune thyroiditis o inflammatory conditions o pituitary failure to produce tsh o hypothalamic failure to produce thyrotropin-releasing hormone (trh) o inborn errors of thyroid hormone synthesis o antithyroid medications such as ptu o inability to synthesize thyroid hormone because of iodine deficiency
hypothyroidism: signs and symptoms hypothyroidism: signs and symptoms
myxedema coma
o manifests as hypotension, bradycardia, hypothermia, hyponatremia,
hypoglycemia, respiratory failure, coma o can be precipitated by acute illness, rapid withdrawal if thyroid medication, anesthesia, surgery, hypothermia, use of opioids
hypothyroidism: diagnostics
o o o o o radioimmunoassay tests: ↓ t3 t4 ↑ tsh level with primary hypothyroidism ↓ tsh level with secondary hypothyroidism serum cholesterol and triglyceride levels are increased in myxedema coma o low serum sodium levels o respiratory acidosis because of hypoventilation
hypothyroidism: management
o prevention: prophylactic iodine supplements to decrease the
incidence of iodine deficient goiter o symptomatic cases:
o hormonal replacement: synthroid (synthetic hormone (levothyroxine)) o dosage is increased q 2-3 weeks esp. if the patient is an elderly
nursing management of replacement therapy
o different brands of levothyroxine may not be bioequivalent o warn the patient to tell the doctor if o chest pain, palpitations, sweating, nervousness, or their signs or symptoms of overdosage o signs and symptoms of aggravated cardiovascular disease (chest pain, dyspnea, tachycardia)
nursing management of replacement therapy
o instruct the patient to take thyroid hormones at the same time each
day to maintain constant hormone levels o suggest a morning dosage to prevent insomnia o monitor apical pulse and blood pressure. if pulse is >100, withhold the drug. assess for tachyarrhytmias and chest pain.
nursing management of replacement therapy
o thyroid hormones alter thyroid function test results o for ¹²³i uptake studies o d/c levothyroxine 4 wks before the test o d/c liothyronine 7 to 10 days before the test o monitor prothrombin time o wof: unusual bleeding and bruising
hypothyroidism: nursing interventions
o o o o o
diet: high-bulk, low calorie diet encourage activity maintain warm environment administer cathartics and stool softeners to prevent myxedema coma, tell the patient to continue course of thyroid medication event if symptoms subside o maintain patent airway
o o o o
administer medications – synthroid, glucose, corticosteroids iv fluid replacement wrap patient in blanket treat infection or any underlying illness
disorders of the pancreas
diabetes mellitus
hormones of the pancreas
o insulin o decreases blood sugar by: o stimulating active transport of glucose into muscle and adipose tissue o promoting the conversion of glucose to glycogen for storage o promoting conversion of fatty acids into fat o stimulating protein synthesis o secreted in response to high blood sugar o found in β cells of the islets of langerhans
hormones of the pancreas
o glucagon o increases blood glucose by o causing gluconeogenesis and glycogenolysis in the liver o secreted in response to low blood sugar o found in the α-cells of the islets of langerhans
diabetes mellitus
o chronic disease characterized by hyperglycemia o it is due to total or partial insulin deficiency or insensitivity of the cells
to insulin o characterized by disorders in the metabolism of cho, fats, chon as well as changes in the structure and function of blood vessels
types of diabetes mellitus
o type 1 or iddm o usually occurs in children or in non-obese adults o type 2 or niddm o usually occurs in obese adults or over age 40 o gestational dm o secondary dm o induced by trauma, surgery, pancreatic disease or medications o can be treated as either type 1 or type 2
pathophysiology
o lack of insulin causes hyperglycemia (insulin is necessary for the transport of glucose across the membrane) o body excretes excess glucose through kidneys → osmotic diuresis → polyuria → dehydration → polydipsia o cellular starvation → polyphagia o the body turns to fats and proteins for energy; but in the absence of glucose in the cell, the fats cannot be completely metabolized and ketones are produced
chronic complications
o microangiopathy: retinopathy, nephropathy o macroangiopathy: peripheral vascular diseae, atherosclerosis, cad o neuropathy
instruction in the care of the feet
o hygiene of the feet o wash feet daily with mild soap and lukewarm water. dry thoroughly between the toes by
pressure. do not rub vigorously, as this is apt to break the delicate skin. o rub well with vegetable oil to keep them soft, prevent excess friction, remove scales, and prevent dryness. o if the feet become too soft and tender, rub them with alcohol abut once week.
instruction in the care of the feet
o hygiene of the feet o when rubbing the feet, always rub upward from the tips of the toes. if varicose veins are
present, massage the feet very gently; never massage the legs. o of the toenails are brittle and dry, soften them by soaking for 1 ½ hour each night in lukewarm water containing 1 tbsp of powdered sodium borate (borax) per quart. clean around the nails with an orangewood stick. if the nails become too long, file them with an amery board. file them straight across and no shorter than the underlying soft tissue of the toes. never cut the corner of the nails.
instruction in the care of the feet
o wear low heeled shoes of soft leather that fit the shape of the feet
correctly. the shoes should have wide toes that will cause no pressure, fit close in the arch, and grip the heels snugly. wear new shoes one-half hour only on the first day and increase by 1 our each day following. wear thick, warm, loose stockings.
instruction in the care of the feet
o treatment of corns and calluses o corns and calluses are due to friction and pressure, most often from improperly fitted shoes
and stockings. wear shoes that fit properly and cause no friction or pressure. o to remove excess calluses or corns, soak the feet in lukewarm water, using a mild soap, for about 10 minutes and then rub off the excess tissue with a towel or file. do not tear it off. under no circumstances must the skin be irritated.
instruction in the care of the feet
o treatment of corns and calluses o do not cut corns or calluses. if they need attention it is safer to see a podiatrist. o prevent callus formation under the ball of the foot (a) by exercise, such as curling and stretching the toes several times a day; (b) by finishing each step on the toes and not on the ball of the foot; and (c) by wearing shoes that are not too short and that do not have high heels.
diagnostics: fbs and ogtt
diagnostics: glycosylated hemoglobin
o nv = 7.5% or less, good control o 7.6% to 8.9% fair control o 9% or greater, poor control
therapeutic interventions:
o life-style changes o weight control and exercises o planned diet o 50 – 60% of calories are complex carbohydrates, high fiber o 12 – 20% daily calories is chon o fat intake not to exceed 30% of daily calories, more of polyunsaturated fats o basic tools: food exchange groups o self-monitoring of blood glucose
therapeutic interventions:
o insulin administration o type 1 iddm and type 2 dm when diet and weight control therapy failed o aspirin, alcohol, oral anticoagulants, oral hypoglycemics, beta blockers, tricyclic
antidepressants, tetracycline, maois increase the hypoglycemic effects of insulin o glucocorticoids, thiazide diuretics, thyroid agents, oral contraceptives increase blood glucose levels o illness, infection, and stress increase the need for insulin
insulin administration
complications of insulin therapy
o local allergic reaction, lipodystrophy, insulin resistance o dawn phenomenon o increase in blood sugar because of release of growth hormone at around 3am o tx: give at 10pm, intermediate-acting insulin o somogy effect o rebound hyperglycemia at 7 am after a bout of hypoglycemia at around 2-3am o tx: decrease the evening dose of intermediate acting insulin
complications of insulin therapy
o hypoglycemia o if awake, give 10-15 g of fast-acting simple juice carbohydrate (glucose tablets, fruit juice, and soda) o if unconscious, glucagon sq or im o if in the hospital, 25-50 cc of d50%
oral hypoglycemic agents
o for dm type 2 o may have to be shifted to insulin when sick, under stress, during
surgery o necessary to shift to insulin when pregnant
oral hypoglycemic agents
o sulfonylureas o promotes increase insulin secretion from pancreatic beta cells through direct stimulation o first generation agents: o tolbutamine, acetohexamide, tolzamide, chlorpropamide o second generation agents o glypizide, glyburide
oral hypoglycemics
o biguanides o reduces hepatic production of glucose by inhibiting glycogenolysis o decrease the intestinal absorption of glucose and improving lipid profile o agents: o phenformin, metformin, buformin
oral hypoglycemics
o alpha-glucosidase inhibitors o inhibits alpha-glucosidase enzymes in the small intestine and alpha amylase in the pancreas o decreases rate of complex carbohydrate metabolism resulting to a reduced rate postprandially o agents: o acarbose (precose), miglitol (glyset)
oral hypoglycemics
o thiazolidinediones o enhances insulin action at the cell and post-receptor site and decreasing insulin resistance o agents: o pioglitazone (actos), rosiglitazone (avandia)
acute complication: dka
o characterized by hyperglycemia and accumulation of ketones in the body causing metabolic acidosis o occurs in insulin-dependent diabetic client o precipitating factors: undiagnosed diabetes, neglect of treatment, infection, other physical or emotional stress o onset slow, maybe hours to days
dka: signs and symptoms
o o o o o o o
polydipsia, polyphagia and polyuria nausea and vomiting, abdominal pain skin warm, dry and flushed dry mucous membrane kussmaul’s respirations or hyperventilation; acetone breath alterations in loc hypotension, tachycardia
hyperglycemic hyperosmolar nonketotic coma (hhnk)
o characterized by hyperglycemia and a hyperosmolar state without
ketosis o occurs in niddm or non-diabetic persons (typically elderly persons) o precipitating factors: undiagnosed diabetes, infection, or other stress; certain medications, dialysis, hyperalimentation, major burns
emergency management:
o for both dka and hhnk, treat dehydration first with 0.9% or ).45% saline solution o shift to d5w when glucose level is down to 250-300mg/dl o wof to rapid correction, it can cause rapid fluid shifts (brain edema and increased icp, ards) o iv regular insulin 0.1 unit/kg bolus then 0.1 unit/kg/h drip
o correcting electrolyte imbalance: watch out for hypokalemia as a result of treatment.
disorders of the adrenal glands
cushing’s syndrome hyperaldosteronism adrenal insufficiency pheochromocytoma
adrenal glands adrenal medulla adrenal cortex hormones
o glucocorticoids o cortisol, corticosterone o increase blood glucose levels by increasing rate of gluconeogenesis o increase protein catabolism o increase mobilization of fatty acids o promote sodium and water retention o anti-inflammatory effect o aid the body in coping with stress
adrenal cortex hormones
o mineralocorticoids o aldosterone, corticosterone, deoxycorticosterone o regulate fluid and electrolyte balance o stimulate reabsorption of sodium, chloride and water o stimulate potassium excretion o under the control of renin-angiotensin-aldosterone system
adrenal cortex hormones
o sex hormones o androgens, estrogens o influences the development of sexual characteristics
hypercortisolism (cushing’s syndrome)
o cluster of physical abnormalities due to excessive cortisol release o cortisol excess is due either to: o autonomous steroid release from adrenals o increased acth release from pituitary o complication from exogenous steroid tx
hypercortisolism (cushing’s syndrome)
hypercortisolism (cushing’s syndrome)
complications
o o o o
osteoporosis peptic ulcer immune and inflammatory response is also compromised other complications include hpn, and sexual and psychological complications
cushing’s syndrome: diagnostics
o acth levels → determines whether the syndrome is acth dependent o 24 – hr urine collection for cortisol, midnight serum cortisol o dexamethsone suppression test →1 mg dexamethasone is given at
11 pm and serum cortisol taken at 8 am the next day o radiologic evaluation
cushing’s syndrome: management
o transsphenoidal resection of pituitary tumor o medications: o aminogluthetimide: adrenal enzyme inhibitor o metyrapone and ketokonazole: suppress hypercrtisolism in unresectable adrenal tumor o antihypertensives o adrenalectomy as needed
cushing’s syndrome: nursing considerations
o monitor vs, wof for hpn o safety precaution: o maintain muscle tone o prevent accidents or falls and provide adequate rest o protect client from exposure to infection, monitor wbc o maintain skin integrity o minimize stress o provide diet low in calories, sodium, and high in protein, potassium, calcium and vitamin d o monitor for urine glucose and acetone, administer insulin if necessary o prepare client for adrenalectomy if needed
hyperaldosteronism
o hypersecretion of aldosterone from the adrenal cortex o two types: o primary disease of the adrenal cortex o secondary condition due to increased plasma renin activity o causes: o excessive reabsorption of sodium and water
o excessive renal excretion of potassium
hyperaldosteronism: causes
o primary aldosteronism: autonomous secretion of aldosterone from
adrenals
o benign adrenal adenoma (conn’s syndrome) o bilateral adrenocortical hyperplasia
hyperaldosteronism: causes
o secondary hyperaldosteronism: high renin state → stimulating aldosterone release o renal artery stenosis o wilm’s tumor o pregnancy o oral contraceptive use o nephritic syndrome o cirrhosis with ascites o idiopathic edema o heart failure o extrarenal sodium loss
hyperaldosteronism: signs and symptoms
o hypertension o headache and visual disturbance o hypokalemia o muscle weakness and fatigue o paresthesia and arrhythmias o polyuria and polydipsia o tetany from alkalosis o hypernatremia
hyperaldosteronism: diagnostics
o o o o o o o o hypokalemia (<3.5 meq/l) hypernatremia (>145 meq/l) elevated serum bicarbonate and ph hypomagnesemia elevated plasma and urinary aldosterone ↓ renin in primary hyperaldosteronism ↑ renin in secondary hyperaldosteronism low specific gravity urine (diluted urine)
hyperaldosteronism: treatment
o primary aldosteronism: o unilateral adrenalectomy
o o o o o
potassium-sparing diuretic antihypertensives aminogluthemide diet: sodium restriction, increase potassium treatment of secondary hyperaldosteronism
adrenal insufficiency
o addison’s disease- the most common form of adrenal hypofunction o autoimmune process, circulating antibodies react specifically against
the adrenal tissue o acute adrenal insufficiency, or adrenal crisis (addisonian crisis) is a medical emergency requiring immediate, vigorous treatment
adrenal insufficiency: causes
o autoimmune destruction of the adrenal gland, tuberculosis, bilateral
adrenalectomy, hemorrhage into the adrenal gland, neoplasm, fungal infection o secondary adrenal hypofunction
o hypopituitarism o abrupt withdrawal of long-term corticosteroid therapy
adrenal insufficiency: signs and symptoms
o o o o
weakness, fatigue weight loss, nausea and vomiting, anorexia chronic constipation or diarrhea cardiovascular abnormalities
o postural hypotension, decreased heart size and cardiac output o weak, irregular pulse o decreased tolerance for minor stress
adrenal insufficiency: signs and symptoms
o o o o o
conspicuous bronze skin coloration poor coordination fasting hypoglycemia: and craving for salty food amenorrhea adrenal crisis
adrenal insufficiency: diagnostic tests
o decreased plasma cortisol and serum sodium levels o increased acth (in addison’s), serum potassium, and blood urea
nitrogen level
adrenal insufficiency : treatment
o corticosteroid replacement o fludrocortisone acetate – acts as mineralocorticoid to prevent
dehydration and hypotension o adrenal crisis: prompt iv bolus of corticosteroids, 3 to 5 l of iv fluids, dextrose
adrenal insufficiency: nursing management
o wof: adrenal crisis o hypotension and signs of shock o decreased level of consciousness and urine output o watch for hyperkalemia before treatment and for hypokalemia after treatment (from
excessive mineralocorticoid effect)
o if patient has diabetes, check blood glucose levels periodically because replacement may necessitate changing the insulin dosage
adrenal insufficiency: nursing management
o diet: maintain sodium and potassium balance, high protein, and
carbohydrates o if the patient is anorexic, suggest six small meals per day to increase calorie intake o observe the patient receiving steroids for cushingoid signs, such as fluid retention around the eyes and face
adrenal insufficiency: nursing management
o instruct on lifelong cortisone replacement therapy. “do not omit
medications”. give 2/3 of dose in am and 1/3 in pm o instruct the patient that he’ll need to increase the dosage during times of stress o warn that infection, injury, profuse sweating may precipitate crisis
pheochromocytoma
o rare disorder, a chromaffin-cell tumor of the sympathetic nervous
system, usually in the adrenal medulla, secrets an excess of the catecholamine epinephrine and norepinephrine o causes episodes of hypertension and symptoms of catecholaine excess o usually benign but may be malignant
pheochromocytoma pheochromocytoma: signs and symptoms
o think sympathetic! o persistent or paroxysmal hypertension o palpitations, tachycardia, headache, visual disturbance, diaphoresis, pallor,
warmth or flushing, paresthesia, tremor, excitation o anxiety, fright, nervousness, feelings of impending doom, abdominal or chest pain, tachypnea, nausea and vomiting, fatigue, weight loss, constipation
pheochromocytoma:
o diagnostic tests: o increased plasma levels of catecholamines, elevated blood sugar, glucosuria o elevated urinary catecholamines and urinary vanilymandelic acid levels o avoid coffee, nuts, chocolates, banana o tumor on ct scan
pheochromocytoma: treatment
o surgical removal of the tumor with sparing of normal adrenals o wof: hypo or hypertension post-op o antihypertensives o alpha-adrenergic blocker o beta-adrenergic blocker o calcium channel blockers o metyrosine may be used to block catecholamine synthesis
adrenalectomy
o resection or removal of one or both adrenal glands o the treatment of choice: o for adrenal hyperfunction and hyperaldosteronism o adrenal tumors, such as adenomas and pheochromocytomas
adrenalectomy: pre-op
o correct electrolyte imbalance o potassium o sodium o calcium o manage hypertension
adrenalectomy: post-op
o monitor vital signs o wof: shock from hemorrhage o keep in mind that post-op hypertension is common because of
handling of the adrenal glands stimulate catecholamine release o wof: adrenal crisis – hypotension, hyponatremia, hyperkalemia
adrenalectomy: nursing interventions
o instruct the patient to take prescribed medication as directed
o if patient had unilateral adrenalectomy, explain that he may be able to
taper his medication in a few months o inform patient that sudden withdrawal of steroids can precipitate adrenal crisis
disorders of the parathyroid glands
hyperthyroidism hypothyroidism
parathyroid glands hyperparathyroidism hyperparathyroidism: causes
o primary hyperparathyroidism: o single adenoma, genetic disorders, or multiple endocrine neoplasias o secondary hyperparathyroidism: o rickets, vitamin d deficiency, chronic renal failure, or phenytoin or laxative abuse
hyperparathyroidism
o effect of pth secretion: ↑ calcium o through increased bone resorption, increased gi and renal absorption of calcium o complications o renal calculi → renal failure o osteoporosis o pancreatitis o peptic ulcer
hyperparathyroidism: signs and symptoms
o think of hypercalcemia: o cns; psychomotor and personality disturbances, loss of memory for recent event, depression, overt psychosis, stupor and, possibly coma o gi: anorexia, nausea, vomiting, dyspepsia, and constipation o neuromuscular: fatigue, marked muscle weakness and atrophy, particularly in the legs
hyperparathyroidism: signs and symptoms
o renal: symptoms of recurring nephrolithiasis → renal insufficiency o skeletal and articular: chronic lower back pain and easy fracturing from bone degeneration, bone tenderness, joint pain o others: skin pruritus, vision impairment from cataracts, subcutaneous calcification
hyperparathyroidism:diagnostics
o o o o
↑ serum pth levels ↑ serum calcium and ↓ phosphorus levels x-rays may show diffuse demineralization of bones elevated alkaline phosphatase
hyperparathyroidism: treatment
o surgery to remove adenoma o force fluids: limiting dietary calcium intake o for life threatening hypercalcemia: promote sodium and calcium excretion, using normal saline solution, furosemide; and administering oral sodium or potassium phosphate, calcitonin o postmenopausal women: estrogen supplements
hypoparathyroidism
o a deficiency of parathyroid hormone (pth) o pth primarily regulates calcium balance; hypoparathyroidism leads to
hypocalcemia and produces neuromuscular symptoms ranging from paresthesia to tetany
hypoparathyroidism: causes
o congenital absence or malfunction of the parathyroid glands o autoimmune destruction o removal or injury to one or more parathyroid glands during neck
surgery o massive thyroid radiation therapy o ischemic infarction of the parathyroids during surgery
hypoparathyroidism: signs and symptoms
o o o o o o
neuromuscular irritability increased deep tendon reflexes dysphagia paresthesia tetany seizures psychosis
hypoparathyroidism: signs and symptoms
o arrhythmias o abdominal pain o dry, lusterless hair
o brittle fingernails o dry and scaly skin o weakened tooth enamel
hypoparathyroidism: diagnostic tests
o o o o
↓ pth and serum calcium levels ↑ serum phosphorus levels x-rays reveal increased bone density ecg: prolonged qti, qrs-complex and st-elevation changes
hypoparathyroidism: treatment
vitamin d with supplemental calcium lifelong therapy, except for patient with the reversible form of the disease acute life-threatening tetany calls for immediate iv administration of calcium sedatives and anticonvulsants are given to control spasms until calcium levels rise o seizure precautions o o o o
duke trillanes iii, rn, map
endocrine system endocrine glands endocrine system
o endocrine glands o secrete their products directly into the bloodstream o different from exocrine glands o exocrine glands: secrete through ducts onto epithelial surfaces or into the gastrointestinal tract
hormones
o are chemical substances that are secreted by the endocrine glands. o can travel moderate to long distances or very short distances. o acts only on cells or tissues that have receptors for the specific
hormone. o target organ: the cell or tissue that responds to a particular hormone.
hypothalamus and pituitary gland regulation of hormones: negative feedback mechanism
o if the client is healthy, the concentration or hormones is maintained at
a constant level.
o when the hormone concentration rises, further production of that
hormone is inhibited.
o when the hormone concentration falls, the rate of production of that
hormone increases.
diseases of the endocrine system
o “primary” disease – problem in target gland; autonomous o “secondary” disease – problem outside the target gland; most often
due to a problem in the pituitary gland
disorders of the anterior pituitary gland
hypopituitarism hyperpituitarism
hypopituitarism
o caused by low levels of one or more anterior pituitary hormones. o lack of the hormone leads to loss of function in the gland or organ
that it controls.
causes of primary hypopituitarism
o pituitary tumors o inadequate blood supply to pituitary gland o sheehan syndrome o infections and/or inflammatory diseases o sarcoidosis o amyloidosis o radiation therapy o surgical removal of pituitary tissue o autoimmune diseases o congenital absence
causes of secondary hypopituitarism (affecting the hypothalamus):
o o o o
tumors of the hypothalamus inflammatory disease head injuries surgical damage to the pituitary and/or blood vessels or nerves leading to it
signs and symptoms signs and symptoms
o gonadotropin deficiency
o congenital onset o delayed or absent secondary sexual characteristics o may have micropenis, cryptorchidism o acquired o loss of body hair o infertility, decreased libido, impotence in males, amenorrhea in females o osteopenia, muscle atrophy o prolactin deficiency o failure to lactate
signs and symptoms
o thyroid-stimulating (tsh) deficiency o causes hypothyroidism with manifestations such as fatigue, weakness, weight change, and hyperlipidemia o adrenocorticotropic hormone (acth) deficiency o results in diminished cortisol secretion o symptoms include weakness, fatigue, weight loss, and hypotension
signs and symptoms diagnostics treatment
o surgery for tumors: transsphenoidal hypophysectomy o radiation therapy for tumors o hormonal substitution: maybe for life o corticosteroids o levothyroxine o androgen for males o estrogen for females o growth hormone
hyperpituitarism
o hyperfunction of the anterior pituitary gland → oversecretion of one or
more of the anterior pituitary hormones o usually caused by a benign pituitary adenoma o most common hormones affected:
o prolactin o growth hormone
pituitary tumor: prolactinoma
growth hormone hypersecretion
0 early onset late onset acromegaly epiphyseal closure occur at normal times gigantism acromegalic gigantism 25 50 years
gigantism vs. acromegaly gigantism vs. acromegaly
growth hormone hypersecretion: signs and symptoms
o o o o o o o o o
enlarged hand and feet; carpal tunnel syndrome common coarsening of features esp. in acromegaly; prominent mandible, tooth spacing widens macroglossia hypertension, cardiomegaly, heart failure insulin resistance → dm visual fields defect: bitemporal hemianopsia → complete blindness headaches arthritis hypogonadism
treatment
o medication o bromocriptine and cabergoline (dopamine agonist) for prolactinoma and gh hypersecretion o octreotide (somatostatin) for gh hypersecretion o surgery o transsphenoidal hypophysectomy o radiation therapy for large tumors o diet
nursing interventions
o provide emotional support → striking body change can cause
psychological stress o perform or assist with range of motion exercises to promote maximum joint mobility and prevent injury o evaluate muscle weakness
nursing interventions
o keep the skin dry o be aware that pituitary tumor may cause visual problems.
o warn relatives that hyperpituitarism can cause inexplicable mood
changes
nursing interventions
o if the patient is a child, explain to the parents that surgery prevents
permanent soft-tissue deformities but won’t correct bone changes that have already occurred.
o emphasize the importance of continuing hormonal replacement
therapy.
question
o what is the medication of choice in the treatment of gh hypersecretion and prolactinoma? o o o o
bromocriptine cabergoline octreotide vasopressin
question
o as a nurse which of the following is the most important nursing consideration? o o o o
ensuring a safe environment giving the medications as prescribed providing emotional support and counseling assisting in rom exercises to prevent contractures
question
o the hypothalamus has direct control over which of the
following organs?
o o o o o
adrenal gland thyroid gland kidneys ovaries prostate
disorders of the posterior pituitary gland
diabetes insipidus siadh
vasopressin or antidiuretic hormone
diabetes insipidus diabetes insipidus
o central diabetes insipidus: deficiency of vasopressin o primary diabetes insipidus o maybe familial, occurring as a dominant trait, or sporadic (“idiopathic”) o secondary diabetes insipidus o due to damage to the hypothalamus or pituitary stalk by tumor, surgical or accidental
trauma, infection
diabetes insipidus diabetes insipidus
signs and symptoms o polyuria o intense thirst o dehydration o inadequate water replacement
o hyperosmolality o hypovolemia
diabetes insipidus
diagnostics o fluid deprivation test o administration of desmopressin o 24 hour urine collection for volume, glucose, and creatinine o serum for glucose, urea nitrogen, calcium, uric acid, potassium, sodium
diabetes insipidus
medications o for central di o desmopressin; intranasal
o lypressin; intranasal o vasopressin tannate in oil; im o for nephrogenic di o indomethacin-hydrochlorothiazide o indomethacin-desmopressin o indomethacin-amiloride o clofibrate, chlorpropamide o psychotherapy
diabetes insipidus: nursing management
o maintain fluid and sodium balance o record i and o. weigh patient daily. o maintain fluid intake to prevent severe dehydration o wof: dehydration and shock o keep the side rails up and assist with walking if the patient is dizzy or has muscle
weakness o monitor urine specific gravity between doses. watch for decreased specific gravity with increased urine output. o add more bulk food and fruit juices to diet
diabetes insipidus: nursing management
o provide meticulous skin and mouth care, an apply a lubricant to cracked or sore lips o diet: low in sodium o carry out drug therapy o caution with vasopressin if coronary disease is present → vasoconstriction o assist in searching for the underlying pathology
syndrome of inappropriate antidiuretic hormone (siadh)
o disorder due to excessive adh release o signs and symptoms: o persistent excretion of concentrated urine o signs of fluid overload o change in level of consciousness o hyponatremia o no edema
syndrome of inappropriate antidiuretic hormone (siadh): causes of siadh
o tumors o bronchogenic ca o lymphoma
o o
pancreatic cancer mesothelioma
o pulmonary o tb o pneumonia o lung abscess o copd o pneumothorax o p. carinii pneumonia
syndrome of inappropriate antidiuretic hormone (siadh): causes of siadh o cns
o meningitis o subdural hematoma o subarachnoid hemorrhage o drugs o vincristine o phenothiazines o tricyclic antidepressants
syndrome of inappropriate antidiuretic hormone (siadh): diagnostic tests
o low serum sodium < 135 meq/lo o low serum osmolality o high urine osmolality ( >100 mosmol/kg) o high urine sodium excretion ( >20 mmol/l) o normal renal function (low bun <10 mg/dl)
syndrome of inappropriate antidiuretic hormone (siadh): management
o maintain fluid balance o restriction of water intake o if the patient has evidence of fluid overload – loop diuretics (furosemide) is added. o chronic treatment: lithium or demeclocycline o monitoring of body weight
syndrome of inappropriate antidiuretic hormone (siadh): management
o maintain sodium balance o increase sodium intake o if the serum sodium is below 120 or if the patient is seizing, emergency treatment of 3% nacl followed by furosemide o excessive rapid correction of hyponatremia may cause central pontine myelinolysis
disorders of the thyroid gland
hyperthyroidism hypothyroidism
the thyroid gland function of thyroid hormones function of thyroid hormones tests of thyroid function
thyroid stimulating hormone o single best screening test because of high sensitivity o values should range 0.38 to 6.15 uu/ml o if tsh normal – free thyroxine (ft4) is normal o used for monitoring thyroid hormone replacement therapy
tests of thyroid function
serum free thyroxine
o test used to confirm an abnormal tsh is ft4 o ft4 is a direct measurement of free thyroxine, the only metabolic fraction of t4 o normal levels 0.9 to 1.7 ng/l (11.5 to 21.8 pmol/l).
tests of thyroid function
serum t3 and t4
o normal range for t4 is 4.5 and 11.5 ug/dl (58.5 to 150 nmol/l) o the t3 level appears to be more accurate indicator of hyperthyroidism o normal range for serum t3 is 70 to 220 ng/dl (1.15 to 3.10 nmol/l)
tests of thyroid function
thyroid scan, radioscan, or scintiscan
o in a thyroid scan, a scintillation detector or gamma camera moves back and forth across the area to be studied and a visual image is made of the distribution of radioactivity in the area being scanned o isotopes used o ¹²³i – most commonly used isotope o technetium-99m pertechnetate, thallium, americium
tests of thyroid function
radioactive iodine uptake o measures the rate of iodine uptake by the thyroid gland o the patient is administered a tracer dose of iodine-123 o measures the proportion of the administered dose present in the thyroid gland at a specific
time after administration o hyperthyroidism → high uptake of ¹²³i o hypothyroidism → very low uptake
tests of thyroid function tests of thyroid function
nursing implications of thyroid tests
o it is necessary to determine whether the patient has taken medications or agents that contain iodine because these alter the results of some of the scheduled tests. o assess for allergy to iodine or shellfish o for the scans, tell patient that radiation is minimal
hyperthyroidism
hyperthyroidism:signs and symptoms
o o o o o o o o o o o o o
enlarged thyroid gland tachycardia hypertension heat intolerance, diaphoresis smooth, soft, warm skin fine soft hair diarrhea, weight loss inspite of increased appetite nervousness and fine tremors of hands hyperactive reflexes, body weakness personality changes, mood swings osteoporosis clubbing and swelling of fingers, plummer’s nails menstrual disturbances, decreased infertility
signs and symptoms of grave’s disease
thyroid storm
o a medical emergency: high mortality o marked delirium, severe tachycardia, vomiting, diarrhea, dehydration, high fever o occurs in patients with existing but unrecognizable thyrotoxicosis, stressful illness, thyroid surgery, rai o increased systemic adrenergic activity – epinephrine overproduction and severe hypermetabolism
hyperthyroidism: diagnostics
o o o o o
radioimmunoassay test shows elevated t4 and t3 thyroid scan reveals increased radioactive iodine (¹²³i) uptake ↓ tsh in primary hyperthyroidism ↑ tsh in secondary hyperthyroidism orbital sonography and computed scan confirm subclinical ophthalmopathy
hyperthyroidism: management
antithyroid drug therapy o propylthiouracil (ptu) and methimazole o used for pregnant women and patient who refused surgery or rai treatment o during pregnancy ptu – preferred therapy o a few (1%) of the infants born to mothers receiving antithyroid medication will be
hypothyroid
o mechanism of action: blocks thyroid hormone synthesis o wof: agranulocytosis
hyperthyroidism: management
o radioactive iodine (¹³¹i), potassium or sodium iodide, strong iodine solution (lugol’s solution) o adjunct with other antithyroid drugs in preparation for thyroidectomy o treatment for thyrotoxic crisis o mechanism of action o inhibits the release and synthesis of thyroid hormones o decreases vascularity of the thyroid gland o decreases thyroidal uptake of rai
hyperthyroidism: nursing management
potassium or sodium iodide, strong iodine solution o dilute oral doses in water or fruit juice and give with meals to prevent gastric irritation, to o o o o
hydrate the patient, and to mask the very salty taste warn the patient that sudden withdrawal may precipitate thyrotoxicosis store in light resistant container give iodides through a straw to avoid teeth discoloration force fluids to prevent fluid volume deficit
hyperthyroidism: nursing management of rai treatment
o radioactive iodine o food may delay absorption. the patient should fast overnight before administration o after dose for hyperthyroidism, the patients urine and saliva are slightly radioactive for 24
hours; vomitus is highly radioactive for 6 to 8 hours o institute full radiation precautions during this time o instruct the patient to use appropriate disposal methods when coughing and expectorating
hyperthyroidism: nursing management of rai treatment
o after dose for thyroid cancer, isolate the patient and observe the following precautions: o pregnant personnel shouldn’t take care of the patient o disposable eating utensils and linens should be used o instruct the patient to save all urine in lead containers for 24 to 48 hours so amount of
radioactive material excreted can be determined o or flush the toilet twice after urination
hyperthyroidism: nursing management of rai treatment
o the patient should drink as much fluid as possible for 48 hours after
drug administration to facilitate excretion o limit contact with the patient to 30 minutes per shift per person the 1st day; may increase time to 1 hour on 2nd day and longer on 3rd day
hyperthyroidism: nursing management of rai treatment
o if the patient is discharged less than 7 days after ¹³¹i dose for thyroid
cancer, warn patient
o to avoid close, prolonged contact with small children o not to sleep in the same room with his spouse for 7 days after treatment → increase risk of thyroid cancer in persons exposed to ¹³¹i.
hyperthyroidism: management
o b-blockers, digoxin, anticoagulation o prednisone for ophthalmopathy o treatment for thyroid storm o ptu o i.v. propanolol to block sympathetic effects o corticosteroids to replace depleted cortisol levels o iodide to block release of thyroid hormone
hyperthyroidism: management
o surgery: thyroidectomy o preop: give lugol’s iodide to prevent thyroid storm o care of post-thyroidectomy client o monitor for respiratory distress o have tracheotomy set, oxygen, and suction at bedside o semi-fowlers position
o monitor for laryngeal nerve damage o monitor for signs of hypocalcemia and tetany o monitor for thyroid storm
hyperthyroidism: nursing management
o o o o o o
record vital signs and weight monitor serum electrolyte levels, and check periodically for hyperglycemia and glycosuria monitor cardiac function check levels of consciousness and urine output if patient is in her 1st trimester of pregnancy: report for signs of spontaneous abortion diet
o o o
high protein, high calorie, vitamin supplements low sodium diet for patients with edema no stimulants like coffee, tea
hyperthyroidism: nursing management
o for exophthalmos o suggest sunglasses or eye patches to protect eyes from light o moisten the conjunctivae with artificial tears o warm the patient with severe lid retraction to avoid sudden physical movement that might cause the
lid to slip behind the eyeball
o o
elevate the head of the bed to reduce periorbital edema
o stress the importance of regular medical follow-up after discharge because hypothyroidism may
develop drug therapy and rai therapy require careful monitoring and comprehensive teaching
hypothyroidism hypothyroidism
o a state of low serum thyroid hormone levels or cellular resistance to thyroid hormone o causes: o may result from thyroidectomy o radiation therapy o chronic autoimmune thyroiditis o inflammatory conditions o pituitary failure to produce tsh o hypothalamic failure to produce thyrotropin-releasing hormone (trh) o inborn errors of thyroid hormone synthesis o antithyroid medications such as ptu o inability to synthesize thyroid hormone because of iodine deficiency
hypothyroidism: signs and symptoms hypothyroidism: signs and symptoms
myxedema coma
o manifests as hypotension, bradycardia, hypothermia, hyponatremia,
hypoglycemia, respiratory failure, coma o can be precipitated by acute illness, rapid withdrawal if thyroid medication, anesthesia, surgery, hypothermia, use of opioids
hypothyroidism: diagnostics
o o o o o radioimmunoassay tests: ↓ t3 t4 ↑ tsh level with primary hypothyroidism ↓ tsh level with secondary hypothyroidism serum cholesterol and triglyceride levels are increased in myxedema coma o low serum sodium levels o respiratory acidosis because of hypoventilation
hypothyroidism: management
o prevention: prophylactic iodine supplements to decrease the
incidence of iodine deficient goiter o symptomatic cases:
o hormonal replacement: synthroid (synthetic hormone (levothyroxine)) o dosage is increased q 2-3 weeks esp. if the patient is an elderly
nursing management of replacement therapy
o different brands of levothyroxine may not be bioequivalent o warn the patient to tell the doctor if o chest pain, palpitations, sweating, nervousness, or their signs or symptoms of overdosage o signs and symptoms of aggravated cardiovascular disease (chest pain, dyspnea, tachycardia)
nursing management of replacement therapy
o instruct the patient to take thyroid hormones at the same time each
day to maintain constant hormone levels o suggest a morning dosage to prevent insomnia o monitor apical pulse and blood pressure. if pulse is >100, withhold the drug. assess for tachyarrhytmias and chest pain.
nursing management of replacement therapy
o thyroid hormones alter thyroid function test results o for ¹²³i uptake studies o d/c levothyroxine 4 wks before the test o d/c liothyronine 7 to 10 days before the test o monitor prothrombin time o wof: unusual bleeding and bruising
hypothyroidism: nursing interventions
o o o o o
diet: high-bulk, low calorie diet encourage activity maintain warm environment administer cathartics and stool softeners to prevent myxedema coma, tell the patient to continue course of thyroid medication event if symptoms subside o maintain patent airway
o o o o
administer medications – synthroid, glucose, corticosteroids iv fluid replacement wrap patient in blanket treat infection or any underlying illness
disorders of the pancreas
diabetes mellitus
hormones of the pancreas
o insulin o decreases blood sugar by: o stimulating active transport of glucose into muscle and adipose tissue o promoting the conversion of glucose to glycogen for storage o promoting conversion of fatty acids into fat o stimulating protein synthesis o secreted in response to high blood sugar o found in β cells of the islets of langerhans
hormones of the pancreas
o glucagon o increases blood glucose by o causing gluconeogenesis and glycogenolysis in the liver o secreted in response to low blood sugar o found in the α-cells of the islets of langerhans
diabetes mellitus
o chronic disease characterized by hyperglycemia o it is due to total or partial insulin deficiency or insensitivity of the cells
to insulin o characterized by disorders in the metabolism of cho, fats, chon as well as changes in the structure and function of blood vessels
types of diabetes mellitus
o type 1 or iddm o usually occurs in children or in non-obese adults o type 2 or niddm o usually occurs in obese adults or over age 40 o gestational dm o secondary dm o induced by trauma, surgery, pancreatic disease or medications o can be treated as either type 1 or type 2
pathophysiology
o lack of insulin causes hyperglycemia (insulin is necessary for the transport of glucose across the membrane) o body excretes excess glucose through kidneys → osmotic diuresis → polyuria → dehydration → polydipsia o cellular starvation → polyphagia o the body turns to fats and proteins for energy; but in the absence of glucose in the cell, the fats cannot be completely metabolized and ketones are produced
chronic complications
o microangiopathy: retinopathy, nephropathy o macroangiopathy: peripheral vascular diseae, atherosclerosis, cad o neuropathy
instruction in the care of the feet
o hygiene of the feet o wash feet daily with mild soap and lukewarm water. dry thoroughly between the toes by
pressure. do not rub vigorously, as this is apt to break the delicate skin. o rub well with vegetable oil to keep them soft, prevent excess friction, remove scales, and prevent dryness. o if the feet become too soft and tender, rub them with alcohol abut once week.
instruction in the care of the feet
o hygiene of the feet o when rubbing the feet, always rub upward from the tips of the toes. if varicose veins are
present, massage the feet very gently; never massage the legs. o of the toenails are brittle and dry, soften them by soaking for 1 ½ hour each night in lukewarm water containing 1 tbsp of powdered sodium borate (borax) per quart. clean around the nails with an orangewood stick. if the nails become too long, file them with an amery board. file them straight across and no shorter than the underlying soft tissue of the toes. never cut the corner of the nails.
instruction in the care of the feet
o wear low heeled shoes of soft leather that fit the shape of the feet
correctly. the shoes should have wide toes that will cause no pressure, fit close in the arch, and grip the heels snugly. wear new shoes one-half hour only on the first day and increase by 1 our each day following. wear thick, warm, loose stockings.
instruction in the care of the feet
o treatment of corns and calluses o corns and calluses are due to friction and pressure, most often from improperly fitted shoes
and stockings. wear shoes that fit properly and cause no friction or pressure. o to remove excess calluses or corns, soak the feet in lukewarm water, using a mild soap, for about 10 minutes and then rub off the excess tissue with a towel or file. do not tear it off. under no circumstances must the skin be irritated.
instruction in the care of the feet
o treatment of corns and calluses o do not cut corns or calluses. if they need attention it is safer to see a podiatrist. o prevent callus formation under the ball of the foot (a) by exercise, such as curling and stretching the toes several times a day; (b) by finishing each step on the toes and not on the ball of the foot; and (c) by wearing shoes that are not too short and that do not have high heels.
diagnostics: fbs and ogtt
diagnostics: glycosylated hemoglobin
o nv = 7.5% or less, good control o 7.6% to 8.9% fair control o 9% or greater, poor control
therapeutic interventions:
o life-style changes o weight control and exercises o planned diet o 50 – 60% of calories are complex carbohydrates, high fiber o 12 – 20% daily calories is chon o fat intake not to exceed 30% of daily calories, more of polyunsaturated fats o basic tools: food exchange groups o self-monitoring of blood glucose
therapeutic interventions:
o insulin administration o type 1 iddm and type 2 dm when diet and weight control therapy failed o aspirin, alcohol, oral anticoagulants, oral hypoglycemics, beta blockers, tricyclic
antidepressants, tetracycline, maois increase the hypoglycemic effects of insulin o glucocorticoids, thiazide diuretics, thyroid agents, oral contraceptives increase blood glucose levels o illness, infection, and stress increase the need for insulin
insulin administration
complications of insulin therapy
o local allergic reaction, lipodystrophy, insulin resistance o dawn phenomenon o increase in blood sugar because of release of growth hormone at around 3am o tx: give at 10pm, intermediate-acting insulin o somogy effect o rebound hyperglycemia at 7 am after a bout of hypoglycemia at around 2-3am o tx: decrease the evening dose of intermediate acting insulin
complications of insulin therapy
o hypoglycemia o if awake, give 10-15 g of fast-acting simple juice carbohydrate (glucose tablets, fruit juice, and soda) o if unconscious, glucagon sq or im o if in the hospital, 25-50 cc of d50%
oral hypoglycemic agents
o for dm type 2 o may have to be shifted to insulin when sick, under stress, during
surgery o necessary to shift to insulin when pregnant
oral hypoglycemic agents
o sulfonylureas o promotes increase insulin secretion from pancreatic beta cells through direct stimulation o first generation agents: o tolbutamine, acetohexamide, tolzamide, chlorpropamide o second generation agents o glypizide, glyburide
oral hypoglycemics
o biguanides o reduces hepatic production of glucose by inhibiting glycogenolysis o decrease the intestinal absorption of glucose and improving lipid profile o agents: o phenformin, metformin, buformin
oral hypoglycemics
o alpha-glucosidase inhibitors o inhibits alpha-glucosidase enzymes in the small intestine and alpha amylase in the pancreas o decreases rate of complex carbohydrate metabolism resulting to a reduced rate postprandially o agents: o acarbose (precose), miglitol (glyset)
oral hypoglycemics
o thiazolidinediones o enhances insulin action at the cell and post-receptor site and decreasing insulin resistance o agents: o pioglitazone (actos), rosiglitazone (avandia)
acute complication: dka
o characterized by hyperglycemia and accumulation of ketones in the body causing metabolic acidosis o occurs in insulin-dependent diabetic client o precipitating factors: undiagnosed diabetes, neglect of treatment, infection, other physical or emotional stress o onset slow, maybe hours to days
dka: signs and symptoms
o o o o o o o
polydipsia, polyphagia and polyuria nausea and vomiting, abdominal pain skin warm, dry and flushed dry mucous membrane kussmaul’s respirations or hyperventilation; acetone breath alterations in loc hypotension, tachycardia
hyperglycemic hyperosmolar nonketotic coma (hhnk)
o characterized by hyperglycemia and a hyperosmolar state without
ketosis o occurs in niddm or non-diabetic persons (typically elderly persons) o precipitating factors: undiagnosed diabetes, infection, or other stress; certain medications, dialysis, hyperalimentation, major burns
emergency management:
o for both dka and hhnk, treat dehydration first with 0.9% or ).45% saline solution o shift to d5w when glucose level is down to 250-300mg/dl o wof to rapid correction, it can cause rapid fluid shifts (brain edema and increased icp, ards) o iv regular insulin 0.1 unit/kg bolus then 0.1 unit/kg/h drip
o correcting electrolyte imbalance: watch out for hypokalemia as a result of treatment.
disorders of the adrenal glands
cushing’s syndrome hyperaldosteronism adrenal insufficiency pheochromocytoma
adrenal glands adrenal medulla adrenal cortex hormones
o glucocorticoids o cortisol, corticosterone o increase blood glucose levels by increasing rate of gluconeogenesis o increase protein catabolism o increase mobilization of fatty acids o promote sodium and water retention o anti-inflammatory effect o aid the body in coping with stress
adrenal cortex hormones
o mineralocorticoids o aldosterone, corticosterone, deoxycorticosterone o regulate fluid and electrolyte balance o stimulate reabsorption of sodium, chloride and water o stimulate potassium excretion o under the control of renin-angiotensin-aldosterone system
adrenal cortex hormones
o sex hormones o androgens, estrogens o influences the development of sexual characteristics
hypercortisolism (cushing’s syndrome)
o cluster of physical abnormalities due to excessive cortisol release o cortisol excess is due either to: o autonomous steroid release from adrenals o increased acth release from pituitary o complication from exogenous steroid tx
hypercortisolism (cushing’s syndrome)
hypercortisolism (cushing’s syndrome)
complications
o o o o
osteoporosis peptic ulcer immune and inflammatory response is also compromised other complications include hpn, and sexual and psychological complications
cushing’s syndrome: diagnostics
o acth levels → determines whether the syndrome is acth dependent o 24 – hr urine collection for cortisol, midnight serum cortisol o dexamethsone suppression test →1 mg dexamethasone is given at
11 pm and serum cortisol taken at 8 am the next day o radiologic evaluation
cushing’s syndrome: management
o transsphenoidal resection of pituitary tumor o medications: o aminogluthetimide: adrenal enzyme inhibitor o metyrapone and ketokonazole: suppress hypercrtisolism in unresectable adrenal tumor o antihypertensives o adrenalectomy as needed
cushing’s syndrome: nursing considerations
o monitor vs, wof for hpn o safety precaution: o maintain muscle tone o prevent accidents or falls and provide adequate rest o protect client from exposure to infection, monitor wbc o maintain skin integrity o minimize stress o provide diet low in calories, sodium, and high in protein, potassium, calcium and vitamin d o monitor for urine glucose and acetone, administer insulin if necessary o prepare client for adrenalectomy if needed
hyperaldosteronism
o hypersecretion of aldosterone from the adrenal cortex o two types: o primary disease of the adrenal cortex o secondary condition due to increased plasma renin activity o causes: o excessive reabsorption of sodium and water
o excessive renal excretion of potassium
hyperaldosteronism: causes
o primary aldosteronism: autonomous secretion of aldosterone from
adrenals
o benign adrenal adenoma (conn’s syndrome) o bilateral adrenocortical hyperplasia
hyperaldosteronism: causes
o secondary hyperaldosteronism: high renin state → stimulating aldosterone release o renal artery stenosis o wilm’s tumor o pregnancy o oral contraceptive use o nephritic syndrome o cirrhosis with ascites o idiopathic edema o heart failure o extrarenal sodium loss
hyperaldosteronism: signs and symptoms
o hypertension o headache and visual disturbance o hypokalemia o muscle weakness and fatigue o paresthesia and arrhythmias o polyuria and polydipsia o tetany from alkalosis o hypernatremia
hyperaldosteronism: diagnostics
o o o o o o o o hypokalemia (<3.5 meq/l) hypernatremia (>145 meq/l) elevated serum bicarbonate and ph hypomagnesemia elevated plasma and urinary aldosterone ↓ renin in primary hyperaldosteronism ↑ renin in secondary hyperaldosteronism low specific gravity urine (diluted urine)
hyperaldosteronism: treatment
o primary aldosteronism: o unilateral adrenalectomy
o o o o o
potassium-sparing diuretic antihypertensives aminogluthemide diet: sodium restriction, increase potassium treatment of secondary hyperaldosteronism
adrenal insufficiency
o addison’s disease- the most common form of adrenal hypofunction o autoimmune process, circulating antibodies react specifically against
the adrenal tissue o acute adrenal insufficiency, or adrenal crisis (addisonian crisis) is a medical emergency requiring immediate, vigorous treatment
adrenal insufficiency: causes
o autoimmune destruction of the adrenal gland, tuberculosis, bilateral
adrenalectomy, hemorrhage into the adrenal gland, neoplasm, fungal infection o secondary adrenal hypofunction
o hypopituitarism o abrupt withdrawal of long-term corticosteroid therapy
adrenal insufficiency: signs and symptoms
o o o o
weakness, fatigue weight loss, nausea and vomiting, anorexia chronic constipation or diarrhea cardiovascular abnormalities
o postural hypotension, decreased heart size and cardiac output o weak, irregular pulse o decreased tolerance for minor stress
adrenal insufficiency: signs and symptoms
o o o o o
conspicuous bronze skin coloration poor coordination fasting hypoglycemia: and craving for salty food amenorrhea adrenal crisis
adrenal insufficiency: diagnostic tests
o decreased plasma cortisol and serum sodium levels o increased acth (in addison’s), serum potassium, and blood urea
nitrogen level
adrenal insufficiency : treatment
o corticosteroid replacement o fludrocortisone acetate – acts as mineralocorticoid to prevent
dehydration and hypotension o adrenal crisis: prompt iv bolus of corticosteroids, 3 to 5 l of iv fluids, dextrose
adrenal insufficiency: nursing management
o wof: adrenal crisis o hypotension and signs of shock o decreased level of consciousness and urine output o watch for hyperkalemia before treatment and for hypokalemia after treatment (from
excessive mineralocorticoid effect)
o if patient has diabetes, check blood glucose levels periodically because replacement may necessitate changing the insulin dosage
adrenal insufficiency: nursing management
o diet: maintain sodium and potassium balance, high protein, and
carbohydrates o if the patient is anorexic, suggest six small meals per day to increase calorie intake o observe the patient receiving steroids for cushingoid signs, such as fluid retention around the eyes and face
adrenal insufficiency: nursing management
o instruct on lifelong cortisone replacement therapy. “do not omit
medications”. give 2/3 of dose in am and 1/3 in pm o instruct the patient that he’ll need to increase the dosage during times of stress o warn that infection, injury, profuse sweating may precipitate crisis
pheochromocytoma
o rare disorder, a chromaffin-cell tumor of the sympathetic nervous
system, usually in the adrenal medulla, secrets an excess of the catecholamine epinephrine and norepinephrine o causes episodes of hypertension and symptoms of catecholaine excess o usually benign but may be malignant
pheochromocytoma pheochromocytoma: signs and symptoms
o think sympathetic! o persistent or paroxysmal hypertension o palpitations, tachycardia, headache, visual disturbance, diaphoresis, pallor,
warmth or flushing, paresthesia, tremor, excitation o anxiety, fright, nervousness, feelings of impending doom, abdominal or chest pain, tachypnea, nausea and vomiting, fatigue, weight loss, constipation
pheochromocytoma:
o diagnostic tests: o increased plasma levels of catecholamines, elevated blood sugar, glucosuria o elevated urinary catecholamines and urinary vanilymandelic acid levels o avoid coffee, nuts, chocolates, banana o tumor on ct scan
pheochromocytoma: treatment
o surgical removal of the tumor with sparing of normal adrenals o wof: hypo or hypertension post-op o antihypertensives o alpha-adrenergic blocker o beta-adrenergic blocker o calcium channel blockers o metyrosine may be used to block catecholamine synthesis
adrenalectomy
o resection or removal of one or both adrenal glands o the treatment of choice: o for adrenal hyperfunction and hyperaldosteronism o adrenal tumors, such as adenomas and pheochromocytomas
adrenalectomy: pre-op
o correct electrolyte imbalance o potassium o sodium o calcium o manage hypertension
adrenalectomy: post-op
o monitor vital signs o wof: shock from hemorrhage o keep in mind that post-op hypertension is common because of
handling of the adrenal glands stimulate catecholamine release o wof: adrenal crisis – hypotension, hyponatremia, hyperkalemia
adrenalectomy: nursing interventions
o instruct the patient to take prescribed medication as directed
o if patient had unilateral adrenalectomy, explain that he may be able to
taper his medication in a few months o inform patient that sudden withdrawal of steroids can precipitate adrenal crisis
disorders of the parathyroid glands
hyperthyroidism hypothyroidism
parathyroid glands hyperparathyroidism hyperparathyroidism: causes
o primary hyperparathyroidism: o single adenoma, genetic disorders, or multiple endocrine neoplasias o secondary hyperparathyroidism: o rickets, vitamin d deficiency, chronic renal failure, or phenytoin or laxative abuse
hyperparathyroidism
o effect of pth secretion: ↑ calcium o through increased bone resorption, increased gi and renal absorption of calcium o complications o renal calculi → renal failure o osteoporosis o pancreatitis o peptic ulcer
hyperparathyroidism: signs and symptoms
o think of hypercalcemia: o cns; psychomotor and personality disturbances, loss of memory for recent event, depression, overt psychosis, stupor and, possibly coma o gi: anorexia, nausea, vomiting, dyspepsia, and constipation o neuromuscular: fatigue, marked muscle weakness and atrophy, particularly in the legs
hyperparathyroidism: signs and symptoms
o renal: symptoms of recurring nephrolithiasis → renal insufficiency o skeletal and articular: chronic lower back pain and easy fracturing from bone degeneration, bone tenderness, joint pain o others: skin pruritus, vision impairment from cataracts, subcutaneous calcification
hyperparathyroidism:diagnostics
o o o o
↑ serum pth levels ↑ serum calcium and ↓ phosphorus levels x-rays may show diffuse demineralization of bones elevated alkaline phosphatase
hyperparathyroidism: treatment
o surgery to remove adenoma o force fluids: limiting dietary calcium intake o for life threatening hypercalcemia: promote sodium and calcium excretion, using normal saline solution, furosemide; and administering oral sodium or potassium phosphate, calcitonin o postmenopausal women: estrogen supplements
hypoparathyroidism
o a deficiency of parathyroid hormone (pth) o pth primarily regulates calcium balance; hypoparathyroidism leads to
hypocalcemia and produces neuromuscular symptoms ranging from paresthesia to tetany
hypoparathyroidism: causes
o congenital absence or malfunction of the parathyroid glands o autoimmune destruction o removal or injury to one or more parathyroid glands during neck
surgery o massive thyroid radiation therapy o ischemic infarction of the parathyroids during surgery
hypoparathyroidism: signs and symptoms
o o o o o o
neuromuscular irritability increased deep tendon reflexes dysphagia paresthesia tetany seizures psychosis
hypoparathyroidism: signs and symptoms
o arrhythmias o abdominal pain o dry, lusterless hair
o brittle fingernails o dry and scaly skin o weakened tooth enamel
hypoparathyroidism: diagnostic tests
o o o o
↓ pth and serum calcium levels ↑ serum phosphorus levels x-rays reveal increased bone density ecg: prolonged qti, qrs-complex and st-elevation changes
hypoparathyroidism: treatment
vitamin d with supplemental calcium lifelong therapy, except for patient with the reversible form of the disease acute life-threatening tetany calls for immediate iv administration of calcium sedatives and anticonvulsants are given to control spasms until calcium levels rise o seizure precautions o o o o
