endocrine - test 2 - nursing 210

ENDOCRINE SYSTEM (http://www.endocrineweb.com/)The ANATOMY of the Endocrine System

The endocrine system is composed of ductless glands that release their hormones directly into the bloodstream

The Hypothalamus controls most of the endocrinal activity of the pituitary gland

The pituitary gland controls most of the activities of the other endocrine glands

The Hypothalamus

This part of the DIENCEPHALON is located below the thalamus and is connected to the pituitary gland by a stalk

The PHYSIOLOGY of the Endocrine System: Hypothalamus

Secretes RELEASING HORMONES for the pituitary gland

Secretes OXYTOCIN that is stored in the Posterior pituitary gland

Secretes Anti-Diuretic Hormone or VASOPRESSIN that is stored also in the posterior pituitary gland

The Pituitary Gland

Is a gland located below the hypothalamus at the base of the brain

The optic chiasm passes over this structure

Is divided into two parts- the anterior or adenohypophysis and the posterior or the neurohypophysis

Anterior Pituitary secretes the following hormones:

1. Growth hormone

2. Prolactin

3. Gonadotrophins- LH and FSH

4. Stimulating hormones and trophic hormones

ACTH

TSH

MS

Posterior Pituitary stores and releases

1. OXYTOCIN 2. ADH/Vasopressin

The THYROID gland

Located in the anterior neck lateral to the trachea

Contains two lobes connected by the isthmus

Microscopically composed of thyroid follicles where the hormones are produced and stored

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http://www.endocrineweb.com/

The PHYSIOLOGY of the Endocrine System: Thyroid

Produces the thyroid hormones by the thyroid follicles:

1. Tri-iodothyronine or T3

2. Tetra-iodothyronine or thyroxine or T4

The Parafollicular cells secrete CALCITONIN

The PARAthyroid glands

Located at the back of the thyroid glands

Four in number

Secretes PARATHYROID hormone (PTH) that controls calcium and phosphorus levelsThe ANATOMY of the Endocrine System

The Adrenal Glands

Located above the kidneys

Composed of two parts- the outer Adrenal Cortex and the inner Adrenal medulla

Adrenal Cortex

Secretes three types of STERIOD hormones

1. Glucocorticoids- like Cortisol, cortisone and corticosterone

2. Mineralocorticoids- like Aldosterone

3. Sex hormones- like estrogen and testosterone

Adrenal Medulla

Essentially a part of the SYMPATHETIC autonomic system

Secretes Adrenergic Hormones:

1. Epinephrine 2. Nor-epinephrine

The Pancreas

This retroperitoneal organ has both endocrine and exocrine functions

The endocrine function resides in the ISLETS of Langerhans

The islets have three types of cells- alpha, beta and delta cells

The ALPHA cells secrete GLUCAGON

The BETA cells secrete INSULIN

The DELTA cells secrete SOMATOSTATIN

The GONADS- Ovaries

These two almond-shaped glands are found in the pelvic cavity attached to the uterus by the ovarian ligament

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The GONADS- Testes

These two oval-shaped glands are found in the scrotumGonads

The Ovaries contains Granulosa and Theca cells which secrete ESTROGEN and Progesterone

The testes contains Leydig cells that secrete Testosterone

COMMON LABORATORY PROCEDURES

Hormone Levels Assay

These are blood examinations fro the levels of individual hormones

Measurements can also be done after stimulation and suppression of the secretions- Stimulation and Suppression tests

Hormone Levels of T3/T4

Usually done to diagnose hypo/hyperthryroidism

If T3 is elevated, T4 is elevated and TSH is depressed- Primary HYPERthyroidism

If T3 is depressed,T4 is depressed and TSH is elevated- Primary HYPOthyoidism

Radio-Active iodine uptake (RAI)

This is a thyroid function test to measure the absorption of the injected iodine isotope by the thyroid tissue

Increased uptake may indicate HYPERfunctioning gland

Decreased uptake my indicate HYPOfunctioning gland

Thyroid Scan

Performed to identify nodules or growth in the thyroid gland

RAI is used

Pretest- Check for pregnancy, Thyroid medication may be withheld temporarily. NPO,

Post-test- Ensure proper disposal of body wastes

FASTING BLOOD GLUCOSE

Aids in the diagnosis of Diabetes

Pre-test; NPO for 8 hours

Normal FBS- 80-109 mg/dL

GLUCOSE tolerance test

Aids in the diagnosis of DM

Pre-test: Provide high-carbohydrate foods x 3 days, instruct to avoid caffeine, alcohol and smoking, NPO 10 hours prior to test

Post-test: avoid strenuous activity for 8 hours

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Normal OGTT

Glycosylated Hemoglobin A 1-C

Blood glucose bound to RBC hemoglobin

Reflects how well blood glucose is controlled for the past 3 months

FASTING is NOT required!

Normal level- expressed as percentage of total hemoglobin

N- 4-7%

Good control- 7.5%or less

Fair control- 7.5 % to 8.9%

Poor control- 9% and above

DISORDERS OF THE ENDOCRINE GLAND

Disorders are generally grouped into:

1. HYPER- when the gland secretes excessive hormones

2. HYPO- when the gland does not secrete enough hormones

Hyper and Hypo can be classified as PRIMARY when the Gland itself is the problem or SECONDARY when the pituitary or the hypothalamus is causing the problem

HYPOPITUITARISM

Hyposecretion of the anterior pituitary gland

CAUSES: Congenital, Post-partal necrosis, infection and tumor

PATHOPHYSIOLOGY: Depends on the major hormone/s depleted

ASSESSMENT Findings

1. Retarded physical growth due to decreased GH- dwarfism

2. Low intellectual development

3. poor development of secondary sexual characterisitcs

NURSING INTERVENTIONS

1. provide emotional support to the family

2. encourage client and family to express feelings

3. administer prescribed hormonal replacement therapy

HYPERPITUITARISM

The hypersecretion of the gland

also called ACROMEGALY/GIGANTISM

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CAUSES: tumor, congenital

PATHOPHYSIOLOGY

Depends on the hormone/s that is/are increased

ASSESSMENT FINDINGS

1. Increased growth- Gigantism or Acromegaly

2. large and thick hands and feet

3. Visual disturbances

4. Hypertension, hyperglycemia

5. Organomegaly

NURSING INTERVENTION

1. provide emotional support to clients and family

2. provide frequent skin care

3. prepare patient for surgery- removal of pituitary gland


Post-operative care

1. Monitor VS, LOC and neurologic status

2. Place patient on Semi-Fowler’s

3. Monitor for Increased ICP, bleeding, CSF leakage

4. instruct patient to AVOID sneezing, coughing and nose-blowing

5. Monitor development of DI- measure I and O

6. Administer prescribed medications- antibiotics, analgesics and steroids

DIABETES INSIPIDUS

A hyposecretion of ADH

CAUSES: Conditions that increase ICP, Surgical removal of post pit, tumor

PATHOPHYSIOLOGY

Decreased ADH- failure of tubular reabsorption of water- increased urine volume

ASSESSMENT findings

1. Polyuria of more than 4 liters of urine/day

2. Polydipsia

3. Signs of Dehydration

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4. Muscle pain and weakness

5. Postural hypotension and tachycardia

DIAGNOSTIC TEST

1. Urinary Specific gravity- very low, 1.006 or less

2. Serum Sodium levels- high


1.Monitor VS, neurologic status and cardiovascular status

2. Monitor Intake and Output

3. Monitor urine specific gravity

4. Provide adequate fluids

5. Administer Chlorpropamide or Clofibrate as prescribed to increase the action of ADH if decreased

6. Administer VASOPRESIN. Desmopressin or Lypressin. Pitressin is given IM

SIADH

Hypersecretion of ADH abnormally

CAUSES: tumor, paraneoplastic syndromes

PATHOPHYSIOLOGY: Increased ADH- water reabsorption- water intoxication, hypervolemia

DIAGNOSTIC TEST

1. urine specific gravity is increased

2. Hyponatremia

3. CBC shows hemodilution

ASSESSMENT findings

1. Signs of Hypervolemia

2. Mental status changes

3. Abnormal weight gain

4. hypertension

5. Anorexia, Nausea and Vomiting

6. HYPOnatremia


1. Monitor VS and neurologic status

2. provide safe environment

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3. Restrict fluid intake (less than 500cc/day)

4. Monitor I and O and daily weight

5. Administer Diuretics and IVF carefully

6. Administer prescribed Demeclocycline to inhibit action of ADH in the kidney

DISORDERS OF the ADRENAL GLAND

HYPOSECRETION: ADDISON’S DISEASE

Decreased secretion of adrenal cortex hormones, especially glucocorticoids and mineralocorticoids

CAUSE: tumor, idopathic

PATHOPHYSIOLOGY

Decreased Glucocorticoids- decreased resistance to stress

Decreased mineralocorticoids- decreased retention of sodium and water

ASSESSMENT Findings for Addison’s disease

1. Weight loss

2. GI disturbances

3. Muscle weakness, lethargy and fatigue

4. Hyponatremia

5. hyperkalemia

6. hypoglycemia

7. dehydration and hypovolemia

8. Increased skin pigmentation


1. Monitor VS especially BP

2. Monitor weight and I and O

3. Monitor blood glucose level and K

4. Administer hormonal agents as prescribed

5. Observe for ADDISONIAN crisis

6. Educate the client regarding lifelong treatment, avoidance of strenuous activities, stress and seeking prompt consult during illness

7. Provide a high-protein, high carbohydrate and increased sodium intake

ADDISONIAN CRISIS

A life-threatening disorders caused by acute severe adrenal insufficiency

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CAUSES: Severe stress, infection, trauma or surgery

PATHOPHYSIOLOGY

Overwhelming stimuli- mobilize body defense- decreased stress hormones- inadequate coping

ASSESSMENT Findings for Addisonian Crisis

1. Severe headache

2. Severe pain

3. Generalized weakness

4. Severe hypotension

5. Signs of Shock


1. Administer IV glucocorticoids, usually hydrocortisone

2. Monitor VS frequently

3. Monitor I and O, neurological status, electrolyte imbalances and blood glucose

4. Administer IVF

5. Maintain bed rest

6. Administer prescribed antibiotics

HYPERSECRETION: CUSHING’S DISEASE

A condition resulting from the hypersecretion of glucocorticoids from the adrenal cortex

CAUSES: Pituitary tumor, adrenal tumor, abuse of steroids

PATHOPHYSIOLOGY: Increased Glucocorticoids- exaggerated effects of the hormone

ASSESSMENT FINDINGS for Cushing

1. generalized muscle weakness and wasting

2. truncal obesity

3. moon-face

4. buffalo hump

5. easy bruisability

6. Reddish-purplish striae on the abdomen and thighs

7. Hirsutism and acne

8. Hypertension

9. hyperglycemia

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10. Osteoporosis

11. Amenorrhea

DIAGNOSTIC TEST

1. Serum cortisol level

2. Serum glucose and electrolytes


1. Monitor I and O , weight and VS

2. Monitor laboratory values- glucose, Na, K and Ca

3. Provide meticulous skin care

4. Administer prescribed medications like aminogluthetimide to inhibit adrenal hyperfunctioning

5. Prepare client for surgical management- pituitary surgery and adrenalectomy

6. protect patient from infection

Hypersecretion: CONN’S DISEASE

Hypersecretion of Aldosterone from the adrenal cortex

CAUSES: pituitary tumor, adrenal tumor

PATHOPHYSIOLOGY: Increased Aldosterone- exaggerated effects

ASSESSMENT findings in CONN’S disease

1. Symptoms of HYPOkalemia

2. hypertension

3. hypernatremia

4. Headache, N/V

5. Visual changes

6. Muscles weakness, fatigue and nocturia

DIAGNOSTIC TEST

1. Urine gravity- low

2. Serum Sodium- high

3. Serum Potassium- low

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4. Increased urinary Aldosterone


1. Monitor VS, I and O and urine sp gravity

2. Monitor serum K and Na

3. Provide Potassium rich foods and supplements

4. Administer prescribed diuretic- Spironolactone

5. Maintain sodium-restricted diet

6. Prepare patient for possible surgical interventions

Hypersecretion: Pheochromocytoma

Increased secretion of epinephrine and nor-epinephrine by the adrenal medulla

CAUSE: tumor

PATHOPHYSIOLOGY: Increased Adrenergic hormones- exaggerated sympathetic effects

ASSESSMENT Findings in Pheochromocytoma

1. Hypertension

2. Severe headache

3. Palpitations

4. Tachycardia

5. Profuse sweating and Flushing

6. Weight loss, tremors

7. Hyperglycemia and glycosuria


1. Monitor VS especially BP

2. Monitor for HYPERTENSIVE crisis

3. Avoid stimulation that can cause increased BP

4. Administer Anti-hypertensive agents like alpha-adrenergic blockers- Phenoxybenzamine

5. Prepare Phentolamine for hypertensive crisis

6. Monitor blood glucose and urine glucose

7. promote adequate rest and sleep periods

8. provide HIGH calorie foods and Vitamins/mineral supplements

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9. Prepare patient for possible surgery

DISORDERS OF the THYROID GLAND

HYPOsecretion: HYPOTHYROIDISM

A hypothyroid state characterized by decreased secretions of T3 and T4

CAUSES: Hypofunctioning tumor, IDG, Pituitary tumor, Ablation therapy, Surgical removal of thyroid

PATHOPHYSIOLOGY: Decreased T3 and T4- decreased basal metabolism

ASSESSMENT findings for Hypothyroidism

1. Lethargy and fatigue

2. Weakness and paresthesia

3. COLD intolerance

4. Weight gain

5. Bradycardia, constipation

6. Dry hair and skin, loss of body hair

7. Generalized puffiness and edema around the eyes and face

8. Forgetfulness and memory loss

9. Slowness of movement

10. Menstrual irregularities and cardiac irregularities


1. Monitor VS especially HR

2. Administer hormone replacement: usually Levothyroxine-should be taken on an empty stomach

3. Instruct patient to eat LOW calorie, LOW cholesterol and LOW fat diet

4. Manage constipation appropriately

5. Provide a WARM environment

6. Avoid sedatives and narcotics because of increased sensitivity to these medications

7. Instruct patient to report chest pain promptly

HYPERfunctioning: HYPERTHYROIDISM

Called GRAVE’S DISEASE

A hyperthyroid state characterized by increased circulating T3 and T4

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CAUSES: Auto-immune disorder, toxic goiter, tumor

PATHOPHYSIOLOGY: Increased hormone activity- increased Basal Metabolism

ASSESSMENT Findings for Hyperthyroidism

1. Weight loss

2. HEAT intolerance

3. Hypertension

4. Tachycardia and palpitations

5. Exopthalmos

6. Diarrhea

7. Warm skin

8. Diaphoresis

9. Smooth and soft skin

10. Fine tremors and nervousness

11. Irritability, mood swings, personality changes and agitation


1. Provide adequate rest periods

2. Administer anti-thyroid medications that block hormone synthesis- Methimazole and PTU

3. Provide a HIGH-calorie diet

4. Manage diarrhea

5. provide a cool and quiet environment

6. Avoid giving stimulants

7. Provide eye care

8. Administer PROPRANOLOL for tachycardia

9. Administer IODIONE preparation- Lugol’s solution and SSKI to inhibit the release of T3 and T4

10. Prepare clients for Radioactive iodine therapy

12. Prepare patient for thyroidectomy

13. Manage thyroid storm appropriately

THYROID STORM

An acute LIFE-threatening condition characterized by excessive thyroid hormone

CAUSE: Manipulation of the thyroid during surgery causing the release of excessive hormones in the blood

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ASSESSMENT Findings for Thyroid Storm

1. HIGH fever

2. Tachycardia, Tachypnea

3. Systolic HYPERtension

4. Delirium and coma

5. Severe vomiting and diarrhea

6. Restlessness, Agitation, confusion and Seizures


1. Maintain PATENT airway and adequate ventilation

2. Administer anti-thyroid medications such as Lugol’s solution, Propranolol, and Glucocorticoids

3. Monitor VS

4. Monitor Cardiac rhythms

5. Administer PARACETAMOL ( not Aspirin) for FEVER

6. Manage Seizures as required. Provide a quiet environment

THYROIDECTOMY

Removal of the thyroid gland

PRE-OPERATIVE CARE - Thyroidectomy

1. Obtain VS and weight

2. Assess for Electrolyte levels, glucose levels and T3/T4 levels

3. Provide pre-operative teaching like coughing and deep breathing, early ambulation and support of the neck when moving

4. Administer prescribed medications

POST-OPERATIVE CARE - Thyroidectomy

1. Position patient: Semi-Fowler’s

2. Monitor for respiratory distress- apparatus at bedside- tracheostomy set, O2 tank and suction machine!

3. Check for edema and bleeding by noting the dressing anteriorly and at the back of the neck

4. LIMIT client talking

5. Assess for HOARSENESS

6. Monitor for Laryngeal Nerve damage – Respiratory distress, Dysphonia, voice changes, Dysphagia and restlessness

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7. Monitor for signs of HYPOCALCEMIA and tetany due to trauma of the parathyroid

8. Prepare Calcium gluconate

9. Monitor for thyroid storm

DISORDERS OF the PARATHYROID GLAND

Hypofunctioning: HYPOPARATHYROIDISM

Hyposecretion of parathyroid hormone

CAUSES: tumor, removal of the gland during thyroid surgery

PATHOPHYSIOLOGY: Decreased PTH- deranged calcium metabolism

ASSESSMENT Findings for HypoParaThyroidism

1. Signs of HYPOCALCEMIA

2. Numbness and tingling sensation on the face

3. Muscle cramps

4. (+) Trosseau’s and Chvostek’s signs

5. Bronchospasms, laryngospasms, dysphagia

6. Cardiac dysrhythmias

7. Hypotension

8. Anxiety, irritability ands depression


1. Monitor VS and signs of HYPOcalcemia

2. Initiate seizure precautions and management

3. Place a tracheostomy set. O2 tank and suction at the bedside

4. Prepare CALCIUM gluconate

5. Provide a HIGH-calcium and LOW phosphate diet

6. Advise client to eat Vitamin D rich foods

7. Administer Phosphate binding drugs

Hyperfunctioning: HYPERPARATHYROIDISM

Hypersecretion of the gland

CAUSE: Tumor

PATHOPHYSIOLOGY: Increase PTH- increased CALCIUM levels in the body

ASSESSMENT Findings for Hyperparathyroidism

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1. Fatigue and muscle weakness/pain

2. Skeletal pain and tenderness

3. Fractures

4. Anorexia/N/V epigastric pain

5. Constipation

6. Hypertension

7. Cardiac Dysrhythmias

8. Renal Stones


1. Monitor VS, Cardiac rhythm, I and O

2. Monitor for signs of renal stones, skeletal fractures. Strain all urine.

3. Provide adequate fluids- force fluids

4. Administer prescribed Furosemide to lower calcium levels

5. Administer NORMAL saline

6. Administer calcium chelators

7. Administer CALCITONIN

8. Prepare the patient for surgery

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endocrine - test 2 - nursing 210

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