ENDOCRINE SYSTEM. Objectives Describe the functions of the endocrine glands and their hormones. Describe the functions of the endocrine glands and their.

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1 ENDOCRINE SYSTEM

2 Objectives Describe the functions of the endocrine glands and their hormones. Describe the functions of the endocrine glands and their hormones. Describe the relationship between the hypothalmus and the pituitary glands. Describe the relationship between the hypothalmus and the pituitary glands. Identify the diagnostic tests used to determine alterations in function in each of the endocrine glands. Identify the diagnostic tests used to determine alterations in function in each of the endocrine glands. Compare hyper/hypo pituitarism (thyroidism, parathyroidism, Addison’s, Cushing syndrome, gigantism, dwarfism, SIADH, diabetes insipidus), causes, clinical manifestations, management and nursing interventions. Compare hyper/hypo pituitarism (thyroidism, parathyroidism, Addison’s, Cushing syndrome, gigantism, dwarfism, SIADH, diabetes insipidus), causes, clinical manifestations, management and nursing interventions. Identify teaching of patients needing steroid therapy. Identify teaching of patients needing steroid therapy.

3 Endocrine System The endocrine system (endo, within) is composed of glands that produce, store and secrete hormones which are carried by the blood to act on target tissue, regulating multiple body processes. (ductless) The endocrine system (endo, within) is composed of glands that produce, store and secrete hormones which are carried by the blood to act on target tissue, regulating multiple body processes. (ductless) The endocrine, nervous and immune system work together to create a precise control over all body organs and metabolic processes. The endocrine, nervous and immune system work together to create a precise control over all body organs and metabolic processes.

4 Hormones Classified as lipid-soluble and water- soluble (protein-based) Classified as lipid-soluble and water- soluble (protein-based) Lipid-soluble hormones = steroid hormones (all hormones produced by the adrenal cortex and sex glands) and thyroid hormones Lipid-soluble hormones = steroid hormones (all hormones produced by the adrenal cortex and sex glands) and thyroid hormones Water-soluble = all other hormones Water-soluble = all other hormones

5 Principal functions of hormones related to… Reproduction Reproduction Response to stress and injury Response to stress and injury Electrolyte balance Electrolyte balance Energy metabolism Energy metabolism Growth and maturation Growth and maturation Fetal growth and development and nourishment of the newborn Fetal growth and development and nourishment of the newborn Aging Aging

6 The Endocrine & Nervous System The effects of hormones secreted by the endocrine system affect the nervous system and are in turn mediated by the nervous system. The effects of hormones secreted by the endocrine system affect the nervous system and are in turn mediated by the nervous system. Example: adrenal medulla secretes substances – epinephrine & norepinephrine – that act as neuro transmitters causing an effect of the sympathetic nervous system. Example: adrenal medulla secretes substances – epinephrine & norepinephrine – that act as neuro transmitters causing an effect of the sympathetic nervous system.

7 Nervous system The nervous system exerts point-to-point control through nerves, similar to sending messages by conventional telephone. Nervous control is electrical in nature and fast.

8 Hormones travel via the bloodstream to target cells The endocrine system sends its hormonal messages to essentially all cells by secretion into blood and extracellular fluid. Like a radio broadcast, it requires a receiver to get the message - in the case of endocrine messages, cells must bear a receptor for the hormone being broadcast in order to respond.

9 Endocrine System & Immune System There is also close interaction between the endocrine and immune systems. There is also close interaction between the endocrine and immune systems. Example: Glucocorticoids play a major role in the body’s response to stress. Example: Glucocorticoids play a major role in the body’s response to stress.

10 PRINCIPAL ENDOCRINE GLANDS Pituitary (anterior and posterior) Pituitary (anterior and posterior) Thyroid Thyroid Parathyroid Glands Parathyroid Glands Adrenal (medulla and cortex) Adrenal (medulla and cortex) Pancreas Pancreas Gonads (ovaries & testes) Gonads (ovaries & testes) ( Hypothalamus link b/t nervous & endocrine systems)

11 Endocrine Glands

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13 Glands, Hormones and Functions Pineal gland Secretes melatonin, a hormone that helps regulate wake-sleep cycle. Pineal gland Secretes melatonin, a hormone that helps regulate wake-sleep cycle. Hypothalmus: primary link btw. the endocrine and nervous system. It controls the release of pituitary hormones. Hypothalmus: primary link btw. the endocrine and nervous system. It controls the release of pituitary hormones. Thymus: Secretes hormones that maintain and contribute to the production of peripheral t-cell population. Thymus: Secretes hormones that maintain and contribute to the production of peripheral t-cell population.

14 Glands, Hormones and Functions Anterior Pituitary Anterior Pituitary 1. Growth hormone (GH)……promotes growth of muscle and bones and tissue repair. 2. Thyroid stimulating hormone (TSH)….synthesis and release of thyroid hormones. 3. Adrenocorticotropic Hormone (ACTH)….secretion of corticosteroids. 4. Follicle-stimulating hormone (FSH) and Lutenizing hormone (LH)….sex hormone secretion, reproductive organ growth 5. Prolactin….milk production in lactating women; unclear function in men.

15 Anterior Pituitary

16 Glands, Hormones and Functions Posterior Pituitary Posterior Pituitary 1. Oxytocin….milk secretion, uterine contractility 2. Antidiuretic Hormone (ADH) or vasopressin….promotes reabsorption of water, vasoconstriction

17 Glands, Hormones and Functions Thyroid Thyroid 1. Thyroxine (T4)….precursor to T3 2. Triiodothyronine (T3)….regulates metabolic rate of ALL CELLS and processes of cell growth and tissue differentiation. Therefore, all cells in the body have intracellular receptors for thyroid hormone. 3. Calcitonin….regulates calcium and phosphorus blood levels; decreases serum calcium levels.

18 Glands, Hormones and Functions Parathyroids Parathyroids Parathyroid hormone (PTH)….regulates calcium and phosphorus blood levels; promotes bone demineralization and increases intestinal absorption of calcium; increases serum calcium levels

19 Glands, Hormones and Functions Adrenal Medulla (inner) Adrenal Medulla (inner) 1. Epinephrine (Adrenaline) 2. Norepinephrine Both respond to stress, enhance and prolong effects of sympathetic nervous system

20 Glands, Hormones and Functions Adrenal Cortex (outer) Adrenal Cortex (outer) 1. Glucocorticoids (ie. cortisol, hydrocortisone)….promotes metabolism, increase blood glucose levels, response to stress. 2. Androgens (ie. testosterone) and estrogen….promotes masculinization in men, growth and sexual activity in women 3. Mineralocorticoids (ie. aldosterone)….regulates sodium and potassium balance and thus water balance

21 Glands, Hormones and Functions Pancreas: endocrine and exocrine functions. Endocrine functions carried out by the Islets of Langerhan which produce insulin and glucagon (regulate blood glucose levels). Somatostatin inhibits insulin and glucagon secretion. Exocrine cells secrete digestive enzymes into the small intestine. Pancreas: endocrine and exocrine functions. Endocrine functions carried out by the Islets of Langerhan which produce insulin and glucagon (regulate blood glucose levels). Somatostatin inhibits insulin and glucagon secretion. Exocrine cells secrete digestive enzymes into the small intestine. Gonads: Gonads: -Women: estrogen….ovaries in abdomen, preparation of uterus for fertilization and fetal development…….progesterone maintains lining of uterus -Male: testosterone……testes in scrotum

22 Gonads

23 Other Structures Producing Hormones Glands within the gastro- intestinal tract… secrete peptide hormones (ie. gastrin) Structures within the heart and blood vessels (atrial natriuretic peptide/factor (ANF or ANP)….water balance in the body Kidney: renin & erythropoietin….increasing BP and rate of red cell production.

24 A cell is a target for a hormone because it has a specific receptor for that hormone Most hormones circulate in blood, coming into contact with essentially all cells. However, a given hormone usually affects only a limited number of cells, which are called target cells. A target cell responds to a hormone because it bears receptors for the hormone.

25 Hormones - Classes based on structure 1. Steroid 2. Peptide (protein)

26 Mechanism of Protein Hormone Are water soluble Bind to cell membrane receptors on target tissue and activate second messenger within. Rapid response time

27 Peptide (Protein) Hormones

28 Steroid Hormones Steroid hormones pass through the plasma membrane & do not require an external receptor.

29 Feedback Control Hormone concentration in the blood stream is maintained at a fairly constant level. When hormone levels rise, further production of the hormones is inhibited. When the hormone level drops, the rate of production increases. Hormone concentration in the blood stream is maintained at a fairly constant level. When hormone levels rise, further production of the hormones is inhibited. When the hormone level drops, the rate of production increases.

30 Feedback control Negative feedback is most common. The gland itself responds by increasing or decreasing hormone levels based on feedback from various factors. Negative feedback is most common. The gland itself responds by increasing or decreasing hormone levels based on feedback from various factors. Positive feedback is less common: The increased activity of hormone production and response stimulates further production. Positive feedback is less common: The increased activity of hormone production and response stimulates further production.

31 The regulation of hormone levels depend mainly on the body’s negative feedback system. For example: Elevated blood sugar levels stimulate the release of insulin from the pancreas. Elevated blood sugar levels stimulate the release of insulin from the pancreas. The insulin facilitates the transfer of sugar from the blood to the cells The insulin facilitates the transfer of sugar from the blood to the cells Low BS inhibits the release of more insulin Low BS inhibits the release of more insulin Negative feedback is the corrective action Negative feedback is the corrective action

32 Feedback Control of Hormone Production Feedback loops are used extensively to regulate secretion of hormones in the hypothalamic-pituitary axis. An important example of a negative feedback loop is seen in control of thyroid hormone secretion

33 Positive Feedback The regulation of hormone levels also depend on the body’s positive feedback system The regulation of hormone levels also depend on the body’s positive feedback system Positive feedback systems amplify changes rather than reversing them Positive feedback systems amplify changes rather than reversing them For example: During labour, muscle contractions becomes stronger & stronger under the influence of oxytocin For example: During labour, muscle contractions becomes stronger & stronger under the influence of oxytocin

34 Hypothalamus and Pituitary as Partners

35 HYPOTHALMUS Coordinates the working of the autonomic nervous system & endocrine system. Receives info from cerebral hemisphere, brain stem, spinal cord, autonomic & peripheral nerves, senses. Coordinates the working of the autonomic nervous system & endocrine system. Receives info from cerebral hemisphere, brain stem, spinal cord, autonomic & peripheral nerves, senses.

36 Hypothalamus Function Produces regulatory hormones that stimulate the anterior pituitary. Produces regulatory hormones that stimulate the anterior pituitary. -Releasing hormones: TRH (thyrotropin- releasing hormone), GHRH (growth hormone-releasing factor), GnRH (Gonadotropin-releasing hormone), CRH (Corticotropin-releasing hormone), PRH, -Inhibiting hormones: PIH (prolactin- inhibiting hormone, GH-IH (Somatostatin) Ultimately the hypothalamus can control every endocrine gland in the body! Ultimately the hypothalamus can control every endocrine gland in the body!

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39 Hypothalamic Hormones Releasing Factor Anterior Pituitary Target Cells TRH TSH thyroid GHRH GH bone, muscle GH-IH GH bone, muscle GnRH FSH, LH ovaries, testes CRH ACTH Adrenal cortex PRH Prolactin mammary glands PIH (dopamine inhibitor)

40 HYPOTHALMUS: SOME MAJOR FUNCTIONS Autonomic nervous system Autonomic nervous system Secretion of pituitary hormones Secretion of pituitary hormones Organization of body metabolism Organization of body metabolism Availability of energy foods such as glucose Availability of energy foods such as glucose sleep & wakefulness sleep & wakefulness Temperature, thirst & water regulation Temperature, thirst & water regulation Hunger & Appetite Hunger & Appetite Behavior - fear, rage, sexual desire Behavior - fear, rage, sexual desire Growth Growth Sexual reproduction Sexual reproduction

41 Hypothalamus Pituitary Partners Due to the unique interaction between the hypothalamus and the pituitary gland, hypothalamic dysfunction is often associated with alterations in pituitary function. Because the hypothalamus is also responsible for many homeostatic regulatory functions, alterations can also occur in behavior, temperature control &, appetite. Due to the unique interaction between the hypothalamus and the pituitary gland, hypothalamic dysfunction is often associated with alterations in pituitary function. Because the hypothalamus is also responsible for many homeostatic regulatory functions, alterations can also occur in behavior, temperature control &, appetite. Assess

42 Hypothalmus: disturbance in function may be triggered by: Mental or emotional upset, grief & worry Weight changes (drastic) Other causes - tumors, cerebral infections, trauma.

43 Common Assessment Abnormalities & Causes: Head & Neck Visual changes: enlargement or pituitary tumor can result in pressure on optic nerve Visual changes: enlargement or pituitary tumor can result in pressure on optic nerve Exophthalmos (protrusion of eyeballs): hyperthyroidism Exophthalmos (protrusion of eyeballs): hyperthyroidism Moon face (periorbital edema & facial fullness): Cushing syndrome Moon face (periorbital edema & facial fullness): Cushing syndrome Myxedema (masklike effect): long-standing hypothyroidism Myxedema (masklike effect): long-standing hypothyroidism Goiter (enlarged thyroid): hyperthyroidism & hypothyroidism Goiter (enlarged thyroid): hyperthyroidism & hypothyroidism

44 Exophthalmos & Goiter of Thyroid Disease

45 Moon Face of Cushing Syndrome

46 Common Assessment Abnormalities & Causes: Integument Hyperpigmentation (darkening of the skin, particularly in creases & skin folds): Addison’s disease Hyperpigmentation (darkening of the skin, particularly in creases & skin folds): Addison’s disease Striae (purplish-red marks below skin surface…abdomen, breasts, buttocks): Cushing Syndrome Striae (purplish-red marks below skin surface…abdomen, breasts, buttocks): Cushing Syndrome Changes in skin texture: Hypothyroidism (thick, cold, dry); GH excess (thick, leathery, oily); Hyperthyroidism (warm, smooth, moist) Changes in skin texture: Hypothyroidism (thick, cold, dry); GH excess (thick, leathery, oily); Hyperthyroidism (warm, smooth, moist) Changes in hair distribution: hair loss (hypo/hyperthyroidism); hirsutism – excessive facial hair on women (Cushing Syndrome) Changes in hair distribution: hair loss (hypo/hyperthyroidism); hirsutism – excessive facial hair on women (Cushing Syndrome) Skin Ulceration (commonly on legs & feet): Diabetes Skin Ulceration (commonly on legs & feet): Diabetes

47 Diabetic Leg Ulcer

48 Common Assessment Abnormalities & Causes: Musculoskeletal Changes in muscular strength (general weakness, fatigue; decreased muscle mass): many endocrine problems Changes in muscular strength (general weakness, fatigue; decreased muscle mass): many endocrine problems *Assess patient’s energy level and muscular strength. Enlargement of bones & cartilage (coarse facial features, increased size of hands & feet): Growth Hormone excess……Acromegaly Enlargement of bones & cartilage (coarse facial features, increased size of hands & feet): Growth Hormone excess……Acromegaly

49 Acromegaly

50 Common Assessment Abnormalities & Causes: Nutrition Changes in weight: Hyperthyroidism (weight loss); Hypothyroidism & Cushing (weight gain) Changes in weight: Hyperthyroidism (weight loss); Hypothyroidism & Cushing (weight gain) Increased serum glucose: Diabetes Mellitus, Cushings, Growth Hormone Excess Increased serum glucose: Diabetes Mellitus, Cushings, Growth Hormone Excess

51 Common Assessment Abnormalities & Causes: Neurologic Lethargy (mental sluggishness): Hypothyroidism Lethargy (mental sluggishness): Hypothyroidism Tetany (intermittent involuntary muscle spasms – extremities): Hypoparathyroidism due to calcium deficiency Tetany (intermittent involuntary muscle spasms – extremities): Hypoparathyroidism due to calcium deficiency Seizure (convulsion): Pituitary tumor; Fluid & electrolyte imbalance from ADH secretion; complications of Diabetes; severe Hypothyroidism Seizure (convulsion): Pituitary tumor; Fluid & electrolyte imbalance from ADH secretion; complications of Diabetes; severe Hypothyroidism

52 Common Assessment Abnormalities & Causes: Gastrointestinal Constipation: Hypothyroidism, Hyperparathyroidism due to calcium imbalance Constipation: Hypothyroidism, Hyperparathyroidism due to calcium imbalance

53 Common Assessment Abnormalities & Causes: Reproductive Changes in Reproductive Function (menstrual irregularities, decreased libido, decreased fertility, impotence): various endocrine abnormalities including pituitary hypofunction, growth hormone excess, thyroid dysfunction, & adrenocortical dysfunction Changes in Reproductive Function (menstrual irregularities, decreased libido, decreased fertility, impotence): various endocrine abnormalities including pituitary hypofunction, growth hormone excess, thyroid dysfunction, & adrenocortical dysfunction

54 Common Assessment Abnormalities & Causes: Other Polyuria (excessive urine output): Diabetes Mellitus secondary to hyperglycemia or Diabetes Insipidus associated with decreased ADH Polyuria (excessive urine output): Diabetes Mellitus secondary to hyperglycemia or Diabetes Insipidus associated with decreased ADH Polydipsia (excessive thirst): Diabetes Polydipsia (excessive thirst): Diabetes Thermoregulation: Hypothyroidism (cold insensitivity); Hyperthyroidism (heat intolerance) Thermoregulation: Hypothyroidism (cold insensitivity); Hyperthyroidism (heat intolerance)

55 Diagnostic Studies of the Endocrine System Laboratory Studies: may include direct measurement of hormone level, or they may involve an indirect indication of gland function by evaluating blood or urine components affected by the hormone (ie. electrolytes) Laboratory Studies: may include direct measurement of hormone level, or they may involve an indirect indication of gland function by evaluating blood or urine components affected by the hormone (ie. electrolytes) Radiologic Studies: Xray, CT, MRI, radiologic isotope….helpful in identifying size of the gland or presence of lesions/tumors, and in some cases function of the gland. Radiologic Studies: Xray, CT, MRI, radiologic isotope….helpful in identifying size of the gland or presence of lesions/tumors, and in some cases function of the gland.

56 Pituitary Studies: Serum Growth Hormone – used to identify GH deficiency or excess. Growth Hormone – used to identify GH deficiency or excess. *Nursing responsibilities: -explain procedure -use sterile technique for blood sampling -apply pressure to venous puncture site -pt fasting and not recently emotionally or physically stressed -put pt fasting status & activity level on lab slip -send blood sample to lab immediately

57 Pituitary Studies: Serum Other lab studies include: Other lab studies include: -Somatomedin C (evaluates GH secretion). -Growth hormone stimulation test (needed to adequately diagnose GH deficiency). -Gonadotropin levels: FSH &LH (to distinguish primary gonadal problems from pituitary insufficiency) -Water deprivation test (to differentiate causes of polyuria) -Prolactin level

58 Pituitary Studies: Radiologic Magnetic Resonance Imaging: useful in identification of tumors involving the hypothalmus or pituitary. Magnetic Resonance Imaging: useful in identification of tumors involving the hypothalmus or pituitary. *Nursing responsibilities: - screen pt for metal parts (aneurysm clips, metallic implants, shrapnel), pacemaker, electronic devices, hearing aids in body. - screen pt for metal parts (aneurysm clips, metallic implants, shrapnel), pacemaker, electronic devices, hearing aids in body. - ensure pt has no metal on clothing/body (ie. zippers, jewlery, credit cards - ensure pt has no metal on clothing/body (ie. zippers, jewlery, credit cards - explain that test is painless and noninvasive. - explain that test is painless and noninvasive. - inform pt of need to lie completely still during procedure (approx. 1 hour). - inform pt of need to lie completely still during procedure (approx. 1 hour). - sedation may be necessary if pt is claustrophobic. - sedation may be necessary if pt is claustrophobic.

59 Thyroid Studies: Serum Thyroid-stimulating hormone (TSH): most sensitive method for evaluating thyroid disease…..recommended as first diagnostic test. Normal values are 0.3 – 5.4 mU/L. Thyroid-stimulating hormone (TSH): most sensitive method for evaluating thyroid disease…..recommended as first diagnostic test. Normal values are 0.3 – 5.4 mU/L. Thyroxine (T4): useful in evaluating thyroid function & monitoring thyroid therapy. Thyroxine (T4): useful in evaluating thyroid function & monitoring thyroid therapy. Triiodothyronine (T3): useful in diagnosing hyperthyroidism if T4 levels are normal. Triiodothyronine (T3): useful in diagnosing hyperthyroidism if T4 levels are normal. Free T4: measures active component of total T4; considered better indication of thyroid function than T4. Free T4: measures active component of total T4; considered better indication of thyroid function than T4. *No specific preparations are needed for these tests. Nurse should explain blood draw procedure.

60 Thyroid Studies: Radiologic Radioactive Iodine Uptake: Radioactive Iodine Uptake: -provides direct measure of thyroid activity. -provides direct measure of thyroid activity. - evaluation of functional activity of thyroid nodules…”hot” nodules (usually benign) or “cold”nodules. - evaluation of functional activity of thyroid nodules…”hot” nodules (usually benign) or “cold”nodules. - pt given radioactive iodine either orally or intravenously. - pt given radioactive iodine either orally or intravenously. -uptake measured with a scanner at several time intervals such as 2 – 4 hrs and at 24 hrs. -uptake measured with a scanner at several time intervals such as 2 – 4 hrs and at 24 hrs. *Nursing responsibilities: - ensure pt NPO for 6 – 8 hrs before test (may resume eating 1 hr after oral iodine dose is taken). - ensure pt NPO for 6 – 8 hrs before test (may resume eating 1 hr after oral iodine dose is taken). - pt should not have supplemental iodine for several weeks before the test. - pt should not have supplemental iodine for several weeks before the test. - assess if pt on thyroid medications as they interfere with the test. - assess if pt on thyroid medications as they interfere with the test.

61 Thyroid Studies: Radiologic Thyroid Scan Thyroid Scan -used to evaluate nodules of the thyroid. -used to evaluate nodules of the thyroid. -radioactive isotopes given orally or intravenously. -radioactive isotopes given orally or intravenously. -scanner passes over thyroid and makes graphic record of radiation emitted. -scanner passes over thyroid and makes graphic record of radiation emitted. - benign nodules appear as “hot” spots because they take up radionuclide. - benign nodules appear as “hot” spots because they take up radionuclide. - malignant tumors appear as “cold” spots because they tend not to take up radionuclide. - malignant tumors appear as “cold” spots because they tend not to take up radionuclide. *Nursing Responsibilities: - No special prep required. - No special prep required. - explain procedure to pt, being sure to make pt aware that radioactive iodine taken orally is harmless. - explain procedure to pt, being sure to make pt aware that radioactive iodine taken orally is harmless.

62 Parathyroid Studies: Serum Parathyroid Hormone (PTH): must be interpreted in relation to serum calcium. Parathyroid Hormone (PTH): must be interpreted in relation to serum calcium. Total serum calcium: helps detect bone and parathyroid disorders. Total serum calcium: helps detect bone and parathyroid disorders. Serum phosphate Serum phosphate *Nursing Responsibilities: -ensure pt has been fasting. -ensure pt has been fasting. -PTH sample must be kept on ice. -PTH sample must be kept on ice. -inform pt that blood sample will be drawn. -inform pt that blood sample will be drawn. -observe venipuncture site for bleeding or hematoma -observe venipuncture site for bleeding or hematoma

63 Adrenal Studies: Serum Cortisol: evaluates status of adrenal cortex function. Cortisol: evaluates status of adrenal cortex function. Aldosterone: to evaluate for hyperaldosteronism. Aldosterone: to evaluate for hyperaldosteronism. Adrenocorticotropic hormone (ACTH, corticotropin): helps to determine if underproduction or overproduction of cortisol is caused by dysfunction of adrenal gland or pituitary gland. Adrenocorticotropic hormone (ACTH, corticotropin): helps to determine if underproduction or overproduction of cortisol is caused by dysfunction of adrenal gland or pituitary gland. *Nursing Responsibilities: -pt should be NPO after midnight for morning blood draw of ACTH. -pt should be NPO after midnight for morning blood draw of ACTH. -pt anxiety should be minimized. -pt anxiety should be minimized. -blood samples should be drawn in morning. -blood samples should be drawn in morning. -mark time of blood draw on lab slip. -mark time of blood draw on lab slip. -indicate pt position (supine, sitting, standing) during venipuncture for Aldosterone draw. -indicate pt position (supine, sitting, standing) during venipuncture for Aldosterone draw. -ACTH blood draw should be placed on ice and sent to lab immediately. -ACTH blood draw should be placed on ice and sent to lab immediately.

64 Adrenal Studies: Urine 17-Ketosteroids: measures androgen metabolites in urine & evaluates adrenocortical & gonadal function. 17-Ketosteroids: measures androgen metabolites in urine & evaluates adrenocortical & gonadal function. Aldosterone: useful in determining therapy for hypertension. Aldosterone: useful in determining therapy for hypertension. Others: free cortisol, vanillylmandelic acid. Others: free cortisol, vanillylmandelic acid. *Nursing Responsibilities: -instruct pt about 24-hour urine collection. -instruct pt about 24-hour urine collection. -specimen must be kept refrigerated during collection. -specimen must be kept refrigerated during collection. -determine whether preservative is required for method used. -determine whether preservative is required for method used. -pt must be on unrestricted diet with normal salt intake and no medication for 3 weeks before collection for Aldosterone. -pt must be on unrestricted diet with normal salt intake and no medication for 3 weeks before collection for Aldosterone. -pt should avoid stressful situations & excessive exercise for Free Cortisol test….also should be on low sodium diet. -pt should avoid stressful situations & excessive exercise for Free Cortisol test….also should be on low sodium diet.

65 Adrenal Studies: Radiologic Computed Tomography (CT): abdominal CT is exam of choice for adrenal gland….used to detect tumor & size of tumor mass or metastatic spread….oral and/or IV contrast may be used. Computed Tomography (CT): abdominal CT is exam of choice for adrenal gland….used to detect tumor & size of tumor mass or metastatic spread….oral and/or IV contrast may be used. *Nursing Responsibilities: -explain procedure to pt. -explain procedure to pt. -inform pt that procedure is painless. -inform pt that procedure is painless. -explain that pt must lie still during procedure. -explain that pt must lie still during procedure. -if IV contrast is used, check for allergy to iodine. -if IV contrast is used, check for allergy to iodine.

66 Pancreatic Studies: Serum Fasting blood sugar (FSB) levels: measures circulating glucose level….normal values for adults are 70 – 110 mg/dl (3.9 – 6.7 mmol/L); for pregnant women they are 60 – 90 mg/dl (3.3 – 5 mmol/L). Fasting blood sugar (FSB) levels: measures circulating glucose level….normal values for adults are 70 – 110 mg/dl (3.9 – 6.7 mmol/L); for pregnant women they are 60 – 90 mg/dl (3.3 – 5 mmol/L). *Nursing Responsibilities: -pt should fast for at least 4 – 8 hours….water intake is permitted -pt should fast for at least 4 – 8 hours….water intake is permitted -if pt has IV infusion containing dextrose, test is not valid. -if pt has IV infusion containing dextrose, test is not valid.

67 Pancreatic Studies: Serum Oral glucose tolerance: Oral glucose tolerance: A. 2-hour test used to diagnose DM if FBS is questionable. Pt drinks 75 g of glucose; samples for glucose are drawn immediately and at 30, 60, and 120 minutes B. 5-hour test used to evaluate hypoglycemia *Nursing Responsibilities: -ensure tests not done on pts who are malnourished, confined to bed for over 3 days, or severely stressed. -ensure tests not done on pts who are malnourished, confined to bed for over 3 days, or severely stressed. -instruct pt to refrain from smoking and caffeine and to fast for 12 hours before test. -instruct pt to refrain from smoking and caffeine and to fast for 12 hours before test. -ensure pt’s diet 3 days before test included 150-300g of carbohydrates with intake of at least 1500 calories per day. -ensure pt’s diet 3 days before test included 150-300g of carbohydrates with intake of at least 1500 calories per day. -screen for estrogens, phenytoin (Dilantin), and corticosteroids, and check for hypokalemia, which may impair glucose tolerance. -screen for estrogens, phenytoin (Dilantin), and corticosteroids, and check for hypokalemia, which may impair glucose tolerance. -simultaneously monitor glucose levels with capillary glucose monitoring. -simultaneously monitor glucose levels with capillary glucose monitoring.

68 Pancreatic Studies: Serum Capillary glucose monitoring: used to give immediate glucose values. Values are usually 10% - 15% less than serum values. Capillary glucose monitoring: used to give immediate glucose values. Values are usually 10% - 15% less than serum values. *Nursing Responsibilities: -explain procedure to pt. -explain procedure to pt. -obtain large drop of blood from clean finger, touch strip to drop of blood (not finger), and insert in digital readout. -obtain large drop of blood from clean finger, touch strip to drop of blood (not finger), and insert in digital readout. -use automatic finger-puncture device if available. -use automatic finger-puncture device if available.

69 Pancreatic Studies: Serum Glycosylated hemoglobin (HbA1C): measures degree of glucose control during previous 3 months (life-span of hemoglobin molecule). Glycosylated hemoglobin (HbA1C): measures degree of glucose control during previous 3 months (life-span of hemoglobin molecule). *Nursing Responsibilities: -inform pt that fasting is not necessary and that blood sample will be drawn. -inform pt that fasting is not necessary and that blood sample will be drawn. -as with any other blood sample, observe venipuncture site for bleeding or hematoma. -as with any other blood sample, observe venipuncture site for bleeding or hematoma.

70 Pancreatic Studies: Urine Glucose: dipstick is dipped into urine and read for color change after 1 minute. Normal results will show negative glucose. Glucose: dipstick is dipped into urine and read for color change after 1 minute. Normal results will show negative glucose. Ketones: measures amount of acetone excreted in urine as a result of incomplete fat metabolism. Also tested with a dipstick. Normal value is negative or trace ketone. Positive result can indicate lack of insulin and diabetic acidosis. Ketones: measures amount of acetone excreted in urine as a result of incomplete fat metabolism. Also tested with a dipstick. Normal value is negative or trace ketone. Positive result can indicate lack of insulin and diabetic acidosis. *Nursing Responsibilities: -use freshly voided urine specimen collected at appropriate time. -use freshly voided urine specimen collected at appropriate time. -know that many different drugs alter glucose readings and errors are great if directions for timing are not followed. -know that many different drugs alter glucose readings and errors are great if directions for timing are not followed. -follow package instructions exactly. -follow package instructions exactly.

71 Pancreatic Studies: Radiologic CT: exam of choice for pancreas….used to identify tumors or cysts….oral and/or intravenous contrast medium may be ordered. CT: exam of choice for pancreas….used to identify tumors or cysts….oral and/or intravenous contrast medium may be ordered. *Nursing Responsibilities as previously listed.

72 Diseases of the endocrine system are related to either: an excess or a deficiency of a specific hormone or an excess or a deficiency of a specific hormone or to a deficit in the receptor site. to a deficit in the receptor site. The thyroid and testes are the only glands that can be examined directly Knowledge of A&P together with data from the history & lab tests are essential in assessing the endocrine system.

73 Hypo and Hypersecretion of Hormones Hyper-secretion is production of too much hormone Hyper-secretion is production of too much hormone Hypo-secretion is production of too little hormone Hypo-secretion is production of too little hormone

74 Endocrine Disorders & Psychiatric Disturbances GlandHypoHyper PituitaryMyxedemaDwarfism Sex Dysfunction Diabetes Insipidus GigantismAcromegaly Sexual Dysfunction ThyroidCretinismMyxedemaGraves ParathyroidTetanyHypercalcemia Adrenal Addison’s Disease Cushing Disease Hyperaldosteronism Pancreas Diabetes Mellitus Hypoglcemia

75 Endocrine disorders may be associated with a wide range of psychological/psychiatric symptoms such as depression, mania, paranoid disorders, cognitive disturbances, hostility, & irritability. Endocrine disorders may be associated with a wide range of psychological/psychiatric symptoms such as depression, mania, paranoid disorders, cognitive disturbances, hostility, & irritability. Nurses need to be aware that such symptoms may precede other manifestations of an endocrine disorder and/or be early indications of its relapse. Nurses need to be aware that such symptoms may precede other manifestations of an endocrine disorder and/or be early indications of its relapse.

76 Endocrine Disorders Commonly Manifesting Psychiatric Characteristics Hyperthyroidism Hyperthyroidism Hypothyroidism Hypothyroidism Addison’s Disease Addison’s Disease Cushing’s Disease Cushing’s Disease

77 Thyroid Glands Disorders Thyroid gland secretes hormones that are involved in human development, growth, and metabolism (T4 and T3) Thyroid gland secretes hormones that are involved in human development, growth, and metabolism (T4 and T3) It also secretes calcitonin when there is a high concentration of calcium in the blood stream. The function of calcitonin is to inhibit the amount of reabsorption of calcium from the bone and to regulate the amount of calcium in the blood stream. It also secretes calcitonin when there is a high concentration of calcium in the blood stream. The function of calcitonin is to inhibit the amount of reabsorption of calcium from the bone and to regulate the amount of calcium in the blood stream.

78 Thyroid Gland Disorders Thyroid gland secretes hormones that are involved in human development, growth, and metabolism (T4 and T3) Thyroid gland secretes hormones that are involved in human development, growth, and metabolism (T4 and T3) It also secretes calcitonin when there is a high concentration of calcium in the blood stream. The function of calcitonin is to inhibit the amount of reabsorption of calcium from the bone and to regulate the amount of calcium in the blood stream. It also secretes calcitonin when there is a high concentration of calcium in the blood stream. The function of calcitonin is to inhibit the amount of reabsorption of calcium from the bone and to regulate the amount of calcium in the blood stream.

79 Hypothyroidism Can be primary (r/t destruction of thyroid tissue or defective hormone synthesis) or secondary (r/t pituitary disease with decreased TSH secretion or hypothalmic dysfunction with decreased TRH secretion). Can be primary (r/t destruction of thyroid tissue or defective hormone synthesis) or secondary (r/t pituitary disease with decreased TSH secretion or hypothalmic dysfunction with decreased TRH secretion). May also be transient, r/t thyroiditis or discontinuance of thyroid hormone therapy. May also be transient, r/t thyroiditis or discontinuance of thyroid hormone therapy.

80 Hypothyroidism Common Causes: Common Causes: -Iodine deficiency -Atrophy of thyroid gland (result of thyroiditis and Graves’ disease which destroy the thyroid gland). *May also develop as a consequence of treatment for hyperthyroidism (surgery or radioactive iodine therapy). *Hypothyroidism in infancy = cretinism caused by thyroid hormone deficiencies during fetal or early neonatal life.

81 Hypothyroidism *Results in deficient production of T4/T3 by the thyroid. *Results in deficient production of T4/T3 by the thyroid. Clinical Manifestations: Clinical Manifestations: 1. Goiter, intolerance to cold. 1. Goiter, intolerance to cold. 2. Fatigue. 2. Fatigue. 3. Constipation. 3. Constipation. 4. Weight gain. 4. Weight gain. 5. Memory and mental impairment and decreased 5. Memory and mental impairment and decreased concentration. concentration. 6. Depression, anxiety. 6. Depression, anxiety. 7. Decreased appetite. 7. Decreased appetite. 8. Coarseness or loss of hair. 8. Coarseness or loss of hair. 9. Dry skin, decreased sweating and pallor. 9. Dry skin, decreased sweating and pallor.

82 Hypothyroidism Clinical Manifestations (cont’d)… Clinical Manifestations (cont’d)… 10. Irregular or heavy menses; anemia 11. Infertility, loss of libido. 11. Infertility, loss of libido. 12. Hoarseness. 12. Hoarseness. 13. Dyspnea 13. Dyspnea 14. Hyperlipidemia. 14. Hyperlipidemia. 15. Reflex delay. 15. Reflex delay. 16. Bradycardia, varied BP changes. 16. Bradycardia, varied BP changes. 17. Hypothermia. 17. Hypothermia. 18. Ataxia. 18. Ataxia. 19. Decreased serum T4,T3 levels. 19. Decreased serum T4,T3 levels.  Treatment: - Hormones replacement therapy (Levothyroxine) - Hormones replacement therapy (Levothyroxine)

83 Hypothyroidism Complications: Complications: *Myxedema: accumulation of mucopolysaccharides in dermis and other tissues. >Characteristics: puffiness, periorbital edema, masklike effect. *Myxedema coma: mental sluggishness, drowsiness and lethargy progressing gradually or suddenly to impairment of consciousness or coma…..can be precipitated by infection, drugs (ie. narcotics), cold & trauma…….MEDICAL EMERGENCY.

84 Hyperthyroidism Definition: a syndrome in which there is a sustained increase in synthesis and release of thyroid hormones (T3 & T4) by the thyroid gland. Definition: a syndrome in which there is a sustained increase in synthesis and release of thyroid hormones (T3 & T4) by the thyroid gland. *Most common form is Graves’ disease….other causes include toxic goiter, thyroiditis, exogenous iodine excess, pituitary tumors and thyroid cancer

85 Graves’ Disease Definition: An autoimmune disease of unknown cause marked by thyroid enlargement and excessive thyroid hormone secretion. Definition: An autoimmune disease of unknown cause marked by thyroid enlargement and excessive thyroid hormone secretion. *Pt develops antibodies to TSH receptor…antibodies attach to receptor & stimulate thyroid to release T3, T4 or both Precipitating factors: insufficient iodine supply, infections, and stressful life events….may interact with genetic factors that control the immune response and metabolic abnormalities to cause Graves’ Disease. Precipitating factors: insufficient iodine supply, infections, and stressful life events….may interact with genetic factors that control the immune response and metabolic abnormalities to cause Graves’ Disease.

86 Hyperthyroidism Clinical Manifestations: Clinical Manifestations: 1. Heat intolerance. 1. Heat intolerance. 2. Palpitations, angina, elevated systolic BP. 2. Palpitations, angina, elevated systolic BP. 3. Weight loss, diarrhea, increased appetite. 3. Weight loss, diarrhea, increased appetite. 4. Menstrual irregularities and decreased libido. 4. Menstrual irregularities and decreased libido. 5. Diaphoresis, palmar erythema. 5. Diaphoresis, palmar erythema. 6. Exophthalmos (bulging eyes) 6. Exophthalmos (bulging eyes) 7. Goiter. 7. Goiter. 8. Nervousness, restlessness, insomnia. 8. Nervousness, restlessness, insomnia. 9. Irritability, agitation, depression. 9. Irritability, agitation, depression. 10. Muscle weakness, fatigue. 10. Muscle weakness, fatigue. 11. Increased serum T4, T3 11. Increased serum T4, T3 12. Dyspnea on mild exertion. 12. Dyspnea on mild exertion.

87 Hyperthyroidism Complications: Complications: *Thyrotoxic Crisis (thyroid storm) -all hyperthyroid manifestations are heightened…..considered a life-threatening emergency. -cause is presumed to be stressors (infection, trauma, sx). -manifestations include severe tachycardia, heart failure, shock, hyperthermia, restlessness, agitation, seizures, abdominal pain, nausea, vomiting, diarrhea, delirium & coma. -Therapy: directed at fever reduction, fluid replacement and elimination or management of the initiating stressors.

88 Hyperthyroidism Diagnostic Studies/findings: Diagnostic Studies/findings: 1. Lab: decreased TSH levels and elevated free T4 levels. 2. Radioactive iodine uptake….used to differentiate Graves’ from other forms of thyroiditis. *Pt with Graves’ will show uptake of 35% - 95% whereas the pt with thyroiditis will show uptake of less than 2%.

89 Hyperthyroidism 3 primary treatment options: 3 primary treatment options: 1. Antithyroid medications (ie. propylthiouracil, methimazole)….inhibit synthesis of T4 & T3. Beta blockers that block the action of thyroid hormones on peripheral cells. 2. Radioactive Iodine Therapy: damage or destruction of thyroid tissue. *Disadvantage: posttreatment hypothyroidism resulting in lifelong thyroid hormone replacement. 3. Subtotal Thyroidectomy: removal of 90% of thyroid tissue. *Indicated for pts unresponsive to antithyroid therapy, those with large goiters causing tracheal compression, pt with malignancy, pt who does not want to take RAI. *Treatment of choice in non-pregnant adults is Radioactive Iodine.

90 Hyperthyroidism Other treatment: Other treatment: *High calorie diet (for increased metabolic rate). *High calorie diet (for increased metabolic rate). >4000-5000 kcal/day >Six full meals; snacks high in protein, carbs, minerals, vitamins, (A, thiamine, B6 & C) >Milk is an excellent food source that provides calcium and protein. >Milk is an excellent food source that provides calcium and protein. >Spicy & high-fiber foods should be avoided as they stimulate the GI tract. >Spicy & high-fiber foods should be avoided as they stimulate the GI tract. >Other stimulants to avoid: coffee, tea, cola, >Other stimulants to avoid: coffee, tea, cola,

91 Hyperthyroidism: Thyroid Surgery Pre-operative Nursing Responsibilities: Pre-operative Nursing Responsibilities: *S & S of thyrotoxicosis must be alleviated and cardiac problems must be controlled before surgery. *If iodine (inhibits synthesis of T3 & T4) used, observe for toxicity (swelling of buccal mucosa & other mucous membranes, excessive salivation, nausea & vomiting, skin reactions). *Pre-op teaching: -coughing, deep-breathing and leg exercises. -coughing, deep-breathing and leg exercises. -how to support head manually while turning in bed….maneuver minimizes stress on the suture line. -how to support head manually while turning in bed….maneuver minimizes stress on the suture line. -ROM exercises for the neck -ROM exercises for the neck -IV infusions post-op -IV infusions post-op -Talking will be difficult for a short time -Talking will be difficult for a short time *Prepare pt room with oxygen, suction and a tracheostomy tray (in case of airway obstruction)

92 Hyperthyroidism: Thyroid Surgery Postoperative Nursing Responsibilities: Postoperative Nursing Responsibilities: *Assess pt every 2 hrs for 24 hrs for signs of hemorrhage or tracheal compression (irregular breathing, neck swelling, frequent swallowing, sensations of fullness at the incision site, choking). *Place pt in semi-Fowlers; support head with pillows; avoid neck flexion and any tension on suture lines. *Monitor VS *Check for signs of tetany r/t hypoparathyroidism (ie, tingling in toes, fingers or around mouth; muscular twitching). *Evaluate difficulty in speaking *Test for hypocalcemia 1. Chvostek’s sign: contraction of facial muscles after light tap on facial nerve. 2. Trousseau’s sign: carpal spasm induced by inflating a BP cuff above the systolic pressure for a few minutes. *Control post-op pain: analgesia *Pt will be permitted to take fluids as soon as tolerated and soft diet next day.

93 Addison’s Disease: Hypofunction of Adrenal Cortex Cause: Cause: - most commonly autoimmune response……adrenal tissue is destroyed by antibodies against pt’s own adrenal cortex. - most commonly autoimmune response……adrenal tissue is destroyed by antibodies against pt’s own adrenal cortex. -other causes include infarction, fungal infections (ie. histoplasmosis), tuberculosis, AIDS and metastatic cancer. -other causes include infarction, fungal infections (ie. histoplasmosis), tuberculosis, AIDS and metastatic cancer.

94 Addison’s Disease: Hypofunction of Adrenal Cortex Clinical Manifestations: Clinical Manifestations: 1. Progressive weakness 1. Progressive weakness 2. Fatigue 2. Fatigue 3. Weight loss 3. Weight loss 4. Anorexia 4. Anorexia 5. Skin hyperpigmentation (esp. over joints; in creases especially palmar creases). 5. Skin hyperpigmentation (esp. over joints; in creases especially palmar creases). 6. Hypotension. 6. Hypotension. 7. Hyponatremia & hyperkalemia. 7. Hyponatremia & hyperkalemia. 8. Nausea & vomiting 8. Nausea & vomiting 9. Diarrhea 9. Diarrhea

95 Addison’s Disease: Hypofunction of Adrenal Cortex

96 Complications: Complications: *Addisonian Crisis: severe insufficiency of adrenocortical hormones……hypotension, tachycardia, dehydration, hyponatremia, hyperkalemia, hypoglycemia, fever, weakness and confusion…..hypotension may lead to shock…..GI manifestations include nausea, vomiting, diarrhea, and abdominal pain……Life Threatening!

97 Addison’s Disease: Hypofunction of Adrenal Cortex Acute Nursing Interventions: Acute Nursing Interventions: -Protect pt from noise, light & extremes of environmental temperature……unable to tolerate physical or emotional stress without exogenous corticosteroids. -Protect pt from noise, light & extremes of environmental temperature……unable to tolerate physical or emotional stress without exogenous corticosteroids. -Monitor VS and signs of fluid volume deficit & electrolyte balance every 30 mins to 4 hours depending on status. -Monitor VS and signs of fluid volume deficit & electrolyte balance every 30 mins to 4 hours depending on status. -Daily weights -Daily weights -Administration of corticosteroid therapy -Administration of corticosteroid therapy -Protect against exposure to infection. -Protect against exposure to infection. -Assist with daily hygiene. -Assist with daily hygiene. Home Care: Home Care: -Teach re: need for lifelong replacement therapy and medical supervision. -Teach re: need for lifelong replacement therapy and medical supervision. -Teach pt to adjust the dose of exogenous hormone to stress levels. -Teach pt to adjust the dose of exogenous hormone to stress levels.

98 Cushing Syndrome: Hyperfunction of the Adrenal Cortex Causes: Causes: -Prolonged administration of high doses of corticosteroids -Prolonged administration of high doses of corticosteroids -ACTH-secreting pituitary tumor (Cushing’s Disease) -ACTH-secreting pituitary tumor (Cushing’s Disease) -Cortisol-secreting neoplasm within the adrenal cortex that can be either carcinoma or adenoma. -Cortisol-secreting neoplasm within the adrenal cortex that can be either carcinoma or adenoma. -Excess secretion of ACTH from carcinoma of the lung or other malignant growth outside the pituitary or adrenal glands. -Excess secretion of ACTH from carcinoma of the lung or other malignant growth outside the pituitary or adrenal glands.

99 Cushing Syndrome: Hyperfunction of the Adrenal Cortex Clinical Manifestations Clinical Manifestations *Most common: weight gain resulting from accumulation of adipose tissue in the trunk, face and cervical area….”Moon face” *Hyperglycemia r/t cortisol induced insulin resistance. *Hypertension r/t fluid retention. *Hypokalemia *Muscle wasting…..muscle weakness d/t protein wasting. *Osteoporosis with fractures, bone and back pain *Skin weaker, thinner d/t loss of collagen. *Mood disturbances (irritability, anxiety), insomnia, irrationality, and occasionally psychosis.

100 Cushing Syndrome: Hyperfunction of the Adrenal Cortex

101 Diagnostic tests: Diagnostic tests: 1. Free cortisol (24 hr urine collection) 1. Free cortisol (24 hr urine collection) 2. CT (used for tumor localization) 2. CT (used for tumor localization) 3. MRI (used for tumor localization) 3. MRI (used for tumor localization)

102 Cushing Syndrome: Hyperfunction of the Adrenal Cortex Acute Nursing Intervention: Acute Nursing Intervention: -Assess for s & s of hormone and drug toxicity and for complicating conditions such as cardiovascular disease, diabetes, infection, nephrolithiasis, pathologic fractures -Assess for s & s of hormone and drug toxicity and for complicating conditions such as cardiovascular disease, diabetes, infection, nephrolithiasis, pathologic fractures -Monitor VS, daily wt, glucose, possible infection. -Monitor VS, daily wt, glucose, possible infection. -Monitor for thromboembolic phenomenon (sudden chest pain, dyspnea). -Monitor for thromboembolic phenomenon (sudden chest pain, dyspnea). -Offer pt emotional support, respect and acceptance (may feel unattractive, unwanted). -Offer pt emotional support, respect and acceptance (may feel unattractive, unwanted).

103 Cushing Syndrome: Hyperfunction of the Adrenal Cortex Preoperative Nursing Care: Preoperative Nursing Care: -Control of hypertension, hyperglycemia, & hypokalemia must be met prior to surgery. -Control of hypertension, hyperglycemia, & hypokalemia must be met prior to surgery. -Teaching depends on type of surgery (hypophysectomy or adrenalectomy). -Teaching depends on type of surgery (hypophysectomy or adrenalectomy). -Inform pt. of post-op monitoring including nasogastric tube, urinary catheter, IV therapy, CVP monitoring, leg compression devices. -Inform pt. of post-op monitoring including nasogastric tube, urinary catheter, IV therapy, CVP monitoring, leg compression devices.

104 Cushing Syndrome: Hyperfunction of the Adrenal Cortex Postoperative Nursing Care: Postoperative Nursing Care: -Maintain pt on bedrest until BP stable. -Maintain pt on bedrest until BP stable. -Monitor for hemorrhage (glands are very vascular). -Monitor for hemorrhage (glands are very vascular). -Monitor BP, fluid balance, electrolyte levels (large amount of hormone dumped in system during surgery). -Monitor BP, fluid balance, electrolyte levels (large amount of hormone dumped in system during surgery). -Administer high-dose corticosteroids (ie. hydrocortisone). -Administer high-dose corticosteroids (ie. hydrocortisone). -Monitor for infection (result of high-dose corticosteroids). -Monitor for infection (result of high-dose corticosteroids). -Collect morning urine samples (same time each morning) for measurement of cortisol…….evaluates effectiveness of surgery. -Collect morning urine samples (same time each morning) for measurement of cortisol…….evaluates effectiveness of surgery. -Assess pt for painful joints, pruritis, peeling skin and severe emotional disturbances…….indicate need for adjustment to drug doses. -Assess pt for painful joints, pruritis, peeling skin and severe emotional disturbances…….indicate need for adjustment to drug doses.

105 Pituitary Disorders Excessive secretion of GH in children is Gigantism….when GH excess occurs before closure of epiphyses. Excessive secretion of GH in children is Gigantism….when GH excess occurs before closure of epiphyses. Excessive secretion in adults results in Acromegaly….overgrowth of bones and soft tissues. Excessive secretion in adults results in Acromegaly….overgrowth of bones and soft tissues. *Overproduction of GH is almost always caused by a benign pituitary tumor.

106 Hyperpituitarism - Acromegaly Clinical Manifestations (excessive GH secretion) Clinical Manifestations (excessive GH secretion) 1. Coarse features( e.g., broad skull, protruding 1. Coarse features( e.g., broad skull, protruding jaw/hands/feet) jaw/hands/feet) 2. Mild joint pain to crippling arthritis 2. Mild joint pain to crippling arthritis 3. Thickened heel pads. 3. Thickened heel pads. 4. Thick tongue resulting in speech difficulties. 4. Thick tongue resulting in speech difficulties. 5. Sleep apnea r/t upper airway narrowing. 5. Sleep apnea r/t upper airway narrowing. 6. Skin becomes thick, leathery & oily. 6. Skin becomes thick, leathery & oily. 7. Possible neuropathy & muscle weakness. 7. Possible neuropathy & muscle weakness. 8. Cardiovascular disease may manifest as HPT, angina, CHF. 8. Cardiovascular disease may manifest as HPT, angina, CHF. 9. Change in ring and shoe size. 9. Change in ring and shoe size. 10. Decreased libido. 10. Decreased libido. 11. Amenorrhea. 11. Amenorrhea. 12. Impotence. 12. Impotence. 13. Visual disturbances r/t pressure created by tumor. 13. Visual disturbances r/t pressure created by tumor. 14. Hyperglycemia r/t GH antagonizing effects on insulin. 14. Hyperglycemia r/t GH antagonizing effects on insulin. 15. Polydipsia & polyuria 15. Polydipsia & polyuria

107 Hyperpituitarism - Acromegaly Collaborative Care: may be 1 or a combination of the following…. Collaborative Care: may be 1 or a combination of the following…. 1. Surgical Therapy (removal of tumor or entire gland)….transsphenoidal approach: incision made in inner aspect of upper lip and gingiva. - lifetime hormone replacement therapy consists of hormones produced by the target organs (glucocorticoids, thyroid hormone, sex hormones). 2. Radiation Therapy: indicated when surgery has failed to produce complete remission. Also used to reduce size of tumor before surgery. 3. Drug Therapy: often used as initial treatment or as adjunctive therapy to surgery or radiation. a. Octreotide (somatostatin): reduces GH levels a. Octreotide (somatostatin): reduces GH levels b. Dopamine agonists: suppresses GH secretion b. Dopamine agonists: suppresses GH secretion c. Alternatively……GH receptor antagonist (Pegvisomant) c. Alternatively……GH receptor antagonist (Pegvisomant)

108 Syndrome of Inappropriate Antidiuretic Hormone: SIADH Definition: overproduction or oversecretion of ADH Definition: overproduction or oversecretion of ADH Cause (most common): malignancy, esp. small cell lung cancer….cells are capable of producing, storing and releasing ADH Cause (most common): malignancy, esp. small cell lung cancer….cells are capable of producing, storing and releasing ADH Characteristics: Characteristics: -fluid retention, increased body weight. -serum hypoosmolality -dilutional hyponatremia -hypochloremia -concentrated urine, low output. -normal or increased intravascular volume. -normal or increased intravascular volume. -normal renal function. -muscle cramps & weakness (caused by hyponatremia) -vomiting, abdominal cramps, muscle twitching, seizures (r/t hyponatremia). *Most common cause of hyponatremia in older adults.

109 Syndrome of Inappropriate Antidiuretic Hormone: SIADH Diagnostic Studies: Diagnostic Studies: *Urine and serum osmolality *Urine and serum osmolality Dilutional hyponatremia = serum sodium less than 134 mEq/L, serum osmolality less than 280 mOsm/kg (280 mmol/kg) and urine specific gravity > 1.005. *Other lab findings: decreased BUN, creatinine clearance, hemoglobin and hematocrit. *Other lab findings: decreased BUN, creatinine clearance, hemoglobin and hematocrit.

110 Syndrome of Inappropriate Antidiuretic Hormone: SIADH Treatment goals Treatment goals -dealing with underlying cause -restore normal fluid volume and osmolality. *If symptoms mild and serum sodium is > 125 mEq/L (125 mmol/L), only treatment may be restriction of fluids to 800 – 1000 ml per day…….500ml restriction if for severe hyponatremia. *In severe hyponatremia (less than 120 mEq/L) especially in presence of seizures, hypertonic saline solution (3% - 5)……very slow administration. *Diuretics (furosemide) only if serum sodium is at least 125 mEq because it may promote further sodium loss. *Administration of potassium supplements.

111 Syndrome of Inappropriate Antidiuretic Hormone: SIADH Nursing Responsibilities: Nursing Responsibilities:*Assessment: -hourly VS, intake & output, measurement of specific gravity. -hourly VS, intake & output, measurement of specific gravity. -daily wts -daily wts -LOC -LOC -Observe for signs of hyponatremia (ie. decreased neurologic function, seizures, nausea and vomiting, muscle cramping). -Observe for signs of hyponatremia (ie. decreased neurologic function, seizures, nausea and vomiting, muscle cramping). -Monitor heart and lung sounds. -Monitor heart and lung sounds.

112 Syndrome of Inappropriate Antidiuretic Hormone: SIADH Nursing Responsibilities: Nursing Responsibilities:*Management: -restrict fluid intake -restrict fluid intake -position head of bed flat or with no more than 10 degrees of elevation to enhance venous return to the heart and increase left atrial filling pressure -position head of bed flat or with no more than 10 degrees of elevation to enhance venous return to the heart and increase left atrial filling pressure -protect from injury (ie. assist with ambulation, side rails up on bed) d/t potential alterations in mental status. -protect from injury (ie. assist with ambulation, side rails up on bed) d/t potential alterations in mental status. -seizure precautions. -seizure precautions. -frequent turning, repositioning and ROM exercises -frequent turning, repositioning and ROM exercises -frequent oral hygiene -frequent oral hygiene -provide distractions to decrease discomfort of thirst related to fluid restrictions. -provide distractions to decrease discomfort of thirst related to fluid restrictions.