Endocrine Disorders
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| What are endocrine disorders? | Too much or too little hormone activity (hypo or hyper) Production/secretion. Tissue sensitivity.
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| Primary disorder | Problem with the gland
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| Secondary Disorder | Caused by problems outside the gland
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| Disorders of Posterior Pituitary (neurohypophysis) | Stores hormones produced in hypothalamus: Their release is stimulated by nerve impulses from the hypothalamus. ADH, Vasopressin/too little=Diabetes Insipidus (water loss). Too Much=SIADH(Syndrome of Inappropriate Antidiuretic Hormone) Water retention.
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| Diabetes Insipidus - Pathophysiology | Insufficient ADH. Kidneys do not reabsorb water. Diurese 3-15L per day. Pituitary Tumor or Trauma, Drugs, Psychogenic (pt drinking excessive amts of water. Nephrogenic (kidneys) There is enough ADH, but the kidneys do not respond to it.
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| Diabetes Insipidus - S/S | Polyuria, Polydipsia, Nocturia, Dilute Urine, Dehydration, Hypovolemic Shock, Decreased LOC, Death.
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| Diabetes Insipidus - Diagnosis | Urine Specific Gravity <1.005 (normal: 1.010-1.025). Serum Osmolality Increased. CT or MRI for cause. Water Deprivation Test (to rule out psychogenic DI).
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| Diabetes Insipidus - Therapeutic Inerventions | IV or SQ Vasopressin. Intranasal DDAVP. Thiazide Diuretics if Nephrogenic. Hypophysectomy if tumor.
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| Urine Specific Gravity | Indicator of kidneys ability to reabsorb water & chemicals from glomerular filtrate. Aids in evaluating hydration status & detecting problems r/t to secretion of ADH.
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| Serum Osmolality Increased | Measures concentration of solutes in serum. Osmolality affects movement of fluids across body membranes & kidney's ability to concentrate or dilute urine. Dehydration=increase in osmolality(diabetes insipidus) Overhydration=decrease in osmolality(SIADH)
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| Water deprivation test Stage I: | Pt deprived water for 6 hrs. Body weight & urine osmolality tested hourly. (urine continues to be diluted, & body weight decreases, DI is suspected)
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| Water deprivation test Stage II: | Pt deprived water for 6 hrs. Pt receives injection of ADH w/final urine test done 1 hour later. If DI is nephrogenic, kidneys do not respond.
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| Purpose of IV or SQ Vasopressin | Replace ADH, Used to control polydipsia & polyuria, regulates reabsorption of water by kidneys, Tx restores normal urination & thirst. Also used post-op for preventing & treating abdominal distention & dispelling gas interfering w/abdominal x-ray studies.
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| Vasopressin IV adverse reactions | Tremor, sweating, vertigo, nasal congestion, N/V, abdominal cramps(giving 1-2 glasses of water w/the dose will help minimize these side effects. water intoxication.
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| Water intoxication | overdosage, toxicity. Used cautiously in pts with CHF or vascular disease because may precipitate angina or myocardial infarction.
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| Intranasal DDAVP | Synthetic ADH(desmopressin) usually 2x day. for longer term replacement
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| Desmopressin routes | Nasal, IV, orally, or SubQ.
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| What happens if pt can't take meds on a routine basis. | If pt w/diabetes insipidus is unable to take routine meds, fluid deficit can happen rapidly. Wear ID, such as a medic-alert bracelet to inform medical personnel and others of the dx of diabetes insipidus and need for meds.
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| Thiazidee Diuretics if nephrogenics | Decreases urine flow in the absence of ADH.
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| Hypophysectomy | If tumor - Removal of pituitary gland.
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| Pre-op care of pt undergoing hypophysectomy | Baseline neurological assessment, pre-op teaching(deep breathing, incentive spirometry, avoid coughing, sneezing, straining post-op
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| Post-op care of pt undergoing hypophysectomy | Neurologic assessment, urine for specific gravity (risk for DI), nasal packing and mustache dressing(look for serous fluid outline, could be CSF), No coughing, sneezing, blowing, straining, bending, report CSF drainage, HRT w/target hormones.
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| DI Nursing Diagnosis | Deficient volume r/t to failure of regulatory mechanisms. Risk for ineffective health maintenance r/t failure of regulatory mechanisms.
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| SIADH Syndrome of Inappropriate ADH - Pathophysiology | Too much ADH, Water retention, hyponatremia, decreased serum osmolality
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| SIADH - Causes | Cancers (bronchogenic lung cancer-main cause), Drugs, Head trauma, Brain tumor.
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| SIADH - S/S | Weight gain, w/o edema (in vascular system), Dilutional hyponatremia, Serum osmolality decreased, concentrated urine, Muscle cramps and weakness, brain swelling because of the hyponatremia, seizures, death.
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| SIADH - Diagnostic tests | Serum/Urine sodium, Serum/urine osmolality, water load test.
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| Serum/Urine Sodium | Dilutional serum hyponatremia, increased urine sodium due to inappropriate concentration
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| Serum/urine osmolality | Serum osmolality decreased, urine osmolality increased.
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| Water load test | Involves administering a specific amt of water, then measuring blood and urine sodium and osmolality hourly for 6 hours. Pt with SIADH retains water instead of excreting it; unsafe fluid overload, so not done frequently.
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| SIADH - Therapeutic Interventions | Eliminate cause, surgical removal of tumor, fluid restriction. Hypertonic saline IV(NACL 3% administered cautiously. No more than 50cc/hr. Lasix or Declomycin.
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| Declomycin | A tetracycline antibiotic that decreases the availability of ADH, Do not put on fluid restriciton w/this med.
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| Lasix | Loop diuretic, given w/sodium supplements to increase urinary solute excretion.
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| A pint's a pound the world around | A gain of 1lb of fluid is equal to approx 1 pint (480 mL) of fluid.
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| SIADH - nursing diagnosis | Excess fluid volume r/t compromised reglatroy mechanism.
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| Disorders of Anterior pituitary | Secretes its hormones in response to releasing hormones from the hypotalamus.
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| Growth Hormone | Too little=short stature(dwarfism) Too Much=gigantism (acromegaly)
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| dwarfism - pathophysiology | Deficient GH in childhood. Growth not affected in adults.
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| dwarfism - Causes | Pituitary tumor, failure of pituitary to develop, psychosocial, malnutrition
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| Dwarfism - S/S | Grow only to 3-4 feet(5th percentile), slowed sexual maturation, may have menta retardation, other symptoms, depending on other pituitary hormones involved.
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| Acromegaly - pathophysiology | Excess GH in adults, bones grow in width, not length, organs and connective tissues also enlarge.
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| Acromegaly - Causes | Pituitary hyperplasia, pituitary tumor, hypothalamic dysfunction.
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| ACTH(adrenocorticotropic hormone) | Corticotropin is an anterior pituitary hormone that stimulates the adrenal cortex to produce and secrete adrenocotical hormones, primarily the glucocorticoids.
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| Uses of ACTH | Diagnostic testing of adrenocortical function, managing acute exacerbations of multiple sclerosis, nonsupurative thyroiditis, & hypercalcemia assoc w/cancer. Used as anti-inflammatory & immunosuppressant drug. Should avoid vaccinations w/live virus.
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| Three hormones produced by the thyroid gland | T4(Thyroxine)90%, T3(Triiodothyronine)10%, calcitonin.
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| T3 & T4 | T3-10% of thyroid secretion, remainder converted from T4 in the tissues. Coversion requires the presence of Iodine. Increase energy production & protein synthesis, increase cellular reaspiration of glucose & fatty acids, which increases the mtabolic rate.
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| Direct stimulus for secretion of T4 & T3 | TSH from anterior pituitary
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| Hypothyroidism - Pathophysiology | Deficient production of thyroid hormone, metabolic rate reduced. Primary=not enough thyroid hormone, Secondary=not enough TSH
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| Hypothyroidism- Causes | Congenital, inflammatory, iodine deficiency, thyroidectomy, autoimmune(hashimoto's thyroiditis-most common)
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| Hypothyroidism - Diagnosis | T3 & T4 low, TSH High in Primary, TSH low in secondary.
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| Hypothyroidism - S/S | Fatigue, bradycardia, constipation, mental dullness, cold intolerance, hypoventilation, dry skin and hair, weight gain, heart failure, hyperlipidemia, myxedema.
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| Hypothyroidism - Complications | Myxedema Coma: medical emergency, hypothermia, decreased VS and LOC, respiratory failure, death.
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| Myxedema Coma - Therapeutic interventions | Monitor VS, Warming blanket, mechanical ventilation, IV Levothyroxine (synthroid)
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| Hypothyroidism - Therapeutic interventions | Hormone replacement, Thyroid med should not be changed by pt to the cheapest generic brand, slight variation in level of hormone DANGEROUS!
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| Hypothyroidism - Medications | Labelled "NO Substitutions". Levothyroxine(levothroid, levoxyl, synthroid). Amour(desiccated thyroid) older version.
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| Amour | drug of choice for hypothyroidism, inexpensive, once a day dosage, more uniform potency. Not therapeutic for several weeks(needs several wks to work).
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| Amour adverse reactions | hyperthyroidism. Weight loss, mild diuresis, increased appetite, an increased pulse rate, and decreased puffiness of the face, hands, and feet. Pt may also rept an increased sense of well-being and increased mental activity.
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| Educating patient on hypothyroidism medication | Replacement therapy for life. Do not increase/decrease/skip dose, take drug in a.m. before breakfast on empty stomach. Dosage of drug may req periodic adj, periodic thyroid function tests will be needed. Weigh yourself weekly rpt gain/loss.
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| Hyperthyroidism-pathophysiology | Increased metabolic rate, increased beta receptors, Primary=too much thyroid hormone, secondary=Too much TSH.
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| Hyperthyroidism -Cause | Autoimmune (Grave's Disease) most common. Multinodular goiter, pituitary tumor(secondary), synthroid overdose.
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| Hyperthyroidism - S/S | Heat intolerance, increased appetite, weight loss, frequent stools, nervousness, hypermetabolic state, tachycardia, palpitations, tremor, heart failure, warm smooth skin, exophthalmos (grave's disease) caused by tissue swelling behind the eyes.
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| Hyperthyroidism - Complications | Thyrotoxic Crisis (Thyroid storm)
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| Thyrotoxic crisis (thyroid storm) | Life threatning, tachycardia, hypertension, extremely high fever, diaphoresis, dehydration, coma, death.
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| Thyroid Storm - Therapeutic interventions | IV fluids, cooling blanket iodine, propranolol(inderal), Acetaminophen(avoid ASA) for fever, oxygen.
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| Thyroid Storm - Diagnosis | Elevated T3 & T4, TSH(low in primary, high in secondary), TSI thyroid stimulating immunoglobulin is present in Grave's disease, CT/MRI if tumor suspected.
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| Thyroid Storm - Medications | Antithyroid drugs, PTU(Propylthiouracil), Tapazole(methimazole)Potassium Iodide(oral iodine), Propranolol(inderal) Adrenergic Beta blocker, Radioactive Iodine(I 131)
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| Antithyroid drugs | Inhibit the manufacture of thyroid hormones, but do not affect existing thyroid hormones circulating in the blod or stored in thyroid gland. Therapeutic effects may not be observed for 3-4 weeks.
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| PTU(propylthiouracil) & Tapazole(methimazole) | Antithyroid drugs or thyroid antagonists, therapeutic effects may not be observed for 3-4 weeks.
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| PTU & Tapazole - Adverse reactions | Agranulocytosis(increased risk for infection), sore throat, skin rash, fever, headache, hay fever.
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| PTU & Tapazole - Patient Education | Take drugs @ reg intervals around the clock (ex. every 8 hours), take as directed. Notify promptly any sign of infection, record weight 2x a week & notify of sudden gain/loss. Give instructions on monitoring & recording pulse rate to bring to DR. visits.
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| Potassium Iodide(oral Iodine) | May be given orally w/Tapazole or PTU to prepare for thyroid surgery. Suppresses release of thyroid hormone by decreasing vascularity of thyroid gland (Iodine effects how much blood gets to the thyroid)
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| Propranolol (inderal) Adrenergic Beta blocker | Given to interrupt sympathetic nervous system effects. Pt w/hyperthyroidism likely to have cardiac symtoms such as tachycardia or palpitations, this is given as adjunctive tx utnil therapeutic effects of antithyroid drug obtained.
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| Radioactive Iodine | Tx of choice for hyper-thyroidism in pts >21 yrs. Contraindicated in pregnant pts. Pts given antithyroid agts to obtain euthroid state pre surgery. Drug stopped 5-7 days before tx w/radioactive iodine. Check for allergies to iodine/shellfish. Given orally
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| Nursing care pts receiving radioactive iodine (in hospital) | Limit time spent w/pts, outer door closed, glove and gown, avoid if pregnant, visitors discouraged, take precautions with urine, emesis, body fluids, double flush toilet, instruct to drink lg amt of water to promote release of radioactive iodine.
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| Nursing care pts receiving radioactive iodine (in home) | Avoid close contact for a week, avoid oral contact, sleep alone, wash hands carefully after urinating, avoid pregnancy for at least a year.
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| Radioactive Iodine - adverse reactions | Tenderness & swelling of neck, sore throat, and cough may occur 2-4 days after radioactive iodine. May also need thyroid hormone replacement if hypothyroidism develops.
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| Goiter | Non toxic goiter is enlargement of thyroid gland from TSH stimulation which occurs due to inadequate thyroid hormone synthesis.
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| Goiter - pathophysiology | Enlarged thyroid gland, elevated TSH, hyperplasia
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| Goiter - Causes | Low thyroid hormone, Iodine deficiency, Rare in USA, Virus, Genetic, Goitrogens(substances that interfere with the body's use of iodine, turnips, cabbage, broccoli, PTU, sulfonamides, lithium, aspirin
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| Goiter - S/S | Enlarged thyroid, hypothyroid, hyperthyroid or euthyroid, dysphagia, difficulty breathing.
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| Goiter - Diagnosis | Thyroid scan (hyperactive- areas of blk regions(hot spots) benign modules. Hyopactive-areas of white(cold spots) Malignanacies.)
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| Goiter - Diagnosis (cont) | pt will remain NPO for 45 mins after ingesting the isotope, scan is performed 24hrs later, If technetium is used, it is admin 30 mins before scan. Iv admin elimintes need for fasting. TSH, T3, T4.
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| Goiter - Therapeutic intervention | Treat cause, avoid goitrogens, treat hypo or hyperthyroidism, thyroidectomy if size causing symptoms.
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| Goiter - nursing care | Monitor breathing(stridor), Monitor swallowing, dietary consult, swallowing evaluation(done by speech therapy)
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| Thyroid Cancer | Tumor of the thyroid gland, usually benign, more common in Women but rare.
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| Thyroid Cancer - Causes | Hyperplasia, radiation(chernobyl accident), Iodine deficiency, goitrogens.
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| Thyroid Cancer - S/S | Hard painless nodule, dysphagia, dyspnea if obstruction, thyroid hormone usually normal.
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| Thyroid Cancer - Diagnosis | Thyroid scan shows "cold spots", biopsy, fine needle aspiration biopsy and local anesthesia, 21 gauge needle inserted into nodule; tissue from thyroid w/drawn and placed on slide for exam. common sore throat after surgery.
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| Thyroid Cancer - Therapeutic interventions | Radioactive iodine, chemo, thyroidectomy (partial or total)
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| Thyroidectomy Pre op nursing care | Monitor breathing & swallowing, assess nutrition status, monitor vital signs, Iodine or antithyroid drugs to achieve euthyroid state(usually takes 6 weeks)Saturated potassium iodide to reduce the vascularity of the gland. Teach post op care.
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| Thyroidectomy Post Op nursing care | Monitor for resp distress, due to hemorrhage, edema, or laryngeal spasms, assess signs of hypocalcemia(paresthesia of mouth, toes, fingers, generalized muscle twitching), hoarseness, Monitor VS, O2 saturation, & dressing q 15 min. progressing to q 4hrs,
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| Thyrotoxic crisis | Rare since use of antithyroid drugs before surgery have become routine. Tetany, caused by low calcium levels if parathyroid glands accidentally removed(tingling, muscle spasms, twitching, cardiac dysrhythmias.)
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| Parathyroid Glands | 4 parathyroid glands, 2 on the back of each lobe of the thyroid gland. Produce parathyroid hormone (PTH) Antagonist to calcitonin, maintains normal blood levels of calcium and phosphate(calcium ions important for blood clotting and neuron transmission.)
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| Parathyroid Glands - target organs | Bone, small intestine, kidneys.
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| PTH | Secreted when calcium levels are low, & inhibited when calcium levels increase. Acts on bone to inhibit bone formation & stimulates bone resorption, release phosphate & Ca++ in blood. stimulates excretion of phosphate & reabsorption of calcium by kidneys
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| Hypoparathyroidism - pathophysiology | Decrease in PTH, Calcium stays in bones, hypocalcemia, hyperphosphatemia.
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| Hypoparathyroidism - Causes | Heredity, Accidental removal of parathyroids during thyroidectomy
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| Hypoparathyroidism - Complications | Tetany(not enough calcium), neruomuscular irritability, numbness and tingling of fingers and perioral area, muscle spasms cardiac dysrhythmias. Positive chvostek's sign(tap face - spasm of face is positive indicating hypocalcemia. Positive trousseau's
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| Hypoparathyroidism - Diagnosis | PTH Low, Serum Calcium low
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| Hypoparathyroidism - Therapeutic Interventions | IV Calcium Gluconate(given for hypocalcemic tetany) Long term Calcium w/vit d, high calcium diet, thiazide diuretics, reduce amt of calcium excreted in urine.
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| Hyperparathyroidism - Pathophysiology | Parathyroid overactivity, increased PTH, hypercalcemia, hypophosphatemia
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| Hyperparathyroidism - Causes | Parathyroid hyperplasia, benign parathyroid tumor, heredity.
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| Hyperparathyroidism - S/S | Fatigue, Depression, Confusion, N/V, Kidney stones, joint pain, pathologic fx, dysrhythmias, cardiac arrest, coma
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| Hyperparathyroidism - Diagnosis | Serum calcium elevated, phosphate decreased, PTH elevated, X-rays for bone density
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| Hyperparathyroidism - therapeutic interventions | IV NS to dilute calcium, furosemide(lasix)to increase urine excretion of calcium. Calcitonin, alendronate(fosamax) prevent calcium rlease from bone.
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| Bone resorption inhibitors | bisphosphonates, alendronate(fosamax), ebandronate(boniva), risedronate(actonel), Zoledronic acid(zometa, reclast) Take w/6-8oz water in a.m., do not lie down 30mins after taking, wait 30mins before taking other food or drink. reverse progression of osteo
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| Calcitonin(miacalcin | Usually intranasal, but can also be given SQ or IM, inhibits osteoclastic bone resorption and promotes renal excretion of calcium.
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| Hyperparathyroidism - Nursing implications | Observe for signs of hypocalcemic tetany, nervousness, irritability, paresthesia, muscle twitching, tetanic spasms, seizures.
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| Hyperparathyroidism - Estrogen therapy | Estrogens contribute to the conservation of calcium and phosphorus. Parathyroidectomy.
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| Adrenal glands | Located on top of each kidney, consists of inner adrenal medulla and outer adrenal cortex.
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| Adrenal Medulla | Cells secrete catecholamines & are sympathomimetic.
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| Epinephrine | secreted in lg amts(4x) increase HR, increase contractions, stimulates vasoconstriciton in skin, stimulates vasodilation in skeletal muscles, Dilates bronchioles, decreases peristalsis, stimulates liver to convert glycogen to glucose, increase use of fats
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| Norepinephrine | Secretion stimulated by the hypothalamus in stressful situations
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| Pheochromocytoma | Uncommon, tumor of chromaffin cells of adrenal medulla, secretes epinephrine and norepinephrine, usually benign, cuase unk.
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| Pheochromocytoma - S/S | Fight or flight, severhypertension, tachycardia, palpitations, tremor, diaphoresis, anxiety, hyperglycemia, HA, vision changes, risk for stroke, risk for organ damage.
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| Pheochromocytoma - Diagnosis | 24-hour urine for metanephrines and VMA, end product of catecholamine metabolism, No caffeine or medications before test. CT or MRI to find tumor.
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| Pheochromocytoma - Therapeutic interventions | Beta blockers (propranolol), reduce fight or flight symptoms. Alpha blockers (phenoxybenzamine) dilate blood vessels to control hypertension. Adrenalectomy.
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| Pheochromocytoma - Nursing Diagnosis | Risk for injury r/t hypertensive crisis.
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| Adrenal cortex | Secretes steroid hormones, mineralcorticoids (aldosterone). promotes salt retention. Glucocorticoids(Cortisol) affect carb metabolism, sex hormones. Male androgens, female estrogen.
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| Adrenal cortex hormone imbalance | Hyposecretion=Addison's disease, Hypersecretion=Cushing's disease
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| Aldosterone | Targe organ the kidneys, increases reabsorption of sodium ions and excretion of potassium ions by kidney.
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| Cortisol | most abundant glucocorticoid. many target tissues. stimulates gluconeogenesis.
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| Addison's Disease - Pathophysiology | Rare, deficient Cortisol and/or aldosterone, and /or androgens
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| Addison's Disease - Cause | Autoimmune, AIDS, CA, Pituitary or hypothalamus problem, Abrupt discontinuance of steroids.
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| Addison's Disease - S/S | Hypotension, sodium loss, potassium retention, hypoglycemia, weakness, fatigue, bronze skin, N/V.
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| Addison's Disease - Diagnosis | Serum and urine cortisol level, blood glucose, electrolytes, BUN/HCT, ACTH stimulation test.
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| Addison's Disease - Complications | Adrenal crisis: profound dehydration, hypotension, hypoglycemia, shock, coma, death.
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| Adrenal Crisis - Therapeutic Interventions | Glucocorticoids and mineral corticoids daily for life. 2/3 a.m. 1/3 p.m. Double or triple in times of stress, may be placed on high sodium diet.
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| Glucocorticoids | Anti-inflammatory activity of these hormones makes them valuable for suppressing inflammation and modifying immune response, but they have many adverse reactions.
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| Glucocorticoids - adverse reactions | GI upset, take orally w/meals or snacks. Increased BS, abnormal fat deposits(moon face, buffalo hump), decreased extremity size, edema hypertension, euphoria, thinned skin w/purpura, glaucoma, peptic ulcers, retardation.
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| Glucocorticoids- medication | Cortisone, Dexamethasone(decadron), methylprednisolone, hydrocortisone, prednisone, prednisolone, triamcinolone, betamethasone.
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| Stopping glucocorticoids | Long term. these medications stop production of seroids by the body, so if the medication is suddenly stopped, the body may be unable to function.
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| Tapering steroids | Stopping the drug suddenly leads to steroid withdrawal syndrome, anorexia, N/V, lethargy, HA, fever, joint pain, skin peeling, myalgia, weight loss, and hypotension. Abruptly stopping drug may also result in rebound of Sx. of condition being treated.
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| Mineralcorticoids | fludrocortisone(florinef). Only currently availabe mineralcorticoid drug, used for replacement therapy for primary and secondary adrenocortical deficiency.
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| Crisis prevention | NEVER ABRUPTLY STOP STEROIDS! Taper dosage gradually, decreasing dosage daily to allow the adrenal gland to return to normal funtion. this will help prevent a secondary adrenal insufficiency.
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| Cushing's Syndrome - Pathophysiology | Excess adrenal cortex hormone, cortisol
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| Cushing's - Causes | Disease=pituitary tumor or hyperplasia Syndrome=prolonged glucocorticoid therapy
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| Cushing's - S/S | Salt and water retention, hypokalemia, thin fragile skin, acne, facial hair in women, amenorrhea "buffalo hump".
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| Cushing's - Diagnosis | Based on appearance, Plasma and urine cortisol, ACTH, Dexamethasone suppression test(elevated plasma cortisol levels in response to dexamethasone admin are assoc w/cushing's syndrome)
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| Cushing's - Therapeutic interventions | Surgery if tumor, every-other-day schedule for steroid therapy, symptom control, diabetes tx, low sodium, high potassium diet.
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| Adrenalectomy Pre op | Monitor electrolytes, glucose, preop training.
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| adrenalectomy post op | Monitor of adrenal crisis, lifelong hormone replacement if both adrenals removed.
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