Cuyahoga Community College Division of Nursing Nursing 2501: Endocrine System Introduction: Anatomy & Physiology of Endocrine System... ● Endocrine System: ○ Communication network that send messages from one location to another ○ Initiate change/make actions occur ○ Collection of ductless glands throughout the body: ■ These glands secrete chemicals (Hormones) ○ Hormones are called chemical messengers, Once secreted by glands they… ■ Enter the bloodstream & carried to predestined locations in the body ■ Hormones deliver messages from glands to organs or body tissue ○ Hormones deliver messages from glands to cell tissue or organs ■ Secreted directly into circulatory system ■ Maintain chemical levels in blood ● Major Endocrine Glands: ○ Pineal ○ Pituitary ○ Pancreas ○ Ovaries ○ Testes ○ Thyroid ○ Parathyroid ○ Hypothalamus ○ Adrenal ● The Endocrine System works in conjunction with the nervous system to… ○ Control body functions & regulations ○ Functions influenced by the endocrine system are: ■ Metabolism ■ Nutrition ■ Growth ■ Reproduction ■ Fluid & electrolyte balance ● Information signal system ● Effects ○ Slow to initiate ○ Prolonged response ○ Last from few hours to weeks Hormones: ● Transported in bloodstream ● Exert effect “chemical messenger” on target tissue: ○ Bind with cells at receptor sites specific for their transference or receptive to messages brought by hormone ● Genetically programmed to carry instructional messages from one location to another: ○ Upon arrival to the target destination, binds with the cell & passes on the chemical message ● Binding process: ○ Transfer affects change on cellular level and causes/initiates changes/actions or maintains balance Types of Hormones & Binding Process ● Water soluble Interacts cell membrane ○ Protein based ○ Cell membrane and interaction with receptor hormone ○ Produces a second messenger; effects intracellular activity ■ Ex: ADH or vasopressin a hormone that increase blood pressure decreasing urine output ■ Cell membrane and fatty components make it difficult for the hormone to deliver its message through the cell membrane. So, it binds to receptors on the cell surface. Binding triggers a chemical reaction or response on the inside of the cell causing a (second messenger) without the original hormone molecule ever entering the cell. ■ The reaction activates enzymes within the cell causing change in cell function to speed up or slow down. The cell function is in response to the instruction received from the hormone. ● Lipid soluble ○ Fat/ cholesterol based ■ Ex: Testosterone & Estrogen ○ Lipid hormone passes through cell membrane enters cell and attaches to receptors moving inside the cell ○ Hormone-Receptor moves to cell nucleus & binds with DNA (protein synthesis) ■ Causing genetic changes to switch on/off activity ● Tyrosine derivatives: ○ Ex: Epinephrine & Norepinephrine, T3 & T4 ○ Different d/t being derived from 1 amino acid & can act like lipid or water soluble based hormones ○ These types of hormone messengers bind using either binding process Regulation: ● Stimulus is an occurrence that evokes a specific functional reaction in an organ or tissue ● Occurrence that arouses activity or energy in someone or something; is an incentive for change ● Once the glands cause hormone secretions that promote change, when enough change has occurred a self adjusting mechanism (feedback regulation) maintains balance in the body ● There are two types of responses determining which feedback loop is used: ○ Negative Feedback= occurs when the response to a stimulus reduces the original stimulus. ○ Complex/Positive Feedback= occurs when the response to a stimulus increases the original stimulus ■ Is less common in biological systems ■ Speeds up the direction of change ● Example: ○ Negative feedback Loop: Control of blood glucose level: ■ Blood glucose concentration rises after a meal (the stimulus) ■ Insulin is released by pancreas & it transports glucose from blood into selected cells (the response) ■ Blood glucose concentrations decrease. Then Secretion of insulin into blood is decreased ○ Positive feedback : Lactation (milk production: ■ As a baby suckles, nerve messages from mammary glands cause Prolactin secretion from pituitary gland ■ The more the baby suckles, the more prolactin is released, Stimulating further milk production ■ This leads to increasing hormone concentration ■ Moving further away from homeostasis Anatomy of Glands and Hormones ● Hypothalamus: Located near optic chiasm ○ Linked to the nervous system ■ Release of hormones by hypothalamus into circulatory system, targets pituitary gland, causing release or withholding of hormone secretions by pituitary gland ■ Produces Oxytocin and ADH (stored in posterior pituitary) ○ Regulates endocrine system hormones: ■ Through nerve & hormone channels in the body, hypothalamus regulates vital biological processes: ● Including…. ○ Body temperature ○ Blood pressure ○ Thirst ○ Hunger ○ Sleep-wake cycle ■ These regulatory hormones are produced & released by the hypothalamus ■ Travel to their designated destination, causing activation of other hormones ■ Secretes hormones that inhibit or release secretions from anterior Pituitary ● Pituitary Gland: ○ Located at the base of the brain has two Lobes... ● Posterior and Anterior Pituitary Gland: ○ Posterior Pituitary: ■ Produces, Stores, & Releases Oxytocin and ADH ■ The size of a pea, protrudes from hypothalamus ○ Oxytocin: ■ Made in hypothalamus ■ Transported to & secreted by pituitary gland ■ Acts as a hormone & as a Brain neurotransmitter ■ Release of oxytocin regulates Reproductive functions (Childbirth & Breast-feeding) ■ During labor makes the muscles of the uterus, womb, contract. Synthetic version, Pitocin… ● Induce labor ● Strengthens uterine contractions ● Controls bleeding after childbirth ● Stimulate uterine contractions in a woman with an incomplete/threatened miscarriage ● Other uses... ○ Antidiuretic hormone (ADH): ■ Helps to control BP, acting on the kidneys & blood vessels ■ Reducing amount of water passed via urine (Water in the urine is taken back into the body) ■ Higher concentrations of antidiuretic hormone cause blood vessels to constrict (become narrower) ● Increasing blood pressure ○ Anterior Pituitary Gland: Associated with more hormones ■ Growth hormone (GH or HGH), aka “somatropin”: ● Is a hormone that stimulates growth, cell reproduction & regeneration in humans ■ Thyroid-stimulating hormone (TSH): ● Test used to evaluate thyroid function & symptoms thyroid disorder ● TSH Stimulates thyroid gland to produce thyroxine (T4), and then triiodothyronine (T3) ○ Which stimulates the metabolism of almost every tissue in the body ■ Adrenocorticotropic hormone (ACTH) ● Stimulates production & release of cortisol in the adrenal gland ● Cortisol levels change throughout the day ● ACTH causes adrenal glands to secrete more cortisol, resulting in high levels in blood ● Cortisol known as “the stress hormone” d/t stress activating cortisol secretion ■ Luteinizing Hormone (LH): In both Men and Women ● In Women: ○ LH is part of the menstrual cycle ○ Works with follicle-stimulating hormone (FSH) ○ Follicle Stimulating Hormone (FSH): ■ Stimulates ovarian follicle causing an egg to grow & production of estrogen ● In Men: ○ LH leads to release of testosterone (hormone necessary for producing sperm cells) ■ Prolactin: ● Known for role in milk production ● Secreted from pituitary gland in response to… ○ Eating ○ Mating ○ Estrogen treatment ○ Ovulation ○ Nursing ■ Melanocyte Stimulating Hormone (MSH): ● Stimulates production & release of melanin in skin & hair ● Increase darkening ● Pineal Body Gland: ○ Located in vertebrae brain ○ Melatonin secreted and regulates biorhythms ○ May influence sexual development ● Thyroid Gland: ○ Resembles a butterfly; has two lobes connected by an isthmus (small connecting stalk) ○ Located in the lower part of neck just below larynx ○ TSH is released by the anterior pituitary causing Thyroid to produce…. ■ Thyroxine (T4) ■ Triiodothyronine (T3) ○ Calcitonin: ■ Is a hormone produced in the thyroid gland ○ T3 & T4: ■ Are called thyroid hormones & produced in thyroid gland ■ T3 and T4 formation requires iodine ■ Triiodothyronine (T3) more potent ■ ○ Thyroid hormone Affects…… ■ Body growth ■ Metabolic rates ■ Development of bones & skeletal muscle ■ TH; Increases sensitivity of cardiovascular system to sympathetic nervous activity ● An effect that maintains a normal heart rate ○ Para follicular cells (C cells): ■ Located between the thyroid gland follicles ■ They produce calcitonin ■ Calcitonin; Substance/hormone that lowers blood Calcium levels ○ Parathyroid Gland: ■ Embedded in back of the thyroid gland ■ Parathyroids consist of four small masses of tissue ■ Secrete Parathyroid Hormone (PTH) ■ Regulates serum Calcium & Phosphate: ● Increases blood calcium by… ○ Increasing activity of bone reabsorption (bone storage site of calcium, release calcium into blood ○ Increases absorption of calcium & phosphorus from food by gut wall(Activates Vit. D) ■ Vitamin D helps the intestines absorb calcium ○ Decreasing excretion of calcium & phosphorus by the kidney (Puts it back in blood) ○ Phosphorus not as dependent works in conjunction with PTH levels…. ■ Vitamin D must first be activated/turned on by PTH ■ Direct feedback Loop Example: ● If serum Ca is low PTH Increases ● If serum Ca is high PTH Decreases/Stops releasing ■ Proper calcium balance: Crucial to normal functioning of the… ● Heart ● Nervous system ● Kidneys ● Bones ○ Adrenal Gland: ■ Vascular tent shaped glands, located on top of each kidney with an outer & inner region ■ Each region involved with specific hormones... ○ Cortex (outer region) secretes hormones.. ■ Glucocorticoids-Cortisol (Stress Response) ● Cortisol raises bs by increasing gluconeogenesis (glucose synthesis via amino acid) ○ Ensures glucose supply for body when under stress ○ Supports the metabolism of fats, carbohydrates & protein ○ Suppresses the immune system ○ Assists in maintaining emotional stability ■ Glucocorticoids-Mineralocorticoids (cortisone & aldosterone r/t fluid balance) ● Aldosterone promotes sodium (salt) reabsorption by stimulating kidneys to absorb more sodium from blood ● Androgen hormones (Estrogen) involved in secondary sex characteristcs… ○ Breast ○ Hair ○ Voice ■ Medulla (inner region): ● Develops from nervous tissue; ANS Controls its secretions ● Secretes Catecholamine: ○ Epinephrine (adrenaline) & Norepinephrine (noradrenaline) ■ Chemicals that raise the blood levels of sugar and fatty acids ■ Involved with stress response; Increase the heart rate/prepare for "Fight or Flight“ ○ Dopamine (neurotransmitter) ■ As well ??? Endocrine System Assessment and Diagnostic Test Assessment: Nursing assessment, how we obtain information, & utilize it for treatment… Gather Subjective & Objective Data ● Subjective Data: Is from….Nursing staff ○ Patient ○ Family ○ Other Nurse’s reports ○ Huddle ○ Interdisciplinary meetings & entities ● During pt interview & discussion of Current/PMH: ○ If endocrine problems suspected: ■ (Gordon’s Functional Health) assess patterns how they affect or r/t… ● Nutrition ● Elimination ● Sexual patterns ● Sleep & rest ● Activity ● Exercise ● Psychosocial perception of health? ● Presenting problem age or gender related? ○ Medications: ○ Vital; Review past & present especially…. ■ Hormone ■ Insulin ■ Oral diabetic medications ■ Thyroid and other specific endocrine medications ■ Question OTC meds such as….. ● Vitamin D ● Phosphorus ● Magnesium ● Calcium ● Objective Data (Measurable info): Physical exam using Nursing skills of… ○ Inspection: ■ Examine visually pt’s overall look, Head to toe starts with…. ● General appearance ● Height ● Weight ● Stature ● Muscle mass ● Fat distribution (BMI) ■ Go to a more focused exam of the head ending at the feet: ● Head & Neck-Thyroid Assessment ○ Facial features: ■ Eyes ■ Mouth ■ Tongue ■ Jaws ■ Forehead ■ Facial puffiness ■ Expression; Flat or Dull ○ Skin conditions (pigmentation, nodules): ■ Patchy pigment loss (vitiligo-melanin problem) ■ Skin infection ■ Wound healing ■ Bruising ■ Petechiae and striae (reddish purple stretch marks adrenal gland) ● Examine Neck for…. ○ Protrusions and enlargement could involve thyroid (complaint about swallowing) ○ Masses/Nodules ● Musculoskeletal: ○ Gait ○ Positioning ○ Bone structure ○ Extremity weakness/strength ● Body Hair Changes: ○ Excessive growth ○ Texture/brittle ○ Hair loss ● Abnormalities with genitalia: ● Note Secondary sex characteristics: ○ Men with enlarged mammary ○ Women with Facial hair & vocal changes ● Labs, Assays (levels of hormone in blood), Tests, & imaging are part of diagnostic test Data ■ Auscultation: With stethoscope Listen for any changes r/t endocrine system ● Heart: ○ Many hormones of endocrine system impact heart activity ○ Rate, Rhythm, & Abnormalities can indicate problem source ○ Enlarged Thyroid increases vascular flow; Bruit can be heard in neck by auscultation ● Vital signs impacted by endocrine disorders ○ Ex: Elevated HR (hyperthyroid) ● Lungs: ○ Abnormal lung sounds related to retention of fluids heard ● Other organs ■ Palpation: ● Palpation feeling for masses, swelling, muscle tone, source of pain ■ Percussion ○ Height & Weight: ■ Growth changes/can determine endocrine problems) ○ Mental/emotional status: ■ Many endocrine disorders present with confusion or psychological s/s Diagnostic Test-Endocrine Assessment: ● Diagnostic Test: ○ Is any kind of medical test performed to aid in the diagnosis or detection of a disease/disorder can be… ■ Invasive ■ Minimally Invasive ■ Non Invasive ○ For general endocrine disorders or more specific/specialized for disorders ○ Diagnostic imaging: provide pictures of structures housing the glands (Ex: skull, neck, chest) ■ X-Rays ■ MRI ■ CT-Scans ○ Ultrasound: some glands observed via US ■ Thyroid ■ Parathyroid ■ Gonads ○ Genetic testing: ○ Urine Testing: ■ Measures…. ● Hormones levels ● Metabolizing of hormones in urine ■ Collecting 24 hour urine measures a specific hormone ■ Teach pt, to empty bladder, discard the first specimen then start ■ Empty bladder for last specimen & check preservatives by asking lab ○ Blood and venous sampling ○ Biopsy ○ Stimulation/Suppression Test: ■ Measures specific hormone levels ■ May have to Trigger responses: ● Stimulation/Induce selected hormones that stimulate target gland for increased production.. ○ If levels are not high problem may be hypo function ● Suppression with drugs/substances decreases target gland production. ○ If no suppression indicates hyper function ○ Assays: ■ Measure specific hormones in blood or body fluids. ■ Very sensitive test ■ Multiple testing of hormones can occur at same time ● Endocrine System: Impacts the psychological responses, behaviors, and personality ○ Ask pt. To report any changes & include family members/close friends when possible r/t changes in pt. ○ Several endocrine disorders affecting patient psychologically; changes in…. ■ Thyroid, Pituitary, & Adrenal glands impacting F & E ■ F&E…... ● Impact balance ● Impair rest ● Impair sleeping ■ Abnormal circulation affect Heart & BP ● Too high or too low initiates confusion & abnormal respirations. ■ Abnormal oxygen exchange affects…. ● Stamina, mobility, speech, & muscular balance ○ Patients may have altered perceptions of themselves and health status ○ Long term dysfunction can cause medication dependency & financial difficulties ○ Use assessment tools to detect possible depression & suicidal intent ● Hypothalamus: d/t Location brain structure & neurological exam included in diagnostics & assessment ○ Reviewing via imaging at the structure in the brain supporting release of hormones & EEG following the electrical/neurological component…. ■ To determine: ● No abnormal masses, structural problems while examining blood flow & circulation ○ Serum levels: Drawn & interpreted… ■ Establish hormone levels & normalcy of systems that come in contact with hypothalamus ○ Fluid and electrolytes ■ Big part of Endocrine System ○ CMP, CBC ○ Kidney, liver: any S/S indicating abnormalities ■ Labs drawn & could involve these presenting signs Some Specific glands & Assessment tools; Labs & Diagnostics…. Thyroid Blood Test: ○ T3, T4, TSH, PBI (protein bound iodine) ○ FTI- free thyroxine index(unbound) Component of T4 are serum levels ○ All serums indicate thyroid function ○ T3 and T4 are decreased with hypothyroid states and increased with hyperthyroid state ○ TSH is increased with low levels of serum thyroid hormones ○ TSH stimulation Test and Thyrotropin releasing Test (TRH stimulation) assess response of anterior pituitary ○ Thyroid Scan and radioactive iodine uptake test ■ Uses radioactive iodine (support formation T3, T4), radioactive precautions ■ No iodine supplements and thyroid hormones e.g. IVP dye for 4 weeks prior to test; interferes with results ■ measures the amount of radioactive iodine (taken by mouth) that accumulates in the thyroid gland check hyperthyroidism, enlarged gland structure ● Pituitary Gland Tests: ○ Blood work, serum levels on various hormones ○ Growth Hormone stimulation test uses insulin and lowers glucose levels ■ Check for hypoglycemia and hypotension, have D5 available ■ GH suppression test uses oral or IV glucose ○ GH levels are suppressed d/t normal high blood glucose levels ○ Check imaging radioimmunoassay of ADH ○ Water Deprivation Test ■ Best to diagnose Central diabetes insipidus ■ Urine production, blood electrolyte levels, & weight measured regularly for about 12 hours: ● During which pt. is not allowed to drink ■ Re-perform vitals & urine osmolality every hour, until….. ● Urine osmolality stabilizes ● Excess body weight loss of 3-5% occurs ● Hypotension develops ■ Pt. with DI will continue to excrete large amounts of urine, even with fluid restrictions & dehydration ○ Evocative/Suppression Testing: ■ A test where one substance is measured before and after the administration of another substance: ● Determines if the levels are stimulated ("evocative") or suppressed ● Commonly performed in the evaluation of possible endocrine disorders ● Certain tests performed in the evaluation of multiple conditions and NOT Radioimmunoassays ○ A technique for determining antibody levels by introducing an antigen labeled with a radioisotope & measuring the subsequent radioactivity of the antibody component ● Based on symptoms pt. Displays the following assessment tools possibly required: ○ Nutrition assessment ○ Mini mental ○ Delirium ■ ADH given and urine osmolality will rise with central DI ○ Nursing Care for Deprivation Test: ■ Monitor and assess accurately vitals, weights, etc. ■ Emotional support ■ Monitor and explain overwhelming thirst ● Parathyroid Gland Tests: Serum levels…. ○ Parathyroid hormones affect the target tissue to maintain calcium balance ■ Hormones interact with the kidney, bones, and gi tract. ■ These hormones affect the Phosphorus levels with Calcium in gut by activating vit. D (for absorption) ● Both impacted by increasing release of calcium & phosphorus from bone to extracellular fluids ● Causing decrease bone formation & increased bone breakdown ● As serum Calcium increases…. ○ More reabsorption of Mag w/ Ca & excretion of phosphorus, bicarbonate & sodium ○ These labs support possible causes for abnormal hormone level ○ Imaging: ■ Arteriography radiography of an artery, carried out after injection of a radio-opaque substance ● "coronary arteriography" ○ Bone density testing ● ● Adrenal Gland Tests ○ Adrenal glands interact with…. ■ F&E balance ■ Glucose levels ■ Immune ■ Emotional stability: Stress response & Emotional activity ○ The stimulation of the nervous system causes changes in various organs & tissues in body ○ Based on pt’s S/S testing could include these basics & extend into specialized areas… ■ Depending on Endocrine Abnormal Manifestations ○ Blood serum: Cortisol, aldosterone, ACTH ○ ACTH stimulation with cosyntropin (synthetic ACTH) ○ ACTH suppression test (dexamethasone suppression) ■ NPO ■ Evaluate for Cushing’s ■ Give the night before should decrease secretion of cortisol ○ Urine Test- 24/Hour urines *review how to collect* ○ 17 hydroxy ketosteroids or 17 ketosteroids ○ Aldosterone keep on normal salt intake ○ Free cortisol avoid stress and exercise ○ Vanillymandelic acid (catecholamine metabolite for pheochromocytoma) ● Nursing Considerations of patients receiving labs/testing for Endocrine Disorders: ○ When communicating pre & post expectations: Have Pt. confirm understanding (ensure no neuro problems) ○ Verify 2 forms of ID & have a signed consent form by the patient or Medical POA ○ Check pre-testing care ○ Most patients have NPO status timeframes: ■ Check compliance & last time pt ate and drank fluids ○ Some procedures require IV access & possible administering of contrast or premeds (conscious sedation) ○ Prior to administering/starting procedure often, everyone will stop listen to patient state name & dob ■ Check ID bracelet & ask Pt. to state what procedure is occurring ■ Upon staff agreement; restart procedure (This is/was the time out) ○ Document & prepare discharge instructions/paperwork after patient stable & returned to baseline ****Body always tries to maintain homeostasis & with the Endocrine system…. ● If abnormal hormone levels detected (even slightest interruption of normal function in one more of these glands) ○ Can throw off delicate balance of hormones in the body & lead to endocrine disorders/diseases ○ Hormone changes can occur rapidly or slowly and take effect for a short period of time or weeks Endocrine System-Pituitary Disorders Variations occur in response to stress, 24 hour cycle changes, feedback mechanism problems, and ACTH producing pituitary adenoma ● Pituitary Gland:: ○ Often called the “Master Gland” ○ Pea sized gland located at base of brain & sits in a protective bony enclosure ○ Has an anterior & posterior portions ○ Anterior portion (3 lobes) ■ Pars distalis ■ Pars tuberalis ■ Pars intermedia ○ Posterior portion (1 lobe) ■ Infundibular stalk ■ Pars nervosa ● Anterior Pituitary: ○ Hormone secretion from APG regulated by release of tropic hormones secreted by the hypothalamus ■ Tropic hormones (hormones which stimulate other glands to secrete) ■ These regulatory hormones, released in blood & travel directly to APG ■ Stimulating or inhibiting release of the anterior hormones ○ Hormones associated with APG: ■ GH ■ TSH ■ MSH ■ FSH ■ LH ■ PRL ● Posterior Pituitary: ○ Posterior portion receives hormones produced & released directly from Hypothalamus ■ Hormones sent via nerves tracks ○ Hormones are stored in nerve endings of PPG & released in the blood when needed ○ Hormones associated with PPG: ■ ADH ■ Oxytocin ● The Feedback System: ○ Helps control balance of hormones in bloodstream: If body has too much or too little of specific hormone... ○ Feedback system signals proper gland/glands to correct problem ● Hormone imbalance may occur if …. ○ Feedback System has trouble keeping right level of hormones in bloodstream ○ Body doesn't clear them out of bloodstream properly ● Causes of Pituitary Disorders: ○ Hormone imbalance: ■ Increased or decreased levels of endocrine hormone can be r/t problem with FBS ○ Disease: ■ Failure of a gland to stimulate another gland to release hormones; Gland function failure... ■ Ex: Problem with Hypothalamus can disrupt hormone production in PG ○ Genetic disorders such as… ■ Multiple endocrine neoplasia (MEN) ■ Congenital Hypothyroidism (underproduction of thyroid hormone) Anterior Pituitary Disorders: ● Hypersecretion Disorders: Prolonged Excess GH (growth hormone): ● Pituitary tumors or tissue overgrowth Can cause….. ○ Gigantism: ■ Is excessive growth in children (d/t open growth plate) ■ It is Often Rare ■ Early diagnosis is important; Hard for parents to detect (Symptoms first seem as normal growth spurt) ■ Prompt treatment can stop/slow changes that cause child to grow larger than Normal ○ Bone destruction: ■ In adults d/t prolonged & increased GH ■ Bones thicken/wide (don't get longer) d/t closed growth plates ■ Abnormal bones of… ● Jaw ● Fingers ● Toes ■ Cause muscle weakness and pressure on nerves ■ Resulting heaviness of the jaw and increased size of digits referred to as Acromegaly ■ Osteoporosis can occur ■ Acromegaly Disease: Causes abnormal enlargement in other body systems such as…. ● Liver & Heart… ● Resulting in HTN, & left ventricular hypertrophy ■ Some changes are reversible with treatment ■ Skeletal changes are permanent ○ Shock & Hypotension: d/t Decreased circulation to gland ■ Trauma, Infection, and AIDS impair pituitary gland function ■ Some changes reversible, skeletal changes permanent ■ May be familial ○ Tumors: ■ Tumors are benign & grow slowly producing more hormone secretions ■ Tumor (adenoma) growth may become large enough to cause ● Neurological problems… ○ Impair & alter vision d/t pressure on optic nerve ○ Headaches ● Deficiency of other pituitary hormones by displacement ● Hyposecretion Disorders: ○ Reduced liver production somatomedins (that trigger growth & maintain activities) ○ Most disorders d/t GH secreting adenoma ○ GH, PRL, and ACTH with increased secretion of MSH ● Adrenocorticotropic hormone (ACTH): ○ Excess ACTH stimulates adrenal cortex ○ Stimulates secretion of glucocorticoids (cortisol) ○ ACTH overproduction related to tumor is… ● ● ● ● ■ Cushing’s Disease/syndrome ■ S/S of excess cortisol Life Threatening ACTH and TSH: ○ Decrease in sexual hormones in.… ■ Males, can result in…. ● Testicular failure ● Low testosterone ● Possible sterility ■ Women, may experience ● Absence of Menses ● Infertility Anorexia nervosa: ○ Often seen early in teens ○ Can cause severe malnutrition/rapid body fat loss ■ Which impairs pituitary function ○ Decreased secretions of hormones from adrenal and thyroid glands Prolactinomas: ○ Manifestations as a result of deficiencies and over secretions with one or more anterior pituitary hormones: ■ Usually one hormone in excess of PRL< ACTH or GH ○ Secreting tumors developing in the pituitary gland (“aka” Adenoma) ○ PRL overproduction caused from: ■ Medications ■ Other types of pituitary tumors ■ Underactive thyroid ■ Injury S/S from PRL levels in blood r/t pressure from tumor on surrounding tissue ○ Reproductive symptoms Females: ■ Galactorrhea (lactation not associated w/ childbirth) ■ Ovarian dysfunction ■ Decreased libido ■ Excessive hair growth (hirsutism) ○ Reproductive symptoms Males: ■ Impotence ■ Decreased libido ■ Decreased sperm count ■ Vision changes ● Diagnostics/Tests: ○ Look at the test and diagnostics. ○ First, Check hormone levels and presenting effects ○ Assessments need to be performed Anterior Pituitary Disorder Treatments: ● Somatostatin (Sandostatin): ○ Synthetic version of GH somatropin; treats disorders of GH production or deficiency ○ Somatostatin analog that reduces GH levels ○ Norditropin & Omnitrope (Brand Names) ○ Used for children w/ low or no GH ○ For Adults with no production GH ○ Injection can cause serious side effects may see: ■ Knee pain, limp, (slipped capital femoral epiphysis); ■ Worsening of pre-existing curvature of the spine (scoliosis) ■ Hearing/Ear problems ○ High risk of death in people who have…. ■ Critical illnesses ■ Heart or stomach surgery ■ Trauma ■ Serious breathing (respiratory) problems ● Octreotide (Long Acting) somatostatin IM usually every 4 hours: Treats…. ○ Severe watery diarrhea ○ Sudden reddening of face & neck (caused by certain types of tumors) ○ Acromegaly d/t over secretion of GH ■ Treating acromegaly helps reduce risk of serious problems such as Diabetes & Heart disease ○ Side Effects: ■ Nausea ● ● ● ● ● ● ● ● ■ Vomiting ■ loose/oily stools ■ Constipation ■ Stomach upset (Gas, bloating) ■ Dizziness ■ Headache ■ Pain & irritation at injection site may also occur ○ Check medication reactions ○ Know stop and starting of medication ○ Watch changes in… ■ Glucose levels (hypo/hyperglycemia) ■ Fluid & Electrolytes ■ Fat absorption in intestines ○ Patient teaching related to injections Dopamine Agonist: ○ Suppress GH secretion Bromocriptine (Parodel): ○ Used for several medical problems (al caused by pituitary problems) ■ Amenorrhea ■ Female infertility ■ Galactorrhea ■ Hypogonadism ■ Acromegaly ○ Many potential side effects: ■ Most frequent S/E Nausea & Orthostatic hypotension ■ Headaches ■ Vomiting ■ Vasospasms with serious consequences such as… ● MI & Stroke have been reported ○ Bromocriptine is associated with causing/worsening psychotic symptoms: ■ Its mechanism in opposition of most antipsychotics (a mechanisms that generally blocks dopamine) Dostinex: ○ Treats high levels of prolactin hormone in the body ○ Elevated prolactin in women can cause symptoms such as…. ■ Unwanted breast milk ■ Missed periods ■ Difficulty becoming pregnant Replacement therapy can be administered by IM injections or patches ○ Will see changes in secondary characteristics ○ Treatment can be decreased but may be required for life ○ High dose of testosterone is continued until virilization (appearance secondary sex characteristic) is achieved. ○ For fertility GnRH & Testosterone both administered Patient with prostate cancer ○ Avoid androgen therapy, Side effects: ■ Gynecomastia ■ Acne ■ Enlarged prostate ■ Baldness Women who have estrogen & progesterone replacement: ○ Risk of thrombus & HTN (especially smokers) ○ Regular visits are needed to reduce risks Adults may receive GH injections at night to simulate normal GH release ○ Sexual function difficulty, change in appearance, joint pain, & self-image are problems ○ Medications are treatment for over secretion of hormones Radiation Therapy: ○ Used if cause is a tumor ○ Can take a long time and tumor side effects remain until tumor eradicated ○ Radiation therapy used when malignant tumors present ■ 1. In conjunction with other treatments ■ 2. For tumors that have returned after surgery ■ 3. In conjunction w/ chemo after surgery to destroy any remaining cancer cells ■ This kind of radiation therapy is called Adjuvant therapy ○ Types of radiation: ■ Image-Modulated Radiation Therapy (IMRT) ● Advanced form of radiation therapy using computer-generated images to guide multiple beams of various intensity aimed from many angles. ● Stops tumor growth, & in some cases, shrink or destroy your tumors minimizing damage to surrounding healthy tissue ■ Stereotactic Radiotherapy Using the Gamma Knife: ● External-beam radiation therapy is highly precise ● Delivers much higher doses of radiation to your tumor than conventional radiotherapy, while sparing surrounding healthy tissue ● Offered in single doses or fractured doses ● Sometimes called gamma knife or cyber knife radiosurgery is a radiation treatment ● Gamma Knife is not a surgical procedure ● Hypopituitarism: ○ Hypofunction of the pituitary ○ Hypopituitarism outcome is to replace hormones ○ Assess symptoms as related to target organ function ○ Hyposecretion changes are rare can be life threatening ○ Symptoms may be nonspecific Hypophysectomy: ● ● ● ● ● Transsphenoidal approach used to remove tumors, enters through the nose Can make incision above upper lip Performed for acromegaly Goal remove tumor only Preoperative Care: ○ Teaching and preparation for the surgical procedure: ■ Some changes reversible… ● Sex functions, pain, etc, ■ Some body changes may not be reversible after surgery ● Organ enlargement, visual changes, etc., ○ Discuss… ■ Infection Risk ■ Neuro status ■ Fluid balance ■ Cardiac ■ Kidney ■ Bowel elimination ■ Incision site ■ Activity level interfere with healing ■ About Avoiding ICP ■ Medication plan: ● How & when to administer medications ● May need antibiotic nose drops prophylaxis ● Mouth breathing due to packed nose ● Mustache dip pads ● Postoperative Care: ○ Medicate for pain/relief ○ Avoid increasing cranial pressure ■ Keep HOB elevated ■ No straining (valsalva, coughing, sneezing) ■ Assess nasal drainage: ● Clear drainage may indicate CSF leak ● Send to lab ● Halo sign-check gauze for blood middle surrounded by yellow liquid ● CSF if glucose 30>mg/dl positive for CSF ● May require closure or spinal taps to reduce pressure and permit healing ● Monitor for infection (possible) ○ Endoscopic smaller instruments used ■ Less damage to structures ■ Performed under general anesthesia ■ After gland removal a muscle graft is taken (from thigh) ● Support area ● Prevent CSP leakage ● Nasal packing applied after closing incision ● Drip pad applied if either surgery method cannot be used ○ Craniotomy may be used ■ Oral care-no toothbrush ■ Monitor for infection ■ DI is a complication of pituitary surgery ○ Transsphenoidal: ■ Surgical method recommended for removal of pituitary tumors from conditions like… ● Hyperadrenocorticism (Cushing’s Syndrome) ● Acromegaly ■ If Pituitary Adenoma; Incision just above the upper lip inside one of the nares ■ Tumor removed through one of the nasal sinus; If surgery successful…. ■ Symptoms resulting from tumor pressing on surrounding tissues, Improve Quickly! ■ Nose jammed with sponge packing to soak in drainage from operative site ■ Small plastic materials known as stents sewed into septum of the nose: ● Stents & Packing taken away before sufferers leave hospital ● Stitches in the lining of gums dissolve ■ Surgery requires a lot of care, even a minor error can damage delicate tissues adjacent PG ■ The Success of this operation depends on Surgeon’s experience & skill ■ Small Adenomas recur in 80-85% cases ■ Large Adenomas may come back in 50-65% cases after surgery ■ Some may need lifelong hormone replacement following surgery ○ Post-operative: ■ Neuro ■ Vision ■ LOC ■ Infection ■ Symptoms of Diabetes Insipidus ■ CSF leakage (nasal drip or repeat swallowing) ■ ICP bed elevated ■ Watch for halo sign ■ Check fluid for glucose ■ Problem is severe headaches ■ Most leaks resolve with bedrest ■ Avoid coughing ■ Deep breathing ■ Decrease respiratory risk ● If Patient reports abnormal symptoms of hyperpituitarism r/t hormone replacement ○ Identifies posterior pituitary (PP) gland disorders & hormone levels. ○ PP not as glandular as Anterior Pituitary… ○ PP is a large collection of neuron axons from Hypothalamus ○ Two hormones produced in Hypothalamus & Stored in Posterior Pituitary ■ Oxytocin (Pitocin): Targets… ● Uterus ● Mammary Glands ● Effects Uterine contractions; Lactation ■ Vasopressin= Antidiuretic hormone (ADH): ● Targets Kidneys or Arterioles to stimulate water retention ● Raises blood pressure by contracting arterioles; Induces male aggression Posterior Pituitary Disorders: SIADH & DI ● Oversecretion of Vasopressin, Syndrome of Inappropriate Antidiuretic Hormone (SIADH) ○ Urine Osmolality: A measure of urine concentration ○ Large values indicate concentrated urine ○ Small values indicate diluted urine ● Also called neurohypophysis the posterior lobe of gland ● Interacts with neurons Diabetes insipidus: ● Insufficient secretion of ADH (a Vasopressin) Diabetes Insipidus (DI) ○ With this condition body loses capacity to concentrate urine ○ Affected individuals display polyuria, excreting as much as 20L of diluted urine a day ● Different Types of DI.... ○ Central/Secondary Diabetes Insipidus: Related to pituitary/organic lesions that interfere with ADH synthesis, transport, or release…. ■ In adults usually r/t damage to pituitary gland or hypothalamus,Commonly d/t ● Cranial Surgery ● Tumors ● CNS infections/illness (such as meningitis) ● Inflammation ● Closed Head trauma/injury ■ Idiopathic ■ Occurs suddenly ■ May be permanent or temporary ■ In children ● it’s often an inherited/genetic disorder ● In some cases the cause is unknown ■ Damage disrupts normal Production, Storage & Release of ADH ■ May be permanent or temporary ○ Nephrogenic Diabetes Insipidus: r/t Renal insensitivity to ADH ■ Defect in kidney tubules; kidneys unable to properly respond to ADH defect may be d/t…. ● Inherited (genetic) disorder ● Chronic kidney disorder ● Certain drugs can cause NDI; Such as…. ○ Lithium ○ Demeclocycline (a tetracycline antibiotic) ○ Psychogenic: Related to… ■ Excess fluid intake & Hypervolemia ■ Medications ○ Assessment DI: ■ Excess water loss-dehydration & Hypovolemia despite increased oral intake of fluids ■ Polyuria, causing low specific gravity less than 1.003 ● Serum osmolality is usually elevated ■ Polydipsia, Intake cannot keep up with output severe fluid deficit ○ Diagnostic Test: ■ Labs, especially r/t Fluid & Electrolytes ● CBC ● Urinalysis ■ Testing for possible DI Causes should be done… ● Imaging for structural problems ● Urinalysis: ○ Identify abnormal urine r/t increased output ○ Urine levels ● Screenings (genetic) ● Signs of infection ● Water Deprivation Test Treatment Options: ● For Tumors: Radiation & Surgery (if needed); Medication could be taken for life ○ Desmopressin (Medication of choice) ○ Synthetic Vasopressin ■ Synthetic hormone eliminates increased urination ○ Nasal administration in metered doses… ○ The more severe the larger the dose ○ If S/E present d/t nasal administration Change route to oral, IM or IV; S/E such as…. ■ Ulcerated membranes ■ Allergy ■ Respiratory Infection ○ Vasopressin alternate administration ■ Oral tablets or injection ■ 2-3 times a day ○ If condition caused by abnormality in the pituitary gland or hypothalamus (such as a tumor) ○ Dr. will first treat abnormality with surgery, radiation, or both ● Treatment and Nursing Considerations: ○ Maintain fluid and electrolyte balance ○ Monitor output replace with IV fluids ○ Monitor serum sodium (other electrolytes) ○ Vital signs, weights, check urine specific gravity ○ Overmedication can cause fluid volume excess ○ Diabinese (antidiabetic medication) PO decreases urine output ○ Vasopressin (Pitressin) IM, SQ, or nasal spray; Desmopressin (DDAVP) oral or nasal ○ Intranasal is not as potent for the vasoconstrictive effect as is long term therapy ● If Nephrogenic diabetes insipidus: ○ Desmpression NOT an Option! ● Dr. may prescribe; low-salt diet (helps reduce u/o kidneys make) ○ Must drink enough water to avoid dehydration ● Hydrochlorothiazide: ○ Used alone or in conjunction with other medications ○ May improve symptoms ○ Although a Diuretic (usually increasing urine o/p) sometimes reduce u/o for ppl w/ NDI SIADH: ● Syndrome of Inappropriate secretion of Antidiuretic Hormone (SIADH) ○ Disorder of impaired water excretion d/t inability to suppress secretion of ADH ○ Increased ADH = Increased reabsorption of water into circulation…. ■ Which creates excess fluid volume in extracellular space ■ If water intake exceeds the reduced urine output, the ensuing water retention leads to hyponatremia ■ A combination of symptoms, commonly occurring together to constitute a distinct clinical picture ○ Key to understanding the patho, S/S & Treatment of SIADH is awareness that the hyponatremia… ■ Is a result of excess of water rather than sodium deficiency ■ Physical findings can be seen in severe or rapid-onset hyponatremia & can include… ● Confusion ● Disorientation ● Delirium ● Generalized muscle weakness ● Myoclonus ● Tremor ● Asterixis ● Hyporeflexia ● Ataxia ● Dysarthria ● Cheyne-Stokes respiration ● Pathologic reflexes ● Generalized seizures ● Coma ○ Defined by Classic Bartter-Schwartz criteria, summarized as follows: ■ Hyponatremia ■ Continued renal excretion of sodium ■ Urine less than maximally dilute ■ Absence of clinical evidence of volume depletion ■ Absence of other causes of hyponatremia ■ Correction of hyponatremia by fluid restriction ○ Symptoms: ■ Neurological status ■ Headache ■ Muscular weakness ■ Nausea/Vomiting ■ Tachycardia ■ Hypotension ■ Diarrhea ■ Lethargy ■ Confusion ■ Seizures ■ Depression ■ Dry skin and mucosa ■ Can be missed in elderly (most common cause of hyponatremia) ○ Causes include…. ■ Head trauma ■ Adverse medication reactions ■ Cancer ■ Pain ■ Stress ○ To Diagnose: Labs that may be considered…. ■ CT-Scan or MRI of the head Detects... ● Cerebral edema r/t complication of SIADH ● CNS disorder responsible for SIADH ● To rule out other potential causes of change in neurologic status ● Treatments and Nursing Considerations: ○ Patient interventions are for in hospital & discharge plan for home regime & f/u care ■ Upon Reviewing Interventions for in pt. note/confirm parts to include in discharge plan also.. ○ In an emergency settings: ■ Aggressive treatment of hyponatremia should always be a weighed risk ■ If status becomes more severe: Treatment intervention times change & actions may be more aggressive ○ Medications for SIADH patients along with medications for presenting symptoms ■ Treat underlying cause ■ Fluid restrictions 800-1,000ml/d ■ Hypertonic IV fluids if severe ■ Furosemide to promote diuresis ■ May need supplemental Potassium ○ Monitor ■ I/O’s ■ Weights ■ Urine specific gravity ■ LOC ■ Electrolytes (hyponatremia) ○ Lower HOB (may reduce ADH release) ○ Seizure precautions ○ Check fluid overload ■ Potential heart failure and pulmonary edema) Endocrine Gland-Thyroid Gland Thyroid gland: ● ● ● ● ● ● ● ● ● ● ● ● One of the largest endocrine glands in body Made up of 2 connecting lobes (resembles butterfly) Found at front of neck, immediately below larynx/adam’s apple Thyroid Gland Controls…. ○ How fast body uses energy ○ Makes protein ○ Body’s sensitivity to other hormones Participates in these processes by producing Thyroid Hormones: ○ Triiodothyronine (T3) and thyroxine (T4): Principal hormones ○ These regulate growth & rate of function of many other systems in the body. ○ T3 and T4 are created from iodine & tyrosine Thyroid also produces calcitonin (role in calcium metabolism) Highly vascularized The gland cannot produce hormones on its own. Needs assistance of pituitary gland: ○ Which creates thyroid stimulating hormone (TSH) ○ A nonfunctional pituitary gland eventually leads to thyroid-gland-related issues ○ TSH will either trigger the production of thyroxine or triiodothyronine ■ If TSH is not at the right levels, too much or too little of either hormone will be made ○ Which is regulated by thyrotropin-releasing hormone (TRH) produced by the hypothalamus T3 & T4 help the body to produce & regulate the hormones ○ Adrenaline (epinephrine) ○ Dopamine Hormones are chemical substances that help control certain cells and organs. ○ Epinephrine/Adrenaline & Dopamine ○ Active in many physical and emotional responses, including… ■ Fear ■ Excitement ■ Pleasure Other hormones from this gland: ○ Help regulate metabolism (process which calories and oxygen converted into energy) ○ Without functioning thyroid, body unable to... ■ Break down proteins ■ Process carbohydrates & vitamins In Healthy patient: ○ Gland is not visible yet can be palpated as a soft mass ○ Examination of thyroid gland by locating the thyroid cartilage & passing fingers up and down: ■ Examining for abnormal masses & overall thyroid size. ■ One hand on each side of trachea, gently displacing thyroid tissue moving back & forth ● Checking for masses ■ Next, 2 Lobes of gland compare size & texture using visual inspection & manual/bimanual palpation ■ Finally, ask the patient to swallow to check for mobility of the gland ● Many clinicians find that having the patient swallow water helps this part of the examination ● In Healthy state: Gland is mobile when swallowing (gland & whole larynx moves superiorly) ● Individuals can suffer from overactive or hyperthyroid function or hypothyroid Hyperthyroidism: ● Excess production and release of thyroid hormone ● Thyrotoxicosis ○ Hypermetabolic effect of excess T3, T4 ○ Signs of Hyperthyroidism ○ Heat intolerance ○ Palpitations, chest pain, dyspnea ○ Vision changes ○ Fatigue ○ Increased libido ○ Psychosocial changes ● Causes: ○ Thyroiditis: ■ Thyroid gland inflamed for unknown reasons ■ Inflammation causes excess thyroid hormone stored in the gland to leak into bloodstream ■ Rare type of thyroiditis, known as subacute thyroiditis: ● Causes pain in the thyroid gland ■ Other types: painless and may sometimes occur after pregnancy (postpartum thyroiditis). ○ Toxic Adenoma: ■ This form of hyperthyroidism occurs when one or more adenomas of thyroid produce too much T-4 ■ Adenoma: is A part of the gland that walled itself off from rest of the gland ● Forming noncancerous (benign) lumps that may cause an enlargement of the thyroid ● Not all adenomas produce excess T-4, ● Doctors aren't sure what causes some to begin producing too much hormone. ○ Toxic multinodular Goiter: ■ Is swelling and inflammation of thyroid gland ■ Can result d/t numerous conditions ● Some associated with normal levels of thyroid hormones ● Both inflammation & tumors can cause thyroid enlargement ■ Sometimes entire gland enlarged in symmetrical pattern ■ Goiters, Nodules, Enlargement may develop only in one part of gland ■ When very large, can cause symptoms r/t pressing on adjacent structures ex:Esophagus & Trachea ○ Graves’ disease: ■ Normally Immune system uses antibodies as protection from.. ● Viruses, bacteria & substances that invade the body ■ With Graves, antibodies mistakenly attack thyroid & occasionally… ● Attack tissue behind eyes “Graves ophthalmopathy” ● Attack the skin often lower legs, over the shins “Graves Dermopathy” ● Graves’ Disease causes ○ More common in women ○ Thyrotoxicosis ○ Autoimmune ○ Remissions and exacerbations ○ May destroy thyroid gland cause hypothyroidism ● Assessment ○ Goiter is enlarged thyroid ○ Bruits ○ Exophthalmos-bulging eyes ■ Not common in non-graves hyperthyroidism ■ Fat and edema in tissue behind eye ■ Potential vision loss ● Symptoms-related to hypersecretion of thyroid hormones and hypermetabolic state ○ Increased BMR-weight loss ○ Nervousness, insomnia, tremor, hyperreflexia, progressing to coma ○ Increased HR, hypertension, cardiac changes (arrhythmias), palpations, ○ murmurs (due increased CO), angina, potential CHF ○ Reproductive changes, menstrual irregularities, decreased libido, gynecomastia ○ Skin changes-warm, moist/damp, hair loss, brittle nails ○ Elderly may have atypical symptoms including mental changes Diagnostics: ● ● ● ● ● Imagery Physical examination Blood samples Radioactive uptake Ultrasound Treatment for Exophthalmos: ● ● ● ● ● Patient teaching for changes in condition Artificial tears (moisturize) Sleep with HOB elevated (decrease ocular pressure) Sleep covered eyelids with (soft covering) avoid scratching, damaging to lids Diuretics and steroid therapy Thyroid Crisis/Thyroid Storm ● ● ● ● ● Life threatening Often precipitated by stress in person with hyperthyroid condition Severe hypermetabolic state Hyperthermia Cardiovascular symptoms-tachycardia, dyspnea, chest pain, heart failure, edema, progress to collapse in system and shock ● GI- abdominal pain, N/V, diarrhea ● Neuro- delirium, seizures, somnolence ● Progress to coma and death Thyroid Crisis Care and Treatment ● ● ● ● ● ● ● ● Reduce temperature (no aspirin) Oxygen Supportive Care Treat symptoms Quiet, calm environment Fluid and electrolyte balance Eye care Medications ○ Radioactive Iodine 1311- treatment of choice administered and collects in gland, some tissue is destroyed by radiation, outpatient, contra to pregnancy, ○ Beta Adrenergic Blockers-relieve symptoms excess stimulation SNS, (Propranolol) Inderal or Atenolol (Tenormin) if underlying cardiac disease or asthma ○ IV fluids with Dextrose ○ Hydrocortisone ○ Antithyroids-PTU or Methimazole (Tapazole); Propylthiouracil (PTU); inhibit synthesis of thyroid hormone, PTU blocks conversion T4 and T3. Not permanent changes, disease may reoccur ○ Iodine Salts large dose inhibit synthesis of T3 and T4, blocks their release into circulation, give drops in juice or water and drink with straw, not used for long term therapy, effect seen 1-2 weeks Surgery ● ● ● ● If unresponsive other therapy Large goiter Cancer Establish euthyroid (normal thyroid) state with surgery and in conjunction ○ Prevent thyroid crisis ○ Antithyroid medications and iodine ○ Iodine reduces vascularity and potential bleeding ○ Control cardiac conditions Preoperative Teaching ● ● ● ● Cough and deep breathe exercises Explain neck support, hold head with both hands when moving May have hoarseness should resolve Address anxiety ● Dressing care Procedure ● ● ● ● ● Total thyroidectomy Partial thyroidectomy Endoscopic thyroidectomy-less scarring and faster recovery Quickly reduces circulation levels of T3 and T4 Need to retain the parathyroid glands and blood supply Postoperative Care ● ● ● ● ● Monitor airway Support head and neck Monitor bleeding and edema/check posterior dressing and edema and Hematoma formation Assess voice quality and respirations Stridor (harsh sound with respirations due to airway partial obstruction) c/b due to edema, hematoma, or vocal cord paralysis, this is an emergency ● Hypocalcemia Surgery Complications ● ● ● ● ● Hypothyroidism Bleeding Damage to laryngeal nerve o Hypoparathyroidism Thyroid crisis Infection Nursing Considerations and care ● ● ● ● ● ● ● ● ● ● Vitals respiration and voice Check bleeding or airway compression o Changes in breathing patterns Neck swelling Drooling Inability to swallow Excess blood on dressing Choking Elevated HOB Pain Monitor for signs of hypocalcemia ○ Parathyroid regulates calcium ○ Related to trauma or removal of parathyroid with surgery ○ Monitor for 72 hours post op ○ Numbness and tingling in finger and toes and around mouth Anxiety and irritability ○ Trousseau’s and Chvostek’s sign ○ Seizure and convulsions ○ Cardiac arrhythmias ○ Muscle twitching, tetan ○ Treatment for Hypocalcemia ■ 10% calcium gluconate or 10% calcium chloride IV ■ Dilute D5W and administer slowly 1-3ml/min ■ Do not dilute with NS, sodium encourages calcium loss ■ Calcium Chloride irritating to tissue with infiltration ■ Monitor serum calcium ■ Monitor signs and symptoms ■ Monitor EKG Nutrition Care ● ● ● ● Adequate intake for body needs o Increased Kcal Adequate protein Avoid caffeine and stimulants Avoid high fiber Discharge Instructions ● Follow-up care ● ● ● ● ● Nutrition Weight gain/loss Adequate iodine intake Exercise stimulates thyroid Environmental temperature Hypothyroidism ● ● ● ● Most common disorder US Common in women 30-60 Due insufficient circulating thyroid hormone Decreased thyroid hormone may be related to ○ Hashimoto’s thyroiditis ○ Damage of the thyroid due to surgery or radiation ○ Lack of dietary iodine which is needed to form thyroid hormone Manifestations: ● ● ● ● ● Symptoms related to decrease of BMR Decreased Level circulating thyroid hormone Decreased metabolism cause release stimulating hormones especially TSH TSH cause thyroid gland to enlarge goiter impaired cellular changes occur causing non-pitting edema called myxedema ● Myxedema ○ Non-pitting edema, doughy skin, depressed expression, enlarged tongue and feet Symptoms of Hypothyroidism ● Subtle and occur slowly-fatigue and weight gain ● Menstrual irregularities or depression ● Difficult attributed from aging changes (misinterpreted as dementia in elderly) Assessment/Diagnostic of hypothyroidism ● ● ● ● ● ● ● TSH high seen with normal pituitary function and thyroid hypofunction Free T4 active thyroid hormone low Serum T3 and T4 serum low Elevated blood cholesterol and lipids Iodine levels Imagery Risk cardiovascular disease Treatment Medications ● Standard treatment: Hormonal replacement therapy ● levothyroxine (Synthroid, Levothroid) ○ T4 Replacement ○ Restores adequate hormone levels reverses signs of hypothyroidism ○ 0.025-0.05mg increase/titrate if needed based on TSH/labs (yearly checks) ○ Lifelong replacement ○ Patient teaching regarding medications ○ Take on empty stomach ○ Take in the AM ○ SE: anxiety, insomnia, changes O2 demand ● Liothyronine (Cytomel) ○ T3 Replacement ○ Not for long term therapy ○ Used initially due to rapid onset of action for myxedema ○ 1-2 weeks after start of treatment pt. ■ Feels less fatigued ■ Gradually lowers cholesterol levels elevated by disease ■ May reverse weight gain ● Determining proper dosage may take time ○ To determine the right dosage of levothyroxine ○ Initially, Doctor checks your level of TSH ○ After two to three months ■ If pt. Has coronary artery disease or severe hypothyroidism, Dr. may start treatment with a smaller amount of medication and gradually increase the dosage ■ Progressive hormone replacement allows your heart to adjust to the increase in metabolism. ■ Pt. talks to Dr. if: ● They eat large amounts of soy products ● High-fiber diet ● Takes other medications such as…. ○ Iron supplements ○ Cholestyramine ○ Aluminum hydroxide: found in some antacids & Calcium supplements Parathyroid Disorders Parathyroid Gland: ● Location: ○ Four small endocrine glands ○ In the neck on the back of the thyroid gland ○ Not visible, not able to palpate during neck examinations ● Produce parathyroid hormone (PTH) ● Maintain body’s calcium level and phosphorus level under close parameters ● Support serum Ca and Phosphorus provide electrical energy for nervous system, muscular system and skeletal strength ● Parathyroid DisorderS ○ Hyperparathyroidism ○ Hypoparathyroidism ● Parathyroid regulation ○ Depend on the calcium levels in the blood ○ Calcium levels in blood kept at narrow limits ○ When blood calcium levels are too high, hypercalcemia, and low levels of phosphorus-the parathyroid gland-produces less PTH hormone-also levels cause thyroid gland to release calcitonin; causing the bone to store calcium pulling from the excess detected in the blood. ○ When calcium levels are low-the release of PTH is initiated; calcium levels are raised by releasing calcium stored in the bones, and increasing the absorption of calcium from the small intestine to bloodstream aiding to increase calcium levels. Hyperparathyroidism ● Benign adenomas ● Rare link to cancer ● Frequent in women, 60 years and older ○ Excess PTH ○ PTH regulation problem with reabsorption of calcium, renal reabsorption, excretion of phosphorus, and VIT D activation ○ Excess PTH causes high serum calcium, low serum phosphate, hypercalciuria, ○ Decreased bone density ● Signs and Symptoms ■ General effects: weakness, fatigue, N/V, ■ Said to see “moans, groans, stones, bones, and psychic overtones” ● Diagnostics ○ Blood serum calcium, PTH, phosphorus, and renal labs ○ Bone density ○ Imaging ● Treatments ● Medication, surgery, and long term monitoring ○ Moderate calcium intake ○ Adequate fluid intake ○ NS IV, fluid management, stimulate kidney to promote calcium excretion ○ Avoid certain diuretics ○ Patient teaching s/s of increased calcium levels ○ Medications ■ Etidronate (Didronel)-reduce bone reabsorption, reduce hypercalcemia-Caution GI problems, avoid milk, milk products and antacids ■ Calcitonin (Calcimar, Cibacalcin) ■ Calcimimetics-turns of secretion of PTH, secondary to kidney failure ● Surgery ○ Minimally Invasive Radio guided Parathyroidectomy ○ Pre-Op teaching-Voice changes, hospital stay timeframe ○ Use of imaging to ID glands, visualize problem ○ Post- Op ■ Vital signs ■ Hemodynamic/Cardiac monitoring ■ Gag reflex ■ Voice assessment ■ Hypocalcemia-tetany and muscular irritability ■ Lab results and interpretations r/t narrow parameters Fluid balance/hydration ■ Wound care ■ Patient teaching discharge plan and check adverse S/S Hypoparathyroidism ● ● ● ● ● ● Decreased function of parathyroid glands Underproduction PTH Thyroidectomy with removal/trauma to parathyroid glands Monitor for signs hypocalcemia-numbness/tingling of fingers and toes, periora numbness, tetany, Trousseau’s and Chvostek’s responses, and cardiac symptoms Diagnostics ○ BMP, serum calcium, phosphorus, PTH, Magnesium levels ● Treatments and care ○ Diet-High in calcium –low in phosphorus ○ *milk, cheese and milk products can be high in phosphorus ○ Patient teaching ○ Hypomagnesemia-signs and symptoms, in conjunction low calcium ● Medications ○ Vitamin D supplements, calcitriol (Rocaltrol) ○ IV therapy calcium gluconate ○ Thiazide diuretic (HCTZ)-Metolazone ○ * Patient at risk for renal calculi Endocrine System-Adrenal Gland Disorders Location ● ● ● ● Rest top of each kidney Small in size Supports development and growth, ability deal with stress, and kidney function Cortex and Medulla Cortex ● Produces steroid hormones (Glucocorticoids) regulate metabolism and body stress response ● Mineralocorticoids regulate sodium and potassium balance Medulla: ● Produces epinephrine and norepinephrine Cause of Disorders: ● ● ● ● ● ● Cushing’s syndrome, Addison’s Disease, Pheochromocytoma, and Pituitary Aldosteronism Autoimmune, Medications Adrenal hyperplasia, Cancer, and Tumors Infection Surgery Radiation Damage Etiology Cushing ’s syndrome and Cushing’s Disease ● ● ● ● Excess corticosteroids, primarily glucocorticoids Exogenous developing external steroids (ordered medications) effect syndrome Endogenous has internal cause or origin-Cushing’s Disease ACTH producing pituitary tumor, Tumor adrenal cortex ● ACTH secreting malignancy (outside adrenal gland-GI, lung cancers ● Manifestations related to excess corticosteroids, effect entire body Include: ○ weakness, muscle wasting ○ Negative nitrogen balance ○ Hypokalemia and hypernatremia ○ Hypocalcemia and hypercalciuria ○ Osteoporosis ○ Decreased immune response ○ Severe depression, cognitive difficulty, emotional instability, fatigue, sleep disorder Diagnostics ● ● ● ● ● ● Imagery Saliva test ACTH stimulation Urine Blood levels Cortisol levels Treatments ● ● ● ● ● ● Normalize hormone levels Reduce or remove exogenous steroids (titrate to remove from steroids) Surgery: related tumor Adrenalectomy Treat underlying malignancy Medications ○ ketoconazole (Nizoral) ○ mitotane (Lysodren) ○ metyrapone (Metopirone) ○ Korlym (mifepristone) Addison’s Disease- Adrenocortical insufficiency ● Hypofunction of adrenal cortex ● Corticosteroids, mineralocorticoid, and androgens are deficient ● Causative-autoimmune disease ● ● ● ● Infection impairing/destroying adrenal function Secondary lack of pituitary ACTH or exogenous administration of steroids “No problem” noticed until around 80% of adrenal function lost Advanced disease death may occur before diagnosis Symptoms ● Primary ○ Weakness ○ Nausea ○ Anorexia ○ Weight loss ○ Hypotension ○ Emotional behaviors ● Dehydration, hyponatremia, hyperkalemia, hypercalcemia, hypoglycemia, and abdominal pain ● Addison’s Crisis ○ Appears to 25% of patients upon original diagnosis ○ Severe pain, lower back, abdomen, or legs ○ Severe vomiting and diarrhea; dehydration follows ○ Hypotension ○ Loss consciousness ○ A medical emergency!! Nursing Care ● ● ● ● ● ● ● Treat acute episodes Protect patient from stress-temperature changes, environmental noise, and lighting Monitor VS, fluid end electrolytes Discharge teaching (symptom recognition) Medications Therapy to handle stress reduction which may include hormonal replacements Patient needs to carry emergency hydrocortisone and wear ID bracelet Hyperaldosteronism ● ● ● ● ● ● ● Excessive aldosterone secretions Hypertension, hypokalemic, metabolic alkalosis Edema not present frequently Symptoms include: headache, muscular weakness, fatigue, cardiac arrhythmias paresthesia, nocturia, and polydipsia Diagnostic-:ab test, X-ray, CT, and MRI Treatment: ○ removal of adenoma (adrenalectomy) ○ Spironolactone (aldactone) spare loss of potassium ● Nursing Care ○ I/O’s, fluid and electrolytes, VS, (BP, HR) ○ Treat symptoms ○ BP may not be well controlled even after surgery Pheochromocytoma ● ● ● ● ● Neuroendocrine tumor of the (medulla) adrenal gland Functional chromaffin cells produce excessive catecholamines These tumors can be benign or malignant Can be in the medulla or other parts of body Malignant cells in other parts may produce catecholamines that may not originate in adrenal gland Symptoms ● Severe, episodic hypertension with severe headache, tachycardia, profuse diaphoresis ● Symptoms due to SNS stimulation Diagnostic ● 24 hour urine (metanephrines) and 24 hour urine VMA (vanillylmandelic acid), ● Imaging (CT scan, MRI) ● ● Treatment ○ Hypertensive episode may result in death ○ Medications Treat symptoms ○ Alpha-adrenergic blocking agents-phetolamine mesylate (Regitine, Rogitine) preventing hypertension due to elevated levels of epinephrine or Norepinephrine ○ Medications used prior and during surgery ● Surgery ○ Removal tumor adrenalectomy ● Nursing Care ○ Pre, Intra, Post surgery Care ○ Monitor BP ○ Calm restful environment ○ Limit activity ○ Support ID of stressors ○ Do not palpate abdomen ○ Monitor I/O’s, weights, hydration, etc.
