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THE ENDOCRINE SYSTEM ENDOCRINE METABOLIC ALTERATIONS M.DUBOIS FENNAL, PHD, RN, CNS RELATIONSHIP OF THE ENDOCRINE SYSTEM TO OTHER PARTS OF THE BODY • Endocrine disorders can affect all body systems. Such disorders are usually caused by overproduction or underproduction of hormones Definition • Ductless glands that release secretions (hormones) directly into the blood stream. The Organs of the Endocrine System • • • • • • • • • Pituitary Pineal Thyroid Para-thyroids Thymus Adrenals Pancreas Gonads Adrenals Major Hormone Secreting Glands of the Endocrine System Hypophysis/Pituitary • Located at the base of the brain, has two separate divisions, anterior and posterior. Regulates or controls Pituitary Gland and Its Hormones Thyroid Gland • Located at the level of the thyroid cartilage of the trachea, connected by the isthmus, blood supply, the carotids Thyroid Gland (cont.) Parathyroids • Located on the surface of the thyroid (may be in other areas) 4 to 8 in number, circulation, carotids Parathyroid Gland (cont.) Adrenals • Located on top of the kidneys, blood supply, aorta and the renal artery, secretes glucocorticoids and • mineralocorticoids, catecholamines Adrenal Glands (cont.) Pancreas • Has a head, a body and a tail, located between the spleen and the duodenum, has exocrine and endocrine function, circulation, celiac artery, splenic artery, pancreatic artery Pineal Gland • Shape like a pine cone, located posteriorly to the hypopsis, secretes melatonin, inhibited by sunlight Examination of the metabolic system • History – Medical problems (current and significant past) – Symptoms – Medication history (current) Physical Examination • • • • • Inspection Palpation Percussion (not utilized) Auscultation Vital signs Laboratory Studies • • • • • Blood work Urine Basal metabolic rate Radiological examination Electrocardiogram Disorders of the Endocrine Glands • Primary • Secondary • Tertiary Pituitary Tumors • Primary • Secondary Alteration of the Pituitary Gland • Hypopituitarism: Definition, a disorder of the amount of hormones secreted. Panhypopituitarism is the term used because of the insufficiency of all hormones released from the pituitary gland Etiology • Pituitary tumors, vascular thrombosis, granulomas, idiopathic or autoimmune destruction of the pituitary cells. Incidence • Affects children and adults, with a different pathology for each. Pathophysiology • Decrease in the production, release or stimulation of the hormones of the Anterior pituitary gland. – – – – – – – – ACTH MSH LH (MEN) FSH (MEN) LH (WOMEN) FSH (WOMEN) PROLACTIN GROWTH HORMONE CLINICAL MANIFESTATIONS • Children: short stature, failure of sex organs to develop, fatigue, weakness, anorexia, cold intolerance, impaired sexual function, pale skin. • Adults: hypogonadism, amenorrhea, insulin sensitivity, breast atrophy, pale skin Medical Management • Administration of deficient hormones • Medication route by intramuscular route only Hyperpituitarism • Definition: over secretion of the growth hormone. – Gigantism in children – Acromegaly in adults Etiology • Results from a pituitary tumor that secretes growth hormone or from a hypothalamic abnormality that leads to increase growth hormone release Incidence • Research is limited, few known individuals around the world have been studied – Andrea the giant – Gentleman in Africa – Woman (American?) Pathophysiology • Gigantism: (child) rapid longitudinal growth • Acromegaly: (adult) enlargement of bone structure Medical Management • • • • CT scan Irradiation of the pituitary gland Resection of tumors Suppression of GH using the somatostatin analog Diabetes Insipidus • Definition: a clinical syndrome characterized by excessive amounts of dilute urine. Urine in excess of 50 ml/kg in a 24 hour period. Specific gravity of less than 1.010 and osmolality of less than 300 mOsm/kg. • A defect in the chain of events by which vasopressin is released from the neurohypophysis and acts on the renal system. Etiology • • • • • • • • • Tumors of the hypothalmus Surgery injury of the pituitary gland Intracerebral Vascular occlusions Grandulomas Renal disease Multiple myleoma Sickle cell anemia Hypercalcemia & hyperkalemia Sarcardosis, CVA, Incidence • Occurs most often in clients with head injury accidental or caused and in neurogenic patients • Occurs frequently in clients with conditions that affect the renal tubules, that prevent sensitivity to ADH Pathophysiology • Impairment of renal conservation of water. (polyuria, > 3L in 24 hrs) May be partial or complete, temporary or permanent. ADH deficiency (neurogenic ) and/or ADH insensitivity (nephrogenic) or excessive water intake (secondary to KI) • Deficiency of the antidiuretic hormone arginine vasopressin • Destruction of cells that produce arginine vasopressin Clinical Manifestations • 12 to 24 hour onset after trauma • Dehydration, dry skin, constipation, confusion • Polyuria: 15-29 liters per day and polydipsia • Intense, nearly insatiable thirst • Specific gravity < 1.010 • Serum Osmolality >295 mOsm/kg Medical Management • Skull and chest x-ray, looking for metastatic disease • EEG • Spinal Fluid study • Serology for syphilis • Serum protein level • • • • • • • Check visual fields Bone marrow aspirate (multiple myeloma) Urinalysis, BUN, Creatinine Determine the cause Treat the underlying cause Replace the fluid (1/2 NS) Vasopressin therapy Nursing Management • Maintain fluid replacement for urine output • Prevent dehydration and hypovolemic shock • Accurate intake and output • Management of vasopressin therapy warm the solution) • Correction of underlying cranial problems i.e. increase intercranial pressure Complications • Vasomotor Collapse • Dilatation and hypertrophy of the bladder with megaloureter • Vasopressin resistance Syndrome of Inappropriate ADH • Definition: Inappropriate secretion of Antidiuretic hormone, characterized by hyponatremia, impaired water secretion in the absence of hypovolemia or a deficiency in cardiac, renal, or adrenal function Etiology • Endogenous secretion of arginine vasopressin • Pulmonary disease,(hypercapnia & hypoxia) • Malignant tumors • Disorders of the central nervous system • Surgery Incidence • More common in acutely ill hospitalized patients Pathophysiology • Hyperosmolar syndrome, excessive and inappropriate water retention, severe hyponatremia, producing neurological irritability Treatment • • • • Fluid Restriction Administration of 3%-5% sodium chloride Lasix therapy Demeclocycline Hyperthyroidism/Thyrotoxicosis • Definition: a biochemical and physiological complex that results when tissues are presented with excessive quantities of thyroid hormone Etiology • • • • Graves disease Goiter Hyperfunction of thyroid tissue Ingestion of large quantities of exogenous hormone • Familial traits • Stress • Trauma Incidence • Higher in females • High in individuals with other autoimmune disorders • More frequent in puberty, during menstruation and pregnancy Pathophysiology • Increase level of circulating TH, increase metabolic rate, heighten sympathetic nervous system physiology. Increase cardiac rate and stroke volume, increase cardiac output and peripheral blood flow. Decrease lipids, decrease glucose tolerance, degradation of protein, negative nitrogen balance. Signs and Symptoms • • • • • • • • Exaggerated alertness Flushed face, warm skin, diaphoretic Palmar erythema Increase pigmentation of the skin Bulging eyes, thin fine hair Enlarged thyroid, weight loss, tremors Elevated blood pressure, tachycardia Left ventricular failure, amenorrhea Clinical Presentation • • • • • • • Irritability Nervousness Insomnia Fatigue Palpitations Heat intolerance Emotionally labile Test • • • • • • • TA Test TSH Test T4 Test T3 Test T3 Uptake Test RAI uptake Test Thyroid Suppression Test Medical Management • Pharmacology – Iodine potassium/sodium – Tapazole – PTU – Radioactive therapy – Surgery Nursing Management • • • • • • Provide a cool, quiet environment Eye drops and coverings Between meal snacks Monitor for and treat dysrhythmias Interpret laboratory data Monitor results of medication administration • Provide un-interrupted rest periods Nursing Diagnosis • • • • • • • Risk for decrease cardiac output Sensory-perceptual alteration Risk for altered nutrition Body image disturbance Hyperthermia Activity Intolerance Anxiety • • • • • • Fluid Volume Deficit Altered thought processes Risk for Injury Altered urinary elimination Sleep pattern disturbances Risk for altered health maintenance Thyrotoxic Storm • Usually occurs with Graves Disease, but sometimes with toxic goiter • Occurs with pre-existing thyrotoxicosis or goiter, or exophthalmos or all three, trauma, emotional upset, infection, surgical emergencies, abrupt withdrawal of anti-thyroid drugs • Less common causes include radiation thyroiditis, diabetic acidosis, and toxemia of pregnancy Clinical Presentation • • • • • Fever Profuse Sweating Marked tachycardia Congestive heart failure/pulmonary edema Restlessness, delirium, psychosis Hypothyroidism/Myxedema • Definition: Insufficient production of thyroid hormone Etiology • Primary: Congenital defect or surgery, radiation (loss of thyroid tissue) antithyroid medication, thyroiditis (Hashimoto’s disease) or iodine deficiency. • Secondary: Pituitary Thyroid stimulating hormone deficiency Incidence • • • • More common in women age 30-60 years Older adults With coma, 50% mortality Occurs more frequently in winter Pathophysiology • Acceleration of metabolism and clearance of thyroid hormone in the body • Increase hormone utilization without hormone production or decrease thyroid production • Development of a hypo-metabolic state Clinical Presentation • • • • Apathy, listlessness, tiredness Sensitivity to cold Loss of libido Loss of appetite Signs and Symptoms • • • • • • • • Slowing of intellectual and motor ability Constipation Weight gain Laryngitis Periorbital edema Enlarged tongue Non pitting edema Menstrual disturbances Diagnosis • Protein bound iodine (PBI) below 3.5 mg/100mL plasma • Radioiodine (I 131) • Thyroid scan • Basal metabolic rate (-15% to 40%) • Serum cholesterol above 300 mg. Medical Management • Medication to increase thyroid hormone activity – Desiccated thyroid extract – L-thyroxin (synthroid) – Cytomel – Treat the underlying cause – Restore fluid and electrolyte balance Nursing Management • Administer meds and monitor reaction. Report untoward symptoms • Protect the patient from cold and drafts • Assess for cardiac complications • Watch for signs of overdose of thyroid hormone • Patient and family teaching Nursing Diagnosis • • • • • • Fluid volume deficit Potential for decrease cardiac output Alteration in sensorium Risk for ineffective breathing pattern Risk for injury, skin integrity Impaired communication Myxedema Coma • Occurs with long standing untreated hypothyroidism • Occurs in the winter months mostly due to exposure to cold, trauma, infection, CNS depression, alveolar hypoventilation Physical Signs • • • • • • Mental obtundation to coma Subnormal temperature Bradycardia Hypotension Ventilatory failure Seizures Disorders of the Adrenal Glands • Congenital Adrenal Hyperplasia • Adrenal Cortical Insufficiency • Cushing Syndrome Addison’s Disease • Definition: Disordered function of the adrenal glands resulting in lack of adrenal output. i. e. cortisol and aldosterone Etiology • • • • • Adrenocortical destruction Tuberculosis Idiopathic atrophy of the adrenals Bilateral adrenal tumor with metastasis Amyloidosis Incidence • More common in adults under sixty years of age • More common in women • High in individuals withdrawing from steroid therapy • Clients with AIDS • Clients on anti-coagulants Pathophysiology • Hypo-function of the adrenal glands from primary or secondary mechanisms that suppress corticosteroid secretion. In Addison’s disease there is a deficiency of mineralocorticoids and glucocorticoids • Autoimmune diseases, infection, hemorrhagic destruction Signs and Symptoms • • • • • Pigmentation of the skin Weight loss Hypotension Diarrhea/constipation Syncope Clinical Presentation • • • • • • • • Inability to conserve sodium Weight loss Hypovolemia/hypotension Decrease cardiac size and output Decrease renal blood flow Pre-renal azotemia Increase rennin production Shock, electrolyte imbalance Medical Management • • • • • • Diagnosis Measurement of adrenal reserves Plasma cortisol 17 keto steroids Restoration of fluid and electrolyte balance Prevention of circulatory collapse Nursing Management • • • • • • • Administration of fluid Intake and output maintenance Monitoring electrolytes Safety Emotional support Protection from infection Vital signs, lab work, positioning, conservation of energy Nursing Diagnosis • Fluid volume deficit • Risk for ineffective management of therapeutic regimen • Ineffective individual coping • Activity intolerance • Altered tissue perfusion Hyperosmolar Coma (HHNC) • Definition: Profound hyperglycemia, hyperosmolality and severe dehydration, associated with minimal ketosis resulting from insulin deficiency • Serum glucose >600 Etiology • • • • • • • Debilitation Diminished thirst Inadequate intake Newly diagnosed Type II diabetes Major illness High calorie parenteral and enteral nutrition Sepsis, pancreatitis, uremia, burns, GI hemorrhage, stress and medication, as well as dialysis • Medication – – – – – – – – – – Thiazide diuretics Glucocorticords Sympathometics Phenytoin Chlorpromazine Cimetidine Calcium channel blockers Immunosuppressive agents Beta blockers Diazoxide Incidence • • • • • More common in the elderly In patients receiving TPN or PPN High in clients with diminished thirst Inadequate fluid intake High in individuals with history of stroke or coronary disease Pathophysiology • Hyperglycemia • Deficiency of insulin to handle large quantities of glucose • Hypernatremia • Inadequate renal excretion of solute leading to azotemia • Severe cellular dehydration Signs and Symptoms • • • • • • Dry skin and mucus membranes Fever Tachypnea Tachycardia Hypotension glycosuria Clinical Presentation • • • • • • • Lethargy to stuporous Polyuria Polydipsia (if thirst mechanism is working) Weight loss Decrease urinary output Nausea and vomiting Hypernatremia • • • • • • Hyperglycemia (600-2400) High serum osmolality Soft eyeballs Shock Acute tubular necrosis Mortality rate 50% Medical Management • • • • Airway Control hyperglycemia Restore hydration Correct metabolic acidosis Nursing Management • • • • • • Establish and maintain airway Insert naso-gastric tube Neurological checks and management Cardiac monitoring, vital signs Physical assessment Diagnostic study interpretation Nursing Diagnosis • • • • Alterations in breathing pattern Alteration in fluid volume deficit Risk for injury Alteration in sensorium