NORMAL ASSESSMENT FINDINGS ON PT. W/ ENDOCRINE DISORDERS

- Nervousness

-Depressed

-Wt. gain/loss

-Skin turgor

- Exophthalmos

-Buffalo hump

-Moon face

-Enlarged thyroid gland

-Tremor

INSULIN IN PRODUCED WHERE?

-Beta cells of pancreas & is a hormone

-Major fx is to regulate level of glucose in blood stream

-Is the key that allows body to use glucose for cellular work

INSULIN PLAYS A ROLE IN WHAT 3 THINGS?

1. Fat storage

2. Feeding behavior

3. Glycogen storage

What disorder is the breakdown of one of the more important parts of the bodies autonomic (self-regulating) system? This system deals w/ bodies utilization of glucose and all tissues of the body are affected when breakdown occurs

Diabetes

DIABETES MELLITUS

- Group of metabolic diseases characterized by inappropriate hyperglycemia resulting from defects in insulin secretion, insulin action, or both

WHAT IS TYPE I DIABETES?

-IDDM

-Must take insulin to live

- Often familial

- Usually under age 30

- Not understood why beta cells stop producing insulin

WHAT IS TYPE II DIABETES?

-NIDDM

- Most common type

-Onset often slow, may be elevated for yrs causing damage to cells of body

-Still produce some insulin

-Insulin not effective in unlocking cells of body to let glucose into blood for use of energy

-May finally "blur out" beta cells if bs uncontrolled

-CAD 2X prevalent w/ they type

COMMON COMPLICATIONS W/ DIABETES

1. Large vessels

-Heart disease, CVA, PVD

2. Small vessels

-Neuropathy, Retinopathy, Nephropathy

3. Damage to other body fx

- Filter waste, poor circulation, slower wound healing, loss of sensation, diminished vision

WHAT DIAGNOSTIC CRITERIA IS USED TO DETERMINE IF PT HAS DIABETES?

- FBS: >126

- S/S: polydipsia, polyuria, polyphagia

Unexplained wt. loss

Casual glucose >200

fatigue

Normal level of A1C & how often is test performed?

- 4.5-6.5

- Hgb A1C test done q3mos.

- Normal for diabetic pt. <7% this would be avg bld glucose of 160

COMMON RISK FACTORS FOR DIABETES

- Genetic disposition

- Obesity

- Aging

- Pancreatitis

- Steroid usage

8 Most common s/s of diabetes

1. Fatigue

2. Polydipsia (more than 10 glasses/d

3. Polyuria

4. Numbness & tingling in ft

5. Polyphagia

6. Unexplained wt. loss

7. Blurred vision

8. Sexual dysfunction

COMMON S/S OF HYPOGLYCEMIA

- Shaky

- Tachycardia

- Sweating

- Dizzy

- Anxious

- Hungry

- Blurry vision

- Weakness/fatigue

- HA/irritable

What are some causes of hypoglycemia

- Too little food/skip meal

-Too much insulin or med.

-More active than usual

(s/s are often sudden/may have syncope if untreated)

-check bs; treat; check bs

COMMON S/S OF HYPERGLYCEMIA

- Extreme thirst

-Polyuria

- Dry skin

- Hungry

- Drowsy

- Blurred vision

- Slow healing wounds

(s/s start slowly; may lead to medical emergency if untreated)

DIABETIC KETOACIDOSIS

- Acute insulin deficiency or inability to use what insulin the pancreas may secrete

- Develop d/t compliance (infection) or noncompliance

- S/S onset: 4-10 hrs. (slow)

S/S OF DIABETIC KETOACIDOSIS (DKA)

- Thirst

- Anorexia

- Drowsiness

- Weakness

- Sweet odor breath

- Kussmaul resp

- Low bp

- Unresponsive as ketones accumulate in bloodstream

HOW IS DKA TREATED?

- Main goal is lower serum glucose

-TX:Correct FE imbalances

-clear urine & blood of ketones

-IV insulin

-Frequent vs

-I/O

-Foley cath.

-Frequent bs checks

-Need lots of hydration

HHNKS

- BS >500

-F/E imbalances

-S/S: HTN; fever; tachycardia; dehydration; extreme thirst

-TX: Insulin; correct f/e imbalance; bs checks; i/o; vs; neuro & cognitive checks

HOW DO INSULIN PUMPS WORK

- Basale rates: Delivered continuously 24hrs/d

-Bolus dose: To cover carbs in meals

- Correction or supplemental doses: Can be programmed to give larger doses if you eat more than planned & can correct ^ bs

GLUCOSE TOLERANCE TEST

- Baseline urine/serum glucose

- High cho given then serum check @ 30 mins, 1 hr, 2 hr, & 3 hr

HOW DOES EXCERCISE AFFECT INSULIN NEEDS

- Lowers bs level immediately & approx. 24-48 hrs. after

- Improves blood lipid levels & circulation

Why can't insulin be given orally

- Protein

- If ingested it would be inactivated by GI secretions

WHAT TERM GOES W/ ABILITY TO REABSORB GLUCOSE & RETURN IT TO THE BLOOD STREAM

- Renal threshold

KUSSMAUL RESPIRATIONS

- Fast, shallow resp; puffing blowing

What hormone ^ h2o absorption by kidney tubules, decreases sweating, causes vasoconstriction

ADH

(post. pit. gland

What hormone ^ rate of mitosis, ^ a.a. transport into cells, ^ rate of protein synthesis, ^ use of fats for energy

GH

(ant. pit. gland)

What hormone ^ reabsorption of NA by kidneys to blood, ^ excretion of K by kidney in urine

Aldosterone

(adrenal cortex)

What hormone has anit-inflammatory effect; ^ conversion of glucose to glycogen in the liver

Cortisol

(adrenal cortex)

GIGANTISM

Oversecretion of GH from ant. pit. gland in children

ACROMEGALY

Oversecretion of GH from ant. pit. gland AFTER long bone growth is complete

-Caused by hyperplasia of ant. pit. gland or benign tumor

-Tests: MRI/CT/^ GH found in plasma

S/S  & TX OF ACROMEGALY

-Enlarged facial features

-Lg. hands/ft

-HA/partial blindness

-Enlarged heart, liver, & spleen w/ muscle weakness

-Painful, stiff jts, osteoporosis

-Impotence in men, amenorrhea

-^ facial hair & deepened voice in women

TX: Destroy/ remove pit. gland by radiation/surgery w/ thyroid replacement therapy

SIMMOND'S DISEASE

-Destruction of pit. gland (no pit. hormone activity)

-Causes: Emboli; surgery; tumor; TB

-DX. Tests: Decreased hormone levels; sex hormones; corticosteroids; thyroid

-TX: Replace thyroid hormone; corticosteroid & sex hormones for life

S/S OF SIMMOND'S DISEASE

- Gonadal & genitalia atrophy

- Symptoms of hypothyroidism

- Adrenal insufficiency

- Premature aging

- Cachexia

- Death

DIABETES INSIPIDUS

- Decreased secretion of ADH from post. pit. gland

-Causes: Head trauma; brain tumor; can be congenital, or results from surgical removal of pit. gland

-Dx tests: Lowered specific gravity of urine; fluid deprivation test; 24 hr. urine collection

-TX: Hormone replacement (vasopressin) per nasal spray to reduce urine output to 2-3L/24h

S/S OF DIABETES INSIPIDUS

- Dilute urine (20L+/24h)

- Excessive thirst

- Weakness

- Dehydration

- Wt. loss

1 lb. of fluid = what?

1 pt. ( 480 ml)

S/S of SIADH-syndrome

-Water retention

- HA

- Muscle cramps/twitching

- Anorexia

- N/V

- LOC changes

-Tx: Eliminate cause; osmotic & loop diuretics; IV 3% NaCl (hypertonic) given for severe hyponatremia

Grave's disease

-Hyperthyroidism---oversecretion of thyroid hormones

****more commen in women****

-Causes: autoimmune or inherited, thyroid tumors, pit. tumors, hypothalmic malignancy, stress, infection

- Dx. blood test: T3 & T4 levels ^; Decreased TSH level; thyroid scan has ^ uptake of RAI

HYPOTHYROIDISM

- Undersecretion of thyroid hormones

-Causes: thyroid problem (primary) or d/t pit. undersecretion of TSH

-Dx tests: TSH ^ in primary hypo

T3 & T4 decreased; thyroid scan decreased RAI uptake

S/S OF HYPERTHYROIDISM

- Restlessness

- Highly excitable

- Agitated

- Hand tremors

- Heat intolerance

-Flushed, warm, moist skin

-^ appetite

- Wt. loss

-Goiter; exophthalmos; htn; insomnia

S/S OF HYPOTHYROIDISM

- Lethargic          -thick, hard nails

- Lacks energy         -bradycardia

- Forgetful      -hypotension

- Chronic HA            -Heavy menses

- Masklike expression          -Difficulty conceiving

- Decreased temp & hr

- intolerance to cold

- wt. gain

- pale, cool, dry skin

What foods should you avoid b/c they interfere w/ body's use of iodine? (Goitrogens)

-Turnips

-Cabbage

-Cauliflower

-Broccoli

-Horseradish

-Carrots

-Lithium

-Salicylates

CAUSE OF GOITERS

-Deficiency of iodine in diet

-Inability of thyroid to use iodine

-^ body demand for thyroid hormone (^ wt.)

CAUSES OF THYROIDITIS

-ACUTE: bacterial infection

-SUBACUTE: viral infection

-CHRONIC: autoimmune

-Hashimotos: 20x more common in women

DX OF THYROIDITIS

-ACUTE: WBC ^

-SUBACUTE: T3 & T4 ^ & RAI uptake decreased

-CHRONIC: antibodies & RAI ^ uptake

Symptoms of thyroiditis

-Acute: ^ fever; malaise; swelling & tenderness of thyroid gland

-Subacute: swollen, painful glands, chills, fever, malaise

(may notice 2 wks after URI)

-Chronic: enlarged thyroid & s/s hypothyroidism

Thyrotoxic Crisis

(Thyroid Storm)

- Abrupt, life-threatening form of hyperthyroidism

-Triggered by stress, infection, DKA, trauma, toxemia, manipulation of a hyperactive thyroid gland

-Over secretion of thyroid hormones followed by release of epinephrine

Symptoms of Thyroid Storm

-Temp as ^ as 106

-Rapid pulse

-Dysrhythmias

-Persistent vomiting

-Extreme restlessness

-Delirium

-Chest pain

-Dyspnea

What do you not give for treatment of thyroid storm?

-ASA

-B/c it binds w/ same serum as T4, freeing more T4 into circulation

TX OF THYROID STORM

-Antithyroid drugs/corticosteroids

-IV sodium iodide

-Beta blockers (to reduce effort on heart)

-Acetaminophen for fever

-O2 & elevate HOB

(high metab. rate requires more O2)

-Then treat underlying thyroid problems

Care of pt. after thyroid surgery

-Potential Complications: Resp. distress/obstruction (d/t laryngeal swelling)

-Hemorrhage

-Damage to laryngeal nerve (impaired verbal communication & risk for aspiration)

-Tetany (accidental removal/damage to parathyroid glands--hypocalcemia)

-Thyrotoxic crisis (manipulation of gland during surgery)

Hyperparathyroidism

-Oversecretion of parathyroid hormone resulting in hypercalcemia

-Causes: Primary: Most common adenoma

-Secondary: Hypocalcemia

-EX. of secondary: Vit D deficiency

-renal failure

-lg. doses of thiazide diuretics

-excessive use of laxatives & Ca suppl.

DX of Hyperparathyroidism

- ^ serum Ca & decreased serum phosphorus

-24 hr. urine will have ^ Ca

- Skeletal x-rays show Ca loss in bones

-MRI/CT identifies adenoma

SX of Hyperparathyroidism

-Hypercalcemia

-Fatigue

-Muscle weakness/loss of muscle tone

-Dysrhythmias

-Skeletal tenderness

-Pain on wt. bearing

-Pathologic fx

-Kidney stones

-Pyelonephritis/uremia

Hypoparathyroidism

-Deficiency of parathyroid hormone resulting in hypocalcemia

-Causes: Trauma or accidental removal of all/part of parathyroid glands, congenital absence, autoimmune

-Dx: Serum Ca lowered, serum P ^,

urine levels of Ca & P decreased

Sx of Hypoparathyroidism

-Tetany          -Abd. pain

-Numbness & tingling of fingers & toes or around mouth

-Involuntary jerking        -Seizures

-Cramping

-Positive Chvostek's & Trousseau's sign

-Carpopedal spasms

-Laryngeal spasms

-Resp. distress

-Dysrhythmias

Tx for Hypoparathyroidism

-Adm. IV Ca salt

-Endotracheal intubation & mech. ventilation for resp. support

-Oral Ca or Vit D for long-term tx

ADDISON'S DISEASE

-Decreased fx of adrenal cortex

-Causes: Primary: destruction of adrenal cortex by diseases as TB or autoimmune

-Secondary: Surgical removal, hemorrhagic infarction of adrenals, hypopituitarism (failure or surgical removal of pit. gland), suppression of adrenal fx by adm. of corticosteroids

Dx & Tx for Addison's Disease

-Dx: Lowered serum cortisol, Na & glucose

^ K, Ca, BUN

-Xray/CT may show calcified or atrophied adrenal glands

-Tx: Daily, corticosteroid replacement therapy for life

-will be divided 2/3 daily dose in am & 1/3 daily dose in p.m. to mimic body's own rhythm

-Fludrocortisone (Florinef) contains both glucocorticoids & mineralcorticoids

Sx. of Addison's Disease

- ^ urinary excretion of Na & retention of K

-Dehydration & hypovolemia

-Weakness, fatigue, dizziness, hypotension, hypothermia

-Vascular collapse

-Wt. loss, anorexia, GI sx's

-Nervousness, depression

-Hypoglycemia

-Abnormal pigmentation of skin

-Decreased hair growth

Addisonian Crisis

-Occurs when sudden failure of adrenal glands or when corticosteroid therapy suddenly stopped

-Causes: Stress, salt deprivation, infection, trauma, exposure to cold, over excretion

Sx & Tx of Addisonian Crisis

-Sx: Sudden or gradual...begins w/ anorexia, N/V/D, abd. pain, weakness, ha, hypotension, restlessness, fever

**(If corticosteroids not ^, bp drops & shock develops)**

-Tx: EMERGENCY!!!!!

Death may occur d/t hypotension & vasomotor collapse

-Corticosteroids given IV in solutions of NS & glucose

CUSHING'S SYNDROME

(Adrenocortical hyperfunction)

-Oversecretion of adrenal cortex hormones

-Causes: Overproduction of ACTH by pit. gland

-benign or malignant tumors of pit. gland or adrenal cortex

-Prolonged adm. of ^ doses of corticosteroids

-Dx: ^ urine levels of steroids, ^serum cortisol levels, ^Na & glucose, decreased K; Xray/Ct/MRI may show enlargement

Sx of Cushing's Syndrome

-Muscle wasting/weakness

-Hyperglycemia

-Redistribution of fat (moon face, buffalo hump)

-thin skin

-Ruddy face

-^ Susceptibility to wounds & prolonged healing

-Bruising/peripheral edema

-HTN/Mood changes

-Women: masculinization (hirsutism, amenorrhea)

Pheochromocytoma

-Tumor (usually benign) of adrenal medulla that causes hyperfunction (excess epinephrine & norepinephrine)

-Triggers: Excercise, emotional distress, trauma, manipulation of tumor, postural changes

-Dx: 24 hr urine for VMA ^

Urine catecholamines ^;  CT, MRI, US, aortagram, retrograde pyelogram reveal tumor

Sx of Pheochromocytoma

-HTN

-Tachycardia

-Palpitations

-Potential for CVA

-Tremors

-Nervousness; sweating

-N/V;  HA

-Polyuria;  vertigo

-Hyperglycemia

Hyperaldosteronism

-Hypersecretion of aldosterone by adrenal cortex

-Causes: Benign aldosterone-secreting adenoma, malignant adrenal tumor, unknown pregnancy, CHF, renal artery stenosis, cirrhosis

-Dx: ^ Na, bicarbonate, aldosterone, & renin; decreased K

CT, MRI, or adrenal venogram identify tumor

-Tx: Surgical removal of tumor; antihypertensives; K-sparing diuretics, Na restricted diet

Teaching for adrenal insufficiency & lifetime corticosteroid replacement therapy

-Never omit, decrease or ^ dose

-Avoid exposure to infections & excessive fatigue

-Wear ID stating adrenal insufficiency

-Seek med. attention for dosage readjustment when there's stress (infection, MVA, family crisis, heavy work load)

Postop care after bilateral adrenalectomy

-Risk: hemorrhage, atelectasis, pneumothorax

-Monitor vs frequently & observe for adrenal insufficiency sx's

-Never omit corticosteroid-essential for life

-Avoid infections, stressful situations

-Eat well balanced diet, get adequate rest

-Monitor for hypotension & tachycardia d/t Na & H2O loss

Glycosylated Hgb

-Amt. of glucose stored by hgb