Endocrine

system

* hypothalamus & pituitary

* thyroid & parathyroid

* Adrenals

* Islet of Langerhans (Pancreas)

* Testes & Ovaries

Assessment

of

endocrine dysfunction

Health HX:

1) severity

2) length of time

3) effect on ADLs

4) effect on pt.'s self image

5) identify the gland & the hormone(s) it secretes

6) identify major action of the gland

7) identify whether the problem is hypersecretion or hyposecretion

Assessment

of

endorcrine dysfunction

continued

Physical assessment:

VS

visual head-to-toe

tactile examination

current health probs. inlcuding energy levels, elimination, sex & repro., physical appearance

demographics; age & gender

Pituitary Gland

Master gland: influences other endocrine glands

controlled by the hypothalamus; which is connected by pituitary stalk

Anterior pituitary secretes:

follicle stimulating hormone (FSH)

lutenizing hormone (LH)

prolactin

adrenocorticotropic hormone (ACTH)

thyroid stimulating hormone (TSH)

growth hormone (GH)/somatotropin 

Hyperpituitarism

Common reason: pituitary adenoma

S/SX:

neurologic

visual defects

HA

ICP

confusion-impaired memory (rare)

Anterior Pituitary Hormone

Functions

adrenocorticotropic (ACTH)

thyroid stimulating hormone (TSH)

follicle stimulating hormone (FSH)

luteinizing hormone (LH):

ALL release hormones from other glands

Prolactin: stimulates breast milk production

Growth hormone: essential for normal growth

oversecretion most often involves ACTH or GH

Undersecretion commonly involves all the anterior pituitary hormones, causing thyroid gland, adrenal cortex, & gonads to atrophy from loss of TSH.

Posterior Pituitary Hormone

Functions:

Secretes  vasopressin known as ADH; antidiuretic hormone

Vasopressin controls excretion of water by kidneys

Oxytocin secretion is stimulated during pregnancy & birth.

Growth Hormone

Oversecretion results in Acromegaly

Acromegaly: excess of GH in adults

Gigantism: excess of GH in children; can be 7 0r 8ft tall

Undersecretion in children results in dwarfism

Acromegaly

Excess GH in adults

Clinical manifestations:

Hypertrophy of vocal chords

Hypertrophy of Eustachian tubes (ears)

Nerve entrapment

Demyelinization of peripheral nerves

Glucose Intolerance

TX can include:

Somatostatin (sandostatin)

Dopamine agonists (bromocriptine)

Growth hormone receptor antagonist (pegvisomant)

Diabetes Insipidus

(DI)

Deficiency of ADH

excessive thirst; polydipsia

large amounts of dilute urine

urine specific gravity 1.001 to 1.005

pt may drink 2-20L of fluid per day

2* head trauma, brain tumor, injury to PG, pt can become hypernatremic,

Treatment for

DI

Mild DM:

no TX if able to stay hydrated

Diabinese or thiazide diureticsb/c they potentiate action of vasopressin.

Severe DM:

DDVAP- Demopressin

Monitor for nasal irritation

DDVAP can be given IM

D/C

for

DI

Provide specific verbal & written instruction per facility policy & assess carefully for understanding

Medication administration & SE

S/SX of hyponatremia

Syndrome of Inappropriate

Antidiuretic Hormone (ADH) Secretion

(SIADH)

p.1253

Occurs w/out regard for serum osmolality

secrestion of too much ADH.

Water is retained which results in:

Dilutional hyponatremia

Expansion of ECF volume

occurs as PC of some CA: when some malignant cells release ADH

Disorders of CNS: head injuries or brain tumor thought to produce SIADH by direct stimulation of pituitary

SIADH;

Syndrome of Inappropriate

ADH secretion

Clinical Manifestations:

anorexia

N/V

lethargy

HA

hosility

uncooperativeness

disorientation

change in LOC

tachycardia

SIADH Interventions:

Fluid restriction: 500-600ml per day

Drug TX- either to TX complications of fluid volume overload (CHF)

or

Decleomycin: an antibiotic;

w/inhibiting activity of ADH in the renal tubules

Daily wts

I/O

Freq. mouth care

Provide safe enviro.

Thyroid Gland

p.1253

Butterfly shaped organ that straddles the trachea

Two lobes connected by the isthmus

Secretes:

thyroxine (T4)

triiodothyronine (T3)

calcitonin

secretion is controlled by TSH; thyroid stimulating hormone (thyrotropin)

Iodine is essential to the thyroid for synthesis of it's hormones.

Function

of the

Thyroid Hormones

T4 & T3: controll cellular metabolic activity

Calcitonin:

reduces the plasma level of Ca+ by increasing its deposition to bone

Inadequate secretion during fetal & neonataldevelopment results in cretinism: deficiency in thyroid-mental & physical development.

Inadequate secretion in adulthood results in:

lethargy

slow mentation

slowing of bodily functions

constipation 

Physical exam

of

Thyroid Gland

palpate thyroid for size, shape, consistency, symmetry, tenderness

If palpation reveals enlarged thyroid, both lobes are then auscultated. Bruit indicates increased blood flow associated w/hyperthyroidism.

Firmness can indicate chronic (Hashimoto's) thyroiditis or malignancy.

*Hashimoto's=autoimmune disease in which the thyroid gland is slowly destroyed by a variety of cell & antibody immune processes, bouts of hypo/hyperthyroidism.

Thyroid Tests

Serum TSH: best screening test .5-4.5/5.0

Serum T3 & T4:

T3 is 70-220ng/dL

T4 is 4.5-11.5

Radioactive iodine uptake: radioactive tracer, inj. /probe to measure how much tracer the thyroid gland absorbs from the blood.

Hypothyroidism

p.1256

affects all body functions

ranges from mild, subclinical myxedema; life threatening PC of hypothyroidism> can lead to coma (rare, more common in elderly) s/sx: lethargy, fatigue, mental impairment, depression, cold intolerance, hoarseness, dry skin, wt.gain, HA, constipation, change in menses. (also for hypothyroidism.

Most common cause:

autoimmune thyroiditis= Hashimoto's disease.

Can result from radioiodine or other tx for hyperthyroidism

most freq. affects older women

Primary form refers to dysfunction of thyroid gland itself

Secondary: is caused by a pituitary gland disorder

Clinical

Manifestations

of

hypothyroidism

fatigue

hair loss, brittle nails, dry skin

amenorrhea

low body temp

wt gain

skin becomes thickened due to accumulation of mucopolysaccharides in subQ tissue

irritable, then mentation slows & pt. seems apathetic

Severe Hypothyroidism

elevated serum cholesterol

Atherosclerosis, CAD, & poor left ventricular function

Abnl sensitive to sedatives, opiods, & anesthia

Myxedema Coma

life threatening: pt is hypothermic & unconscious

possibly precipitated by infection or sedatives

Initially, may show as depression, lethargy, somnolence, decreased LOC.

Progresses to stupor, depressed resp. drive, coma

Mortality rate 20-25%

Medical management

of

hypothyroidism

Hormone replacement:

synthroid

levonthroid

must proceed slowly, starting w/low dose

Nsg Dx:

activity intolerance

risk for imbalanced temperature, constipation, knowledge deficit r/t therapeutic regimen.

Collaborative Dx for myxedema & myxedema coma

Pt. teaching must include education that therapy must be lifelong.

Hyperthyroidism

p.1262

Graves disease: results from excessive output of thyroid hormones

Affects women more than men

S/SX:

nervousness

irritability

rapid pulse

skin is flushed; salmon color

exophthalmos:bulging of anterior eye

increases appetite

wt loss

weakness & fatigue

amenorrhea

systolic BP elevated, heart failure, osteoporosis & fx

Medical management

of

hyperthyroidism

antithyroid meds.

irradiation w/iodine

risk of relaspe w/hyperthyroidism

risk of hypothyroidism

Beta blockers given to control tachycardia & other s/sx

Thyroid Storm

p.1263 chart 42-6

severe HYPERTHYROID; usu. onset is sudden

often fatal if untreated

S/SX:

High fever >101.3

tachycardia >130bpm

altered mental state

wt loss

diarrhea

edema

chest pain

Surgical management

of

hyperthyroid

p.1265

no longer primary method of TX

Thyroidectomy is reliable w/pts w/goiter

Preop:

pt may receive K+ iodine (KI), Lugol's solution of K+ iodine (SSKI) to reduce activity & vascularity of the thyroid.

Postop/after surgery:

pt might become hypothyroid & require thyroid hormone replacement therapy.

Nsg process

for pt

w/Hyperthyroidism

p.1265

Health Hx & exam

assess nutritional status

Dx include:

imbalanced nutrition; less than body requirements r/t exaggerated metabolic rate.

ineffective coping r/t irritability, hyperexcitibility.

low self-esteem r/t changes in appearance, excessice appetite.

altered body tempeature

Collaborative probs.:

thyrotoxicosis or thyroid storm, & hypothyroidism.

Thyroiditis

p.1268

Acute, subacute, & chronic

Acute: rare, caused by infection

-Tx w/antimicrobial agents

Subacute: inflammatory disorder

-Tx w/beta blockers

Chronic: Hashimoto's Disease

pts w/hashimoto's disease should be evaluated for thyroid lymphoma.

Surgery may be necessary if hormone therapy doesn't relieve symptoms

Thyroid tumors

* Endemic (iodine deficient) Goiter:

most commonn type

* Nodular Goiter:

areas of hyperplasia

* Thyroid Goiter:

*Thyroid cancer: less prevalent, but 90% of endocrine malgnancies. p.1269

Thyroidectomy

Tx of choice for thyroid carcinoma is surgical removal

-parathyroid is spared if possible

Postop care:

1) check drsg, be sure to check sides and back of neck for bleeding.

2) Assess for sensation of pressure or fullness at the incision site.

3) medicate for pain PRN, give supportive care.

4) advise pt to talk as little as possible, but assess for voice changes.

5) teach pt how to support neck w/hands when he/she moves.

Parathyroid Glands

p.1271

Usu. 4 glands: imbedded in the thyroid gland

Produce parathormone: regulates calcium & phosphorus metabolism

Hyperparathyroidism:

can result in bone decalcification & development of renal calculi containing Ca+

Hypoparathyroidism:

causes tetany: a general muscle & hypertonia-tremor & spasms.

Adrenal Glands

p.1275

Sit on top of kidneys

Adrenal medulla secretes catecholamines:

epinephrine & norepinephrine

Adrenal cortex secretes steroid hormones:

glucocorticoids (hydrocortisone)

mineralocorticoids (aldosterone)

androgens: mainly male sex hormones

Adrenocortical Insufficiency

Addison's Disease

Adrenal cortex function is inadequate

most commonly caused by therapeutic use of corticosteroids

S/SX:

muscle weakenss

anorexia

GI symptoms

fatigue

dark pigmentation (addison tan)

low blood glucose

can progress to Addison Crisis:

circulatory shock, HA, nausea, confusion, restlessness.

can be fatal if not treated.

TX:

cortisol replacement

aldosterone replacement

IV NS if hospitalized & not taking PO

Nsg Dx

for

Addison's Disease

Risk for imbalanced nutritoin; less than body requirements r/t anorexia & nausea

Risk for FVD r/t excessive loss of Na+ & H2O 2*to polyuria

Diarrhea r/t increased excretion of Na+ & H2O

Risk for disturbed self-concept r/t appearance changes

risk for injury r/t postural hypotension

risk for therapeutic regimen management r/t insufficient knowledge of disease & risks for crisis

Cushing's Syndrome

p.1281

Excessive adrenocortical activity

S/SX:

central type obesity

buffalo hump

thin extremities

skin thin & fragile

bruises easily

kyphosis

backache

"moon face"

acne

hyperglycemia

In females: virilization occurs: excessive facial hair, breast atrophy, voice deepens.

Transsphenoidal Hypophysectomy

Chp. 61

surgical removal of pituitary tumor

Preop teaching:

1) teach pt they will have general anesthia

2) teach pt. that they will have nasal catheter & packing post procedure

3) tests are ordered

4) assess visual field

Post-op

care

for

Transsphenoidal

Hypophsectomy

MONITOR:

neuro status

fluid status; possibly transient DI

encourage pulmonary hygiene: TDB: incentive spirometer

DO NOT cough, blow nose, or sneeze

Keep HOB elevated

use dental floss & oral mouth rinses: DO NOT brush teeth

Instruct to AVOID bending

monitor nasal drip pad

monitor BM: prevent constipation & straining

Teach self administration of prescribed hormones

Assess visual field

Corticosteroid Therapy

Suppresses inflammation & autoimmune reactions, controlling allergic reactions, & reducing rejection after organ transplant.

SE:

thin skin

bruising

increased BS

moonface

other cushing like s/sx

Dose must be tapered