Endocrine Notes

Vascular Disorders

Assessment of the Endocrine System

Anatomic location of the thyroid gland.1Endocrine System

The locations of various glands within the endocrine system.2Anatomy & Physiology ReviewHypothalamusPituitary glandsGonadsAdrenal glandsThyroid glandParathyroid glandPancreas3Hypothalamus

The hypothalamus, hypophysial stalk, anterior pituitary gland, and posterior pituitary gland.4Endocrine Glands: Adrenal GlandAdrenal cortexMineralocorticoids (aldosterone)Corticosteroids (cortisol)

Adrenal medullaCatecholamines (norepinephrine and epinephrine)5Thyroid Gland Control of metabolismCalcium and phosphorus balance

6Assessment MethodsPatient historyNutrition historyFamily history and genetic riskCurrent health problemsCurrent health problems including any changes in:Energy levelsEliminationSexual and reproductive functionsPhysical appearance7Physical AssessmentExamine for:Prominent forehead or jawRound or puffy faceDull or flat expressionExophthalmosVitiligoStriaeHirsutism8Laboratory TestsStimulation/suppression testsAssaysUrine testsTests for glucoseImaging assessmentOther diagnostic assessment

What priority nursing assessments and interventions are necessary, based on diagnostic findings. 9Care of Patients with Pituitary and Adrenal Gland Problems10Disorders of the Anterior Pituitary GlandPrimary pituitary dysfunctionSecondary pituitary dysfunctionPituitary hypofunctionPituitary hyperfunction11Hypopituitarism Deficiency of one or more anterior pituitary hormonesresults in metabolic problems, sexual dysfunctionPanhypopituitarismdecreased production of all anterior pituitary hormonesMost life-threatening deficienciesACTH and TSHDeficiency of gonadotropinsGrowth hormone stimulates liver to produce somatomedins that enhance growth activity12ACTH is made in the pituitary gland in response to the release of another hormone, called corticotropin-releasing hormone (CRH), by the hypothalamus. In turn, the adrenal glands then make a hormone called cortisol, which helps your body manage stress. Cortisol is needed for life, so its levels in the blood are closely controlled. When cortisol levels rise, ACTH levels normally fall. When cortisol levels fall, ACTH levels normally rise.Hypopituitarism (contd)CausesBrain tumorHead traumaInfections or inflammation of the brain and the tissues that support the brainRadiation therapyStrokeSubarachnoid hemorrhage (from a burst aneurysm)Tumors of the pituitary gland or hypothalamus

Assessment

13Abdominal painDecreased appetiteDecreased sexual interest (in men)Dizziness or faintingExcessive urinationand thirstFailure to release milk (in women)FatigueHeadacheInfertility (in women)Lack of sex drive (in women)VisionproblemsWeakness

Assessment FindingsLoss of armpit or pubic hairLoss of body or facial hair (in men)Low blood pressureLow blood sugarSensitivity to coldShortheight (less than 5 feet) if onset is during a growth periodSlowed growth and sexual development (in children)Stoppingof menstrual periods (in women)Weight loss14Brain CT scanPituitary MRISerum ACTHSerum cortisolSerum estradiol (estrogen)Serum follicle stimulating hormone (FSH)Serum insulin-like growth factor 1 (IGF-1)Serum luteinizing hormone (LH)Serum testosterone levelSerum thyroid stimulating hormone (TSH)Thyroid hormone (T4)

Diagnostic Test15Interventions:Lifelong replacement of deficient hormonesAndrogen therapy for virilization; gynecomastia can occurEstrogens and progesteroneGrowth hormone

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17Causes of Hyperpituitarism Hormone oversecretion occurs with pituitary tumors or hyperplasiaGenetic considerationsPituitary adenoma18GigantismOnset of growth hormone hypersecretion before puberty

The clinical features of growth hormone (GH) excess. Robert Wadlow, the Alton giant, weighed 9 pounds at birth but grew to 30 pounds by the time he was 6 months old. By his first birthday, he had reached 62 pounds. At the time of his death at age 22 from cellulitis of the feet, he was 8 feet, 11 inches tall and weighed 475 pounds.19AcromegalyGrowth hormone hypersecretion after puberty

The progression of acromegaly.20HyperpituitarismCausesAssessmentNonsurgical management:Drug therapy (Parlodel, Dostinex, Permax, Sandostatin, Somavert)RadiationGamma knife procedure21Surgical Management

The transsphenoidal surgical approach to the pituitary gland. Selective adenomectomy leaves normal pituitary tissue undisturbed.The transsphenoidal surgical approach to the pituitary gland. Selective adenomectomy leaves normal pituitary tissue undisturbed.22Postoperative CareMonitor neurologic responseAssess for postnasal dripElevate HOBAssess nasal drainageAvoid coughing soon after surgeryAssess for meningitisHormone replacementAvoid bendingAvoid straining at stool23Postoperative Care (contd)Avoid toothbrushingNumbness in the area of the incisionDecreased sense of smellVasopressin24Diabetes Insipidus (DI)Water metabolism problem caused by an ADH deficiency (either decrease in ADH synthesis or inability of kidneys to respond to ADH)Classifications:NephrogenicPrimarySecondaryDrug-related25DI AssessmentSymptoms of dehydrationIncrease in frequency of urination and excessive thirstDehydration and hypertonic saline tests used for diagnosisUrine diluted with low specific gravity (1 week will suppress adrenal production, and oral steroids should be tapered. Therapies to reduce the resorption of bone may include increased calcium intake, vitamin D supplementation, bisphosphonates (e.g., alendronate [Fosamax]), and institution of a low-impact exercise program.

38Adrenal Gland Hyperfunction Hypersecretion results in Cushings syndrome/disease hypercortisolism or excessive androgen production39Hypercortisolism (Cushings Disease)EtiologyIncidence/prevalencePatient-centered collaborative careAssessment:Clinical manifestationsskin changes, cardiac changes, musculoskeletal changes, glucose metabolism, immune changes40Hypercortisolism (Cushings Disease)Psychosocial assessment

Laboratory testsblood, salivary, urine cortisol levels

Imaging assessment41

42Hypercortisolism: Nonsurgical ManagementPatient safetyAvoid injuries (Patient easily bruise)Avoiding others with infectious diseasesDrug therapyNo abrupt stop of drug therapyNutrition therapyMonitoringPossible bleedingSigns of infectionfever43Hypercortisolism: Surgical ManagementHypophysectomyRemoval of the pituitary gland

AdrenalectomyRemoval of the adrenal gland

See page3 1471-1475 for post op care44Hyperaldosteronism Increased secretion of aldosterone results in mineralocorticoid excess

Primary hyperaldosteronism (Conn's syndrome) result of excessive secretion of aldosterone from one or both adrenal glandsPA affects both genders equally and occurs most frequently between 30 and 50 years of age. It is estimated that approximately 1% of cases of hypertension 45Hyperaldosteronism Clinical ManifestationsElevated levels of aldosterone Sodium retentionElimination of potassiumSodium retention leads toHypernatremiaHypertensionHeadacheCopyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.Edema does not usually occur because the rate of sodium excretion increases, which prevents more severe sodium retention.

46Hyperaldosteronism Clinical ManifestationsEliminating potassium leads toHypokalemiaMuscle weaknessFatigueCardiac dysrhythmiasGlucose intoleranceMetabolic alkalosisMay lead to tetany

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.47Hyperaldosteronism Diagnostic StudiesPrimary aldosteronism plasma aldosterone levels sodium levels potassium levels renin activityAdenomas are localized by CT or MRI.Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.The diagnosis of hyperaldosteronism should be suspected in all hypertensive patients with hypokalemia who are not being treated with diuretics.

48Hyperaldosteronism InterventionsAdrenalectomyPreferred treatment for primary hyperaldosteronism is surgical removal of the adenoma.Before surgery, patients need Low-sodium dietPotassium-sparing diureticsAntihypertensive agentsAssess BPFluid/electrolyte balance

Glucocorticoid replacementWhen surgery cannot be performedspironolactone therapy49Pheochromocytoma Etiology and PathophysiologyCaused by a tumor of the adrenal medullaProduces excessive catecholaminesMost often in young to middle-aged adults

Clinical features includeSevere, episodic hypertensionSevere, pounding headacheTachycardia with palpitationsProfuse sweatingAbdominal or chest painDiagnosis is often missed.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.The most dangerous immediate effect of the disease is severe hypertension. If left untreated, it may lead to hypertensive encephalopathy, diabetes mellitus, cardiomyopathy, and death.

50Pheochromocytoma Catecholamine-producing tumors arising in the adrenal medullaTumors produce, store, release epinephrine and norepinephrine

51Someone with a pheochromocytoma usually has three classic symptoms

HeadacheSweatingHeartpalpitations(a fast heart beat) in association with markedly elevated blood pressure (hypertension). May also have symptoms Anxiety, nausea, tremors, weakness, abdominal pain and weight loss.

52Pheochromocytoma Diagnostic StudiesAdrenal Sampling Best tesing method

Measurement of urinary fractionated metanephrines and catecholamines in 24-hour collection.

Serum catecholamines are elevated.

CT and MRI are used for tumor localization.Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.53Pheochromocytoma TreatmentSurgical removal of tumorCalcium channel blockers control BP.Sympathetic blocking agents may BP symptoms of catecholamine excessBeta blockers to dysrhythmiasCopyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.Treatment with -adrenergic and -blockers is required preoperatively to control blood pressure and prevent intraoperative hypertensive crises. After adequate -adrenergic blockade, -blockers (e.g., propranolol [Inderal]) are used to decrease tachycardia and other dysrhythmias.

54Pheochromocytoma TreatmentPatient needs RestNourishmentEmotional support

Monitor BP closely.Make patient as comfortable as possible.Monitor glucose.

Stress importance of Follow-up care Routine BP monitoringCopyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.55The nurse determines that the patient in acute adrenal insufficiency is responding favorably to treatment when:

1. The patient appears alert and oriented.2. The patients urinary output has increased.3. Pulmonary edema is reduced as evidenced by clear lung sounds.4. Laboratory tests reveal elevations of potassium and glucose serum levels and a decrease in the sodium level. Audience Response QuestionCopyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.56Answer: 1Rationale: The patient in acute adrenal insufficiency will have the following clinical manifestations: Hypotension, tachycardia, dehydration, hyponatremia, hyperkalemia, hypoglycemia, fever, weakness, and confusion. Collaborative care will include administration of corticosteroids. An outcome that would indicate patient improvement would be improved level of consciousness (i.e., alert and oriented).Care of Patients with Problems of the Thyroid and Parathyroid Glands

57Hyperthyroidism Thyrotoxicosis Graves disease: goiter, exophthalmos, pretibial myxedemaAssessmentHistoryPhysical assessmentClinical manifestationsPsychosocial assessment58

59Exophthalmos

Bulging of theeyeanteriorly out of the orbit. Exophthalmos can be either bilateral (as is often seen inGraves' disease) or unilateral (as is often seen in an orbital tumor). 60Exophthalmos is a type of infiltrative ophthalmopathy that is due to impaired venous drainage from the orbit, which causes increased fat deposits and fluid (edema) in the retroorbital tissues. Increased pressure forces the eyeballs outward. The upper lids are usually retracted and elevated, with the sclera visible above the iris. When the eyelids do not close completely, the exposed corneal surfaces become dry and irritated.

61Cardiovascular systemBruit over thyroid glandSystolic hypertension cardiac outputDysrhythmiasCardiac hypertrophyAtrial fibrillation Intolerance to heat sensitivity to stimulant drugsElevated basal temperature

Clinical ManifestationsGI system appetite, thirstWeight lossDiarrheaSplenomegaly Hepatomegaly

Integumentary systemWarm, smooth, moist skinThin, brittle nailsHair lossClubbing of fingersDiaphoresisVitiligo 62Goiter

63Laboratory TestsT3, T4, T3RU, TSH, TSH-RabNormals.Thyroid scanUltrasonographyECG64Nonsurgical ManagementMonitoringReducing stimulationPromoting comfortDrug therapy (antithyroid drugs, iodine preparations, lithium, beta-adrenergic blocking drugs)

See page 497 65Surgical ManagementTotal or subtotal thyroidectomyPostoperative complications:HemorrhageEncourage a balance in activity with frequent breaks between activities to avoid stressRespiratory distressHypocalcemia and tetanyLaryngeal nerve damage66Thyroid storm also called thyroid crisisCan be life threatening Eye and vision problems of Graves diseaseDouble vision, Difficulty focusing, Corneal drynessTeach patients to use sunglasses, artificial tears.Report any pain or abrupt changes immediatelyHead of the bed may need to be elevated to decrease periorbital fluid accumulationManagement Continued67Thyrotoxic crisisManifestations includeTachycardiaHeart failureShockHyperthermiaRestlessnessVomiting DiarrheaDeliriumComa

ComplicationsAgitationSeizuresAbdominal painNauseaAgitationSeizuresAbdominal painNausea68ComplicationsThyrotoxic crisisTreatment Thyroid hormone levels and clinical manifestations with drug therapyTherapyAimed at managing respiratory distress, fever reduction, fluid replacement, and management of stressorsCopyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.69Diagnostic StudiesHistoryPhysical examinationOphthalmologic examinationECGRadioactive iodine uptake (RAIU)Indicated to differentiate Graves disease from other forms of thyroiditisLaboratory testsTSHFree thyroxine (free T4)Total T3 and T4

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.The two primary laboratory findings used to confirm the diagnosis of hyperthyroidism are decreased TSH levels and elevated free thyroxine (free T4) levels.

70Collaborative CareGoalsBlock adverse effects of thyroid hormones. Stop hormone oversecretion.

Three primary treatment optionsAntithyroid medicationsRadioactive iodine therapy (RAI)Subtotal thyroidectomy

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.71Collaborative CareDrug therapyUseful in treatment of thyrotoxic statesNot considered curativeAntithyroid drugsIodine-adrenergic blockers

Antithyroid drugsInhibit synthesis of thyroid hormone Improvement in 1 to 2 weeks Good results in 4 to 8 weeksTherapy for 6 to 15 months

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.72Collaborative CareAntithyroid drugs (contd)Disadvantages includePatient noncomplianceIncreased rate of recurrenceFirst-line examplesPropylthiouracil (PTU)Also blocks conversion of T4 to T3Methimazole (Tapazole)

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. PTU lowers hormone levels more quickly but must be taken 3 times per day. Tapazole is administered in a single daily dose. Indications for the use of antithyroid drugs include Graves disease in the young patient, hyperthyroidism during pregnancy, and the need to achieve a euthyroid state before surgery or radiation therapy.

73Collaborative CareIodine Used with other antithyroid drugs in preparation for thyroidectomy or treatment of crisisLarge doses rapidly inhibit synthesis of T3 and T4 and block their release into circulation.Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.74Collaborative CareIodine (contd) vascularity of thyroid glandMaximal effect seen within 1 to 2 weeksLong-term iodine therapy is not effective.ExamplesSaturated solution of potassium iodine (SSKI)Lugols solutionCopyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.75Collaborative Care-adrenergic blockersSymptomatic relief of thyrotoxicosis resulting from -adrenergic receptor stimulationPropranolol (Inderal) administered with other antithyroid agentsAtenolol (Tenormin) is the preferred -adrenergic blocker for patients with asthma or heart disease.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.76Collaborative CareRadioactive iodine therapy (RAI)Treatment of choice in nonpregnant adultsDamages or destroys thyroid tissueDelayed response 2 to 3 months Treated with antithyroid drugs and Inderal before and during first 3 months of RAIHigh incidence of posttreatment hypothyroidismNeed for lifelong thyroid hormone replacement

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.77Collaborative CareSurgical therapyIndicationsUnresponsive to drug therapyLarge goiters causing tracheal compressionPossible malignancyIndividual not a good candidate for RAI

Subtotal thyroidectomy Preferred surgical procedureInvolves removal of significant portion of thyroid 90% removed to be effectiveEndoscopic thyroidectomy appropriate with small nodules and no malignancyLess scarring, pain, and recovery time

One advantage thyroidectomy has over RAI is a more rapid reduction in T3 and T4 levels.

78Collaborative CareSurgical therapy (contd)Before surgeryAntithyroid drugs, iodine, and -adrenergic blockers may be administeredTo achieve euthyroid state To control symptomsPostoperative complications include hypothyroidism, damage to or inadvertent removal of parathyroid glands causing hypoparathyroidism and hypocalcemia, hemorrhage, injury to the recurrent or superior laryngeal nerve, thyrotoxic crisis, and infection. Postoperative complications include hypothyroidism, damage to or inadvertent removal of parathyroid glands causing hypoparathyroidism and hypocalcemia, hemorrhage, injury to the recurrent or superior laryngeal nerve, thyrotoxic crisis, and infection.

79Collaborative CareNutritional therapyHigh-calorie diet may be ordered 4000 to 5000 cal/day For hunger and prevention of tissue breakdownProtein allowance 1 to 2 g/kg ideal body weightAvoid caffeine, highly seasoned foods, and high-fiber foods This can be accomplished with six full meals a day and snacks high in protein, carbohydrates, minerals, and vitamins, particularly vitamin A, thiamine, vitamin B6, and vitamin C. Increase carbohydrate intake to compensate for increased metabolism.

Copyright 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.A high-calorie diet may involve 4000 to 5000 cal/day. This can be accomplished with six full meals a day and snacks high in protein, carbohydrates, minerals, and vitamins, particularly vitamin A, thiamine, vitamin B6, and vitamin C. Increase carbohydrate intake to compensate for increased metabolism.

80Postoperative MonitoringSome hoarseness is expected for 3 to 4 daysEvery 2 hours for 24 hoursAssess for signs of hemorrhage. Assess for tracheal compression.Irregular breathing, neck swelling, frequent swallowing, chokingSemi-Fowlers position Support head with pillows.Avoid flexion of neck.Tension on suture lines Monitor vitals.Control pain.Check for tetany.Trousseaus and Chvosteks signs should be monitored.Monitor for 72 hours. 81HypothyroidismCausesDifferentiating: aging vs. hypothyroidismDecreased metabolism from low thyroid hormone levelsMyxedemaMyxedema coma82Myxedema

83Hypothyroidism AssessmentHistoryPhysical assessmentClinical manifestationsPsychosocial assessmentLaboratory assessment84

85Thyroiditis Inflammation of thyroid glandThree typesacute subacute (granulomatous)chronic (Hashimotos disease most commonAutoimmune disorder which destroys the gland tissue and becomes fibrousThis causes the gland to get larger - goiter

86Nonsurgical managementdrug therapyLeothyroxineSynthroidMust be taken 1 hour before meals or 2 hours afterwards

Surgical management page 499Monitor siteBreathingAbility to speakAny signs of tetany ( most common the within the first 7 days post-op. Management 87Thyroid CancerFour types:PapillaryFollicularMedullaryAnaplasticCollaborative managementTSH therapy Radioactive iodine and chemptherapy Surgery88

89Hyperparathyroidism Parathyroid glandscalcium and phosphate balanceHypercalcemia and hypophosphatemiaNonsurgical vs. surgical management

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91Hypoparathyroidism Decreased function of parathyroid glandIatrogenicIdiopathicHypomagnesemiaInterventionscorrecting hypocalcemia, vitamin D deficiency, hypomagnesemia

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We are Done !!!!!!!!!!!!94