ENDOCRINE SYSTEM
Revised May, 2008MC
From Saunders Intro to Med/Surg Nursing, 4th Edition
FUNCTIONS
Growth and development
Energy Metabolism
Reproduction
Fluid and electrolyte imbalance
Homeostasis
2 TYPES OF GLANDS
ENDOCRINE
EXOCRINE
Thyroid Gland
located in lower portion of neck
Major role in metabolism and G & D
Thyroid hormone ( thyroxine or T4)
Triiodothyronine ( T3)
Both ^ the bodies rate of metabolism
Calcitonin regulates serum calcium levels
Health hx and PE for pts w/ thyroid disorders
Assess for changes in:
•
Weight
•
Energy level
•
Sleep patterns
•
Personality & emotional state
Page 1 of 15
•
Tolerance to heat or cold
Thyroid Function Tests
1. Thyroid Scan
-radioactive iodine given IV or PO
-X-ray taken to detect pattern of uptake
-”Hyperactive Thyroid” absorbs lg. Amts of iodine
-”Hypoactive Thyroid”or “Thyroid Malignancy” if small amts absorbed
2. Radioactive Iodine Uptake (RAIU)
Radioactive iodine is given PO
Test measures thyroid gland activity
A normal thyroid gland will remove 15-45% of iodine w/i 24 hrs.
Test is painless
Important to wash hands w/ soap & H20 for 24 hrs after voiding
3. Thyroid Ultrasound
Det. Size, shape & position
Abnormal findings indicate cyst/solid nodulecancerous
Non-invasive, short duration test.
4.
Laboratory Studies
Very sophisticated and specialized
T3
T4 (free and total)
TSH*
TRH stimulation test
THYROID DISORDERS
1. HYPERTHYROIDISM
Page 2 of 15
“GRAVES DISEASE” or “toxic diffuse goiter”
Increased synthesis & production of thyroid hormones ( T3 & T4)
Autoimmune disorder
Nrsg. Assessment
Rapid pulse with arrythmias
Elev. Systolic BP
Wm. Skin, elev. Temp
Diaphoresis & heat intolerance
Hand tremors
weight loss & fatique
Amenorrhea
Exophthalmos
Intense nervousness
Thyroid storm/crisis
Nsg Dx: Disturbed sleep pattern r/t metabolic disturbance
MEDICAL TREATMENT
Goal is to decrease excessive thyroid hormone production
Inderal
Tapozole
Lugol’s solution
Radio Active Iodine
SURGICAL TREATMENT
Thyroidectomy or subtotal thyroidectomy
Preop Teaching is important !
1. Drsg on front of neck
Page 3 of 15
2. Avoid straining neck, support head
3. Turn/deep breath, limit coughing
Nursing Post Op Care….
 Assess respiratory status
 Elevate HOB
 Level of consciousness
 Wound drng
 Voice quality
 Neuromuscular irritability (tetany)
 Chvostec’s Sign
 Trousseau’s Sign
Hypothyroidism
1. Cau. By T4 deficiency
2. Metabolism is slowed
3. Congenital FormCretinism
4. Adult Form Myxedema
Signs & Symptoms
Slowing of physical & mental activity
Forgetfulness, Headache, lethargy
Weight gain, constipation
Dry skin, generalized &/or facial edema
Signs and Symptoms may be more subtle in elderly or be masked by other diseases.
Thyroid function test should be routine in elderly
Encourage the elderly to report changes or new sx. This is necessary to provide the best care
Page 4 of 15
Nursing Diagnosis for Hypothyroidism
Risk for impaired skin integrity related to dry skin.
Constipation related to decreased peristalsis
Not: Imbalanced nutrition: decreased body requirements related to intake less than metabolic needs
Patients may look depressed, weary, and always complain of being cold
Trmt. For Hypothyroidism
1. Synthroid
2. Cytomel
3. Pts. Require lifelong hormone replacement therapy & should be monitored to evaluate the
response to therapy
May lead normal life with treatment
Must be taught s/s of hyperthyroidism*
Lab test are frequently done to monitor status
Nrsg. Considerations
Myxedema Coma
Respiratory Depression
Monitor Cardiac function
Review Nrsg Interventions
GOITER
Term used to describe enlargement of the thyroid gland
Usually caused by a dietary deficiency of iodine
Tx depends on thyroid hormone production and degree of enlargement
TREATMENT
•
Iodine 2-3 wks, repeated 3-4/x year
•
Does not cure goiter
•
Iodized table salt easiest way to inc. iodine in diet
Page 5 of 15
•
Surgery needed w/ inc. pressure on airway
CA OF THYROID
1. May present as painless lump
2. Bx done to diagnose
3. Treatments include: Total Thyroidectomy, radioactive iodine trmts, and thyroid replacement
therapy
PARATHYROID GLAND DISORDERS
DIAGNOSTIC TESTS
Blood and urine studies
Radiographs
EKG
HYPERPARATHYROIDISM
1. High levels of PTH  elevated bld calcium levels ( hypercalcemia)
2. Pathologic (spontaneous) fractures(from Ca shifting into blood)
3. Renal calculi and obstruction
4. Dysrhythmias and hypertension
5. Nsg Dx: Impaired urinary elimination r/t urinary calculi
SIGNS & SYMPTOMS
 Elevated serum calcium levels
 weakness, lethargy, depression, anorexia and constipation
 Poor muscle tone, bone pain, HTN, fractures
 Cardiac dysrhythmias, wt. Loss and urinary calculi
TREATMENT
•
Surgery if tumor is cause
•
Inc. fluids dilutes urine
•
Phosphates to reduce calcium level
Page 6 of 15
•
Limit dietary calcium
•
Calcitonin
HYPOPARATHYROIDISM
 Deficiency of PTH
 Low serum calcium (hypocalcemia)
 Common cause – accidental removal
 Classic signs +Chvostek’s and Trousseau’s signs
SIGNS & SYMPTOMS
1. Painful muscle spasms (hands, feet)
2. Fatigue and weakness
3. Tingling/twitching of face
4. Mental/emotional changes
5. Dysrhythmias
6. Nsg Dx: Decreased Cardiac Output r/t hypocalcemia
TREATMENT
Oral calcium salts
Vitamin D
Aluminum hydroxide
ANTERIOR PITUITARY GLAND DISORDERS
Diagnostic Tests
Refer to page 856 Table 42-2
HYPERPITUITARISM
Over production of GH & prolactin
Most often caused by an adenoma
Gigantism
Page 7 of 15
Acromegaly
A. Gigantism
1. Affects infants/children
2. Cau. Proportional over-growth of “all” body tissues
3. May be over 8ft. By adulthood
B. Acromegaly
1. Sx occur in 4th or 5th decades
2. Enlargement of hands and feet
3. Thickened ears, nose, jaw, forehead, bulbous nose
4. Heart, liver & spleen enlarge
DIAGNOSIS
Confirmed by cranial x-rays
CTS
Elevated GH levels
GTT most reliable test for acromegly
MED/SURGICAL TRMT.
Radiation therapy
Parlodel and Sandostatin drug therapy
Hypophysectomy
HYPOPITUITARISM
•
Inadequate secretion of GH
MANIFESTS AS:
1. Dwarfism
or
2. Panhypopituitarism
Page 8 of 15
Dwarfism
Occurs early in life
Ht is 40% below normal
Proportional physical characteristics
Delayed or absent sexual maturation
Higher frequency of mental retardation
Shorter life span
Panhypopituitarism
•
Very rare disease
•
Tumor, infections, post-partum emboli, damage or removal of pituitary gland
•
Simmonds cachexia develops as result
Posterior Pituitary Disorders
Characterized by deficient or excess amounts of ADH (anti diuretic hormone) or “vasopressin”
ADH helps to maintain fluid balance
^ ADH levels = low u/o or fluid retention
Low ADH levels= more H2O passes through kidneys than normal
Diabetes Insipidus
Results from underproduction of ADH*
Char by large volumes of dilute urine (polyuria)
Urine will be very dilute
SIGNS & SYMPTOMS
Copious amounts of very dilute urine, may exceed 30 liters/day
Dehydration
Thirst
hypotension, tachycardia, dizziness weakness, fainting
Page 9 of 15
Medical Treatment
VASOPRESSIN (PITRESSIN)
SQ, IM or nasal spray
Refer to pg. 859 Table 42-3
Nursing Interventions
I&O
IV Fluid Replacement
Encourage oral intake
Weigh daily
Fall Precautions
VS
SIADH (Syndrome Inappropiate Anti-Diuretic Hormone)
•
Opposite of DI
•
Excessive secretion of ADH
•
Results in an inability to excrete dilute urine
•
Fluid retention & water intoxication occur(?cardiac patients)
•
Na deficiency
SIADH
Causative Factors
Brain trauma
Brain tumors
Infections
SIADH
Kidneys retain excessive water. Plasma volume expands.
Leads to:
Page 10 of 15
^BP
Hyponatremia
Na remains in intracellular causing H20 intoxication to develop
SIGNS & SYMPTOMS
•
Weakness, muscle cramps, twitching (r/t low Na)
•
Anorexia
•
Nausea, diarrhea, irritability, HA (r/t H2O retention)
•
Weight gain without edema
H2O Intox and CNS
Change in LOC
Seizures
Coma
Medical Treatment
Intended to correct the cause
Promote elimination of excess water
Lithium Carbonate or demeclocycline (Blocks effect of ADH)
Strict fluid restrictions, especially for cardiac patients
Hypertonic NS (3%) pulls Na out of intracellular space and int extracellular fluids to raise serum NA
High Na diet
ADRENAL GLAND DISORDERS
ADRENAL GLANDS******
CONTAIN 2 PARTS:
Cortex secretes steroid hormones (mineralocorticoids and glucocorticoids), androgens, and
estrogens
Medulla  secretes epinephrine & norepinephrine
Aldosterone*
Page 11 of 15
Most important mineralocorticoid
Regulates Na and K
Keeps blood volume balanced
Cortisol
Most important glucocorticoid
Anti-inflammatory
Immune response
Controls emotional state
ACTH*
ADRENAL CORTICOIDTROPIC HORMONE
Sent to adrenals by pituitary
Stimulates production of hormones
Serum ACTH levels are checked to see if Pituitary gland is sending messages to adrenals
DISORDERS OF ADRENAL GLANDS
Addisons Disease
&
Cushings Syndrome
Addison’s Disease
Decreased functioning of the adrenal cortex hormones (cortisol & aldosterone)
Occurs in 1 per 100,000 people
Decrease of ACTH
TB
Fungal infections
Known as an autoimmune disease (tissue destroyed by own antibodies)
SIGNS & SYMPTOMS
Page 12 of 15
Weakness, lethargy and malaise
Skin hyperpigmentation (looks sun tanned)
Light headedness upon rising
Due to hypovolemia (orthostatic
hypotension)
Have patient move slowly, help getting out of bed
Decrease tolerance to minor stress
Variety of GI complaints
Salt cravings
Acute adrenal crisis also known as Addisonian crisis…*
-may occur after adrenal surgery, pituitary destruction or abrupt withdrawal of steroids
-life threatening because of fluid and electrolyte imbalances
Caused by abruptly stopping steroids or stress, Ex: infections or illness
Medical diagnosis of Addison’s disease
Clinical signs and symptoms
Variety of lab findings
Low cortisol,low glucose,low Na,high K
ACTH stimulation test
High = Adrenals at falt
Low= Pituitary at fault
EKG
Peaked T waves, high K
X-rays
Medical Treatment
Mainstay of treatment is lifelong replacement therapy with glucocorticoids (Cortisol) and
mineralocorticoids (Aldosterone)
See pg 872 Table 42-8
Page 13 of 15
CUSHINGS SYNDROME
(Combination of variety of symptoms)
Results from overproduction of adrenal cortex hormones
Endogenous cause tumor
Exogenous cause prolonged use of high doses of corticosteroids
RA, Lupus, Asthma, Polymyalgia Rheumatica
SIGNS & SYMPTOMS
Moon face
Abdomen is heavy & pendulous (trunchal obesity)
Arms/legs are thin
Bones soften (osteoporosis)
Delayed wound healing
Irritability or Mood swings
Medical Diagnosis
Physical s/s
Lab Studies
Dexamethasone Test
Should show drop of cortisol and steroid levels, compared to baseline. If not, Cushing’s is a
possibility
X-rays if tumor is suspected
Medical treatment
Varies as to the cause
Prescribed steroids
Benign adrenal tumors removed
ACTH causing pituitary tumors removed (surgery or radiation)
Page 14 of 15
Drug therapy (Lysidren, Nizoral,Cytadren) could cause Addisonian crisis
If bilateral surgical removal of adrenal glands  patient is treated for Addison’s Disease….
Lab Stuff
Addison’s Disease
Hypoglycemia, Hypo Natremia, Hyperkalemia
Cushing’s Syndrome
Hyper glycemia, Hypernatremia, Hypokalemia
NRSG. INTERVENTIONS
 Protect from injury
 Reduce risk for infection
 Assess skin integrity
 Prom. Good hygiene
 Mon. wt. Dly, VS, chk. Lytes & sugar
Now, stand up and stretch as we get ready to jump into Diabetes Mellitus
Page 15 of 15