Endocrine disorders

1. Endocrine disorders West Georgia Technical College ADN Program

2. The Endocrine System

3. The Glands • Exocrine • Secrete substances into ducts • Sweat • Tears • Endocrine • Produce hormones that travel to target tissues or organs

4. The Glandular Functions • Hypothalamus • Major regulating organ • Homeostasis • Nerve and glandular tissue • Shares closed circulatory system with anterior pituitary gland • Endocrine function – produces regulatory hormones • Link between the endocrine and nervous system

5. The Glandular Functions • Pituitary • Master gland • Stimulates release of hormones either directly or indirectly • Anterior • Secretes tropic hormones • Posterior • Communicates and works with hypothalamus

6. The Glandular Functions • Thyroid • Releases hormones that affect metabolism • Control of metabolism • Calcium and phosphorus balance • Parathyroid • Maintain calcium and phosphate blood levels

7. The Glandular Functions • Adrenal • Medulla • Plays vital role in response to stress • Cortex • Secretes steroid hormones • Plays vital role in the inflammatory response • Pancreas • Glucagon and insulin to regulate glucose blood levels

8. Hormone-Receptor Binding

9. The Hormones • Chemicals produced and secreted by specific tissues or organs • Regulation • Negative feedback • Controlling hormone levels • Positive feedback • An increased hormone level produces an increase in another hormone • Nervous system • Controls endocrine function through the central and sympathetic nervous system • Detects stress and how we feel

10. Positive and Negative Feedback System

11. Endocrine Assessment • Alterations of endocrine system on other body system functioning • Skin • Hair loss, dry skin, coarse hair, brittle nails, pigmentation • Head/face • Changes in voice, enlargement of neck, puffiness of face • Cardiovascular • Changes in blood pressure and heart rate, edema • Neurological • Memory loss, tremors, decreased sensations, sleep pattern changes including nightmares (disturbed or changes in sleep pattern during the aging progress) • Genitourinary • Changes in menstrual cycle, changes in urination pattern, color, odor • Musculoskeletal • Weakness, aches, changes in activities of daily living • Gastrointestinal • Weight changes, nutritional status, changes in urine and bowel patterns

12. Endocrine Assessment

13. Diagnostic Testing for Endocrine dysfunctions • Thyroid Scan • Medications with iodine may be discontinued for two weeks prior to test • Lugol’s solution, cough syrups, multivitamins • Hyperactivity shows as hot spots • Indicative of benign nodules • Hypoactivity shows as cold spots • Indicative of malignant nodules • Thyroid Ultrasound • Differentiate fluid filled cysts and tumors • No special preparation • Psychosocial nursing management for abnormal results

14. Endocrine disorders • Hyperprolactinemia • Prolactin secreting tumor • More common in women • Potential causes • Injury • Surgery • Estrogen therapy • Diseases • Medications • Haloperidol (Haldol) • Risperidone (Risperidol) • Cimetidine (Tagamet) • Verapamil (Calan)

15. Endocrine disorders • Hyperprolactinemia • Assessment • Excessive milk production, absence of menstruation, Failure to ovulate in women • Decreased facial and body hair in men as well as erectile dysfunction • Hyperprolactinemia • Interventions • Drug therapy- Bromocriptine (Parlodel) • Radiation therapy if not responding to medications • Radiosurgery

16. Acromegaly (Gigantism) Onset of growth hormone hypersecretion before puberty

17. Acromegaly (Gigantism) Goals of intervention Return hormone levels to normal Eliminate or reverse signs and symptoms Prevent complications and reverse body changes Nonsurgical management Drug therapy – octreotide (Sandostatin) Gamma knife procedure and radiotherapy Surgical management Goal- to reverse most signs and symptoms

18. Cushing’s Disease (Hypercorisolism) Etiology – related to pituitary or adrenal problems or the result of drug therapy for another problem Incidence/prevalence – pituitary adenoma; medications to treat asthma, rheumatoid arthritis Cushing’s Disease (Hypercorisolism) Clinical manifestations Skin changes – related to blood vessel fragility Cardiac and musculoskeletal changes – altered electrolytes Glucose metabolism – increased glycogen → glucose Immune changes – immunosuppression

19. Cushing’s Disease Non-surgical management Patient safety Prevent fluid overload Drug therapy – drugs that interfere with ACTH production Nutrition therapy – restrictions of fluids and sodium Monitoring nutrition, intake and output, weight Cushing’s Disease Surgical management Adrenalectomy When caused by adrenal tumor Monitor for signs of hypoadrenalism Lifetime glucocorticoid and mineralocorticoid for bilateral adrenalectomy Hypophysectomy When caused by pituitary tumor Newer approach via endonasal- Less evasive, no incision, reduced recovery time http://youtu.be/_fioC34LZeg

20. Hypopituitarism Deficiency of one or more anterior pituitary hormones results in metabolic problems and sexual dysfunction Panhypopituitarism—decreased production of all of the anterior pituitary hormones Most life-threatening deficiencies—ACTH and TSH Hypopituitarism Causes Benign or malignant tumors, anorexia nervosa, shock or severe hypotension, head trauma, infection, postpartum hemorrhage Treatment Replacement of deficient hormones

21. Diabetes Insipidus Water metabolism problem caused by an antidiuretic hormone deficiency (either a decrease in ADH synthesis or an inability of the kidneys to respond to ADH) Classification Nephrogenic – inherited disorder Primary – defect in hypothalamus or pituitary Secondary – tumors, trauma, injury Drug-related – interfere with kidney response to ADH

22. Diabetes Insipidus Clinical manifestations related to dehydration Increase in frequency of urination and excessive thirst Dehydration and hypertonic saline tests used for diagnosis of the disorder Urine diluted with a low specific gravity (<1.005) Diabetes Insipidus Interventions Drug therapy- aqueous pitressin (Vasopressin) Early detection of dehydration and maintenance of adequate hydration Teach patients to weigh themselves daily to identify weight gain

23. Syndrome of Inappropriate Antidiuretic Hormone (SIADH) Vasopressin is secreted even when plasma osmolarity is low or normal Feedback mechanisms do not function properly Water is retained, resulting in hyponatremia (decreased serum sodium level) Syndrome of Inappropriate Antidiuretic Hormone (SIADH) Assessment Neurological Signs of hyponatremia Seizures if sodium reaches 110 mmol/L Interventions Fluid restriction Drug therapy—diuretics, hypertonic saline Monitor for fluid overload Safe environment

24. Hypofunction/secretion of adrenal gland Adrenocortical steroids decrease as a result of inadequate secretion of ACTH Loss of aldosterone and cortical action Decreased gluconeogenesis Depletion of liver and muscle glycogen Hypoglycemia Reduced urea nitrogen excretion Anorexia and weight loss Potassium, sodium, and water imbalances Hypofunction/secretion of adrenal gland Dysfunction of the hypothalamic-pituitary control mechanism Direct dysfunction of adrenal tissue Restore extracellular fluid volume Replace electrolytes Hydrocortisone replacement

25. Addison’s disease Primary- idiopathic (autoimmune) disease, tuberculosis, metastatic cancer Secondary- sudden cessation of long-term high-dose glucocorticoid therapy, hypophysectomy Addisonian crisis Life-threatening event in which the need for cortisol and aldosterone is greater than the available supply Usually occurs in a response to a stressful event

26. Hyperaldosteronism Increased secretion of aldosterone results in mineralocorticoid excess Excessive secretion of aldosterone from one or both adrenal glands Most common issues—hypokalemia and hypertension Hyperaldosteronism Treatment Surgery is most common treatment in the early stage – adrenalectomy Glucocorticoid replacement Drug therapy –spironolactone (Aldactone)-potassium sparing diuretic to control hypokalemia and hypertension

27. Pheochromocytoma Catecholamine-producing tumors arise in the adrenal medulla Tumors produce, store, and release epinephrine and norepinephrine Hyperstimulation of the adrenal medulla caused by the tumor Interventions Surgery to remove affected adrenal gland(s) is main treatment Assessment of blood pressure is critical during pre- and post-op

28. Hyperthyroidism (Thyrotoxicosis) Elevated T3 and T4, abnormally low TSH level Acceleration of metabolism with toxic manifestations Grave’s disease is the most common cause Symptoms- fatigue, excessive perspiration, heat intolerance, cardiac palpitations, eye changes, loss of appetite, anxiety and irritability

29. Hyperthyroidism Surgical Complications Hypocalcemia and tetany when parathyroid gland is damaged during surgery Monitor for numbness and tingling of the mouth or toes and fingers; hypocalcemia, muscle twitching Have calcium gluconate or calcium chloride available Laryngeal Nerve Damage Monitor the patient’s voice every 2 hours for hoarseness or weakness Hyperthyroidism Thyroid Storm Complications Uncontrolled hyperthyroidism Monitor for fever, tachycardia, and elevated systolic BP, GI disturbance, anxiety and tremors, seizures, and coma Interventions include airway management/ adequate ventilation and stabilizing hemodynamic status http://youtu.be/FncuqMUoMTs

30. Case Study One You are caring for a 41-year-old woman who is the mother of two small children. She states that she has felt “nervous and tired” for approximately 1 month. Today she has had a sudden onset of breathlessness with cardiac palpitations. She states “I have not been feeling well for about a month, but when I felt breathless I thought I should be checked out.” Upon further questioning the nurse finds that the woman also has had a loss of weight of approximately 30 lbs., frequent loose stools, loss of hair on the scalp, and a feeling of “burning up.”

31. Hypothyroidism Decreased metabolism from low levels of thyroid hormones Cellular energy is decreased and metabolites build up Common changes in appearance: coarse features, edema around the eyes and face, blank expression and thick tongue Slowing of intellectual functions Hypothyroidism Myxedema – mucinous edema,tongue thickens, voice husky Myxedema coma – rare complication if untreated or poorly treated hypothyroidism Assess safety and supportive services Hormone replacement and side effects is most important

32. Thyroiditis Inflammation of the thyroid gland Hashimoto’s disease- autoimmune type Drug therapy- thyroid supression using levothyroxine (Synthroid) Radiation therapy

33. Hyperparathyroidism Increased levels of PTH act directly on the kidney Increased reabsorption of calcium and increased phosphate excretion → Hypercalcemia and hypophosphatemia Diuretic and hydration therapies Monitoring – cardiac function, intake and output Prevention of injury from significant bone loss Parathyroidectomy Observe for respiratory distress Keep emergency equipment at bedside Hypocalcemic crisis can occur Recurrent laryngeal nerve damage can occur

34. Hypoparathyroidism Decreased function of the parathyroid gland Latrogenic hypoparathyroidism Caused by surgical removal Idiopathic hypoparathyroidism Spontaneous, unknown, possibly autoimmune Hypomagnesemia Alcoholics, malabsorption syndromes, chronic kidney disease, malnutrition Treatment Electrolyte correction of hypocalcemia, vitaminDdeficiency, and hypomagnesemia Teach drug regimen and interventions to reduce anxiety Stress that therapy for hypocalcemia is lifelong

35. Endocrine Disorders • Diabetes Mellitus • Elevated glucose levels and disturbances in metabolism of fats, carbohydrate, protein • Type I (insulin dependent, juvenile onset), Type 2 (non-insulin dependent, adult onset), Gestational Diabetes (glucose intolerance begins in pregnancy), prediabetes (sugar abnormal high but not high enough to classify as diabetes- usually treated by diet changes) • Other specific conditions resulting in hyperglycemia such as genetic defects, pancreatic diseases, medications, infections • Prolonged hyperglycemia can damage organs and cause long term complications

36. Endocrine disorders • Diabetes Mellitus • Proinsulin secreted and stored in the beta cells of the pancreas • The liver transforms proinsulin to insulin • Insulin attaches to receptors on target cells, where it promotes glucose transport through the cell membrane

37. Endocrine disorders • Diabetes Mellitus • Symptoms occurring when insulin not producing • Hyperglycemia, hypovolemia, hypoxia • Polyuria, polydipsia, polyphagia • Presence of ketone bodies • Acidosis, Kussmaul respiration

38. Endocrine Disorders • Diabetes Mellitus • Diagnostic criteria

39. Endocrine Disorders Diabetes Assessment

40. Endocrine Disorders • Diabetes Prevention • Primary • Lifestyle changes • Weight loss, diet change • Secondary • Controlling diabetes • Carbohydrate control • Alcohol contains sugars • Tertiary • Prevention of complications

41. Endocrine Disorders Diabetic Insulin Therapy

42. Endocrine Disorders • Diabetic Insulin Therapy • Insulin regimens – try to mimic the normal patterns of the pancreas • Factors influencing insulin absorption – injection site; timing, type and dose; physical activity • Mixing insulin changes the time of peak action • Complications of Diabetic Insulin Therapy • Lipoatrophy and lipohypertrophy • Avoid by rotating insulin sites • Forms of Diabetic Insulin Therapy • Continuous subcutaneous infusion • Injection devices-needleless system, pen-type injector • Insulin pump

43. Endocrine Disorders • Diabetes Oral therapy • Prescribed after unsuccessful dietary control • Patient is symptomatic • Started at lowest possible dose and increased every 1 – 2 weeks to obtain desired blood glucose • Insulin therapy is indicated when blood glucose can’t be controlled after the use of two or three different agents • Glipizide (Glucotrol), glyburide (Glynase), glimepiride (Amaryl), Metformin (glucophage) • Beta blockers are also being used to controlsugar and prevent cardiac and kidney problems

44. Case study two The client is a 48-year-old unconscious woman admitted to the ED. She has a known history of type 1 diabetes mellitus. Her daughter accompanies her and tells the staff that her mother has had the “flu” and has been unable to eat or drink very much. The daughter is uncertain whether her mother has taken her insulin in the past 24 hours. The client’s vital signs are temperature 101.8° F; pulse 120, weak and irregular; respiration 22, deep, and fruity odor; and blood pressure 80/42 mm Hg. Blood specimens and arterial blood gases are drawn and an IV infusion begun.

45. Endocrine Disorders • Diabetic Education • Insulin storage – refrigeration, spare bottle • Dose preparation – inspect the bottle • Syringes – size of syringe and needle, disposal, pre-filled syringes • Blood glucose monitoring – permits evaluation of therapy • Infection control measures – related to increased blood glucose, decreased tissue perfusion and effects of chronic illness • Diet therapy – individual plan that balances carbohydrates, protein, fat

46. Endocrine disorders • Nutritional Diabetic Education • Protein – 15% - 20% of total daily calories • Dietary fat and cholesterol – limit to decrease risk for CV disease • Fiber – aim for 14gm per 1000 calories • Sweeteners – approved nonnutritive sweeteners • Alcohol – moderate use when diabetes is well controlled will not affect blood glucose • Exercise Diabetic Education • Benefits of exercise – lower insulin requirements, improved insulin sensitivity • Avoid activities that will increase blood pressure or cause injury

47. Endocrine disorders • Diabetic foot care • Prevention of high-risk conditions • neuropathy, ulcers, amputation • Peripheral sensation management • Footwear and foot care • Breathable footwear • Use only lotions approved for diabetics

48. Endocrine disorders • Diabetic Surgical Management • Transplantation of the pancreas – for patients with end-stage kidney disease • Whole-pancreas transplantation – alone, with kidney or after kidney transplant • Islet cell transplantation – considered experimental • Chronic Pain Management • Neuropathic pain results from damage to the nervous system anywhere along the nerve • Pharmacologic agents – anticonvulsants and antidepressants used for nerve pain • Monitor glucose control

49. End0crine disordersdiabetic Complications • Drug therapy goal- to lower serum glucose level • Monitor for cardiac changes related to electrolyte imbalance • Management of metabolic acidosis • Ketone levels lower • Glucose levels higher • Monitor for cardiac dysrhythmias • Fluid therapy • Correction of hypovolemia state • Elderly have higher mortality rate • Slower recognition of dehydration and decreased cardiac function Diabetic Ketoacidosis Hyperosmolar Hyperglycemic Non-ketotic Syndrome

50. Endocrine disordersdiabetic complications • Blood glucose level <70 mg/dL • At least 15 g of carbs, 3 to 4 glucose tablets, 4 to 6 ounces of juice or Glucagon 1mg • Prevention strategies • Monitor Insulin for excess, adequate nutrition intake • Dawn Phenomenon • Morning hyperglycemia from pre-dawn release of cortisol and growth hormones • Treatment by adjusting medication • Somogyi Effect • Early morning hypoglycemia from too much insulin • Treatment by adjusting insulin Hypoglycemia Hyper vs. Hypo glycemia