Metabolic & Endocrine Function 3

METABOLIC & ENDOCRINE METABOLIC & ENDOCRINE FUNCTIONFUNCTION

A. Assessment and A. Assessment and Management of Patients Management of Patients with Hepatic Disorderswith Hepatic Disorders

LiverLiver

““Largest gland”Largest gland” of the body. of the body.

Contains Kupffer’s cells, which Contains Kupffer’s cells, which remove bacteria in the portal remove bacteria in the portal venous blood.venous blood.

Regulates glucose and protein Regulates glucose and protein metabolism.metabolism.

- Manufactures & secretes biles, has a Manufactures & secretes biles, has a major role for digestion & absorption of major role for digestion & absorption of fats in the GI tract.fats in the GI tract.

- Aids in the digestion of fats, and Aids in the digestion of fats, and carbohydrates.carbohydrates.

- Stores and filters blood ( 200- 400ml of Stores and filters blood ( 200- 400ml of blood stored)blood stored)

- Stores Vitamin A, D, and B12 and IronStores Vitamin A, D, and B12 and Iron

- Removes waste products from the Removes waste products from the bloodstream & secretes into the bile.bloodstream & secretes into the bile.

- Located @ the upper Right portion Located @ the upper Right portion of Abdominal Cavityof Abdominal Cavity

- Weight ( 1500g) and is divided to Weight ( 1500g) and is divided to four lobesfour lobes

Functions of the LiverFunctions of the Liver1.1. Glucose MetabolismGlucose Metabolism

- glucose is taken up from the - glucose is taken up from the portal venous blood by the liverportal venous blood by the liver converted to glycogen stored in converted to glycogen stored in hepatocytes.hepatocytes.

2. Ammonia Conversion2. Ammonia Conversion- Is a by product of the use of - Is a by product of the use of amino acids from protein for amino acids from protein for gluconeogenesis.gluconeogenesis.

- Conversion of Ammonia- Conversion of AmmoniaUrea: Role Urea: Role of the liver.of the liver.

3. Protein Metabolism3. Protein Metabolism- It synthesizes albumin, alpha - It synthesizes albumin, alpha and beta globulins, blood and beta globulins, blood clotting factors, specific clotting factors, specific transport proteins and most of transport proteins and most of the plasma lipoproteins.the plasma lipoproteins.

4.Fat Metabolism4.Fat Metabolism

- fatty acids can be broken down for - fatty acids can be broken down for the production of energy and ketone the production of energy and ketone bodies ( acetoacetic acid, beta- bodies ( acetoacetic acid, beta- hydroxybuteric acid, and acetone).hydroxybuteric acid, and acetone).- this only occurs when availability of - this only occurs when availability of glucose for metabolism is limited glucose for metabolism is limited during starvation or in uncontrolled during starvation or in uncontrolled diabetes.diabetes.

5. Vitamin and Iron Storage5. Vitamin and Iron Storage

- Vitamin A, B, and B- complex Vitamin A, B, and B- complex vitamins are stored in large amounts vitamins are stored in large amounts in the liver.in the liver.

•IronIron•CopperCopper

6. Drug Metabolism6. Drug MetabolismFollowing Medications that the Following Medications that the liver metabolizes:liver metabolizes:1. barbiturates1. barbiturates2. opioids2. opioids3. sedative agents3. sedative agents4. Anesthetics4. Anesthetics5. amphetamines5. amphetamines

Note: Some medication have a Note: Some medication have a large first- pass effect that their large first- pass effect that their use is essentially limited.use is essentially limited.

7. 7. Bile FormationBile Formation- Bile is formed by the hepatocytes Bile is formed by the hepatocytes

and collected in the caniculi and bile and collected in the caniculi and bile ducts.ducts.

- Collected and stored in the Collected and stored in the gallbladder and emptied into the gallbladder and emptied into the intestine when needed for digestion.intestine when needed for digestion.

- Bile salts together with cholesterol Bile salts together with cholesterol and licithin, are required for and licithin, are required for emulcification of fats in the emulcification of fats in the intestine necessary for efficient intestine necessary for efficient digestion & absorption.digestion & absorption.

8. Bilirubin Excretion8. Bilirubin Excretion

- Bilirubin is a pigment derived fro Bilirubin is a pigment derived fro the breakdown of hemoglobin by the breakdown of hemoglobin by cells of the reticuloendothelial cells of the reticuloendothelial system, including Kupffer cells of system, including Kupffer cells of the liver.the liver.

- Increase: indicates presence of Increase: indicates presence of liver disease when the flow of bile liver disease when the flow of bile is impeded or with excessive is impeded or with excessive destruction of RBC.destruction of RBC.

ASSESSMENTASSESSMENTSymptoms that suggests liver Symptoms that suggests liver

disease:disease:JaundiceJaundiceMalaiseMalaiseWeaknessWeaknessFatigueFatiguePruritusPruritusAbdominal PainAbdominal Pain

FeverFeverAnorexiaAnorexiaWeight GainWeight GainEdemaEdemaIncrease abdominal girthIncrease abdominal girthHematemesisHematemesisMelenaMelenaHematocheziaHematocheziaEasy bruisingEasy bruisingDecrease libidoDecrease libidoChanges in mental acuityChanges in mental acuity

Health historyHealth history

- Exposure to hepatotoxic subs. Or Exposure to hepatotoxic subs. Or infectious agentsinfectious agents: ( occupational, : ( occupational, recreational, and travel hx)recreational, and travel hx)

- History of alcohol and drug useHistory of alcohol and drug use (acetaminophen, ketoconazole, and (acetaminophen, ketoconazole, and

valproic acid) or other OTC drugs or valproic acid) or other OTC drugs or dietary supplements.dietary supplements.

- Lifestyle behaviorLifestyle behavior: sexual practices: sexual practices

- Current and Past Medical history- Current and Past Medical history- familial liver disorders ( gallstone familial liver disorders ( gallstone disease, Wilson’s disease)disease, Wilson’s disease)

Serum Enzyme Activity:Serum Enzyme Activity:

- - Alkaline phosphataseAlkaline phosphatase- lactic dehydrogenase- lactic dehydrogenase- serum aminotransferases***- serum aminotransferases***- Serum concentrations of protein- Serum concentrations of protein

albumin and globulins)albumin and globulins)- bilirubin- bilirubin- ammonia- ammonia- clotting factors and lipids.- clotting factors and lipids.

Most Frequently used to test for Liver damageMost Frequently used to test for Liver damage

1.1. Serum Aminotranferases- hepatitis, Serum Aminotranferases- hepatitis, cirrhosis, and liver cancercirrhosis, and liver cancer

2.2. ALT ( Alanine aminotransferase) / SGPT ALT ( Alanine aminotransferase) / SGPT ( serum glutamic- pyruvic ( serum glutamic- pyruvic transaminase)transaminase)

3.3. AST ( aspartate aminotranferase)/ AST ( aspartate aminotranferase)/ SGOT ( serum glutamic- oxaloacetic SGOT ( serum glutamic- oxaloacetic transaminase)transaminase)

4.4. GGT ( gamma glutamyl tranferase)-GGT ( gamma glutamyl tranferase)-cholestasischolestasis

Liver Function Studies:Liver Function Studies:

Serum protein- Serum protein- ( 7-7.5 g/dl)( 7-7.5 g/dl)Albumin- ( 4- 5.5 g/dl)Albumin- ( 4- 5.5 g/dl)Serum globulin- ( 1.7- 3.3 g/dl)Serum globulin- ( 1.7- 3.3 g/dl)Prothrombin Time- 12- 16 secondsProthrombin Time- 12- 16 secondsAST ( SGOT) – 10-40 unitsAST ( SGOT) – 10-40 unitsALT ( SGPT)- 5- 35 unitsALT ( SGPT)- 5- 35 unitsGGT- 10-48 IU/LGGT- 10-48 IU/LLDH- 100-200 unitsLDH- 100-200 units

Serum Ammonia- 2-120 Serum Ammonia- 2-120 microgram/dl/ 150- 250 mg/dlmicrogram/dl/ 150- 250 mg/dl

CholesterolCholesterol1.1. HDL- male: 35-70mg/dl HDL- male: 35-70mg/dl

female: 35-85 mg/dlfemale: 35-85 mg/dl2.2. LDL- < 130 microgram/dlLDL- < 130 microgram/dl

Procedure: Liver BiopsyProcedure: Liver Biopsy

Description:Description: A needle is inserted through theA needle is inserted through the

abdominal wall to the liver to abdominal wall to the liver to obtainobtain

a tissue sample for biopsy and a tissue sample for biopsy and microscopic examination.microscopic examination.

Pre procedure:Pre procedure:a.a. Obtained informed consentObtained informed consentb.b. Assess results of coagulation Assess results of coagulation

tests ( prothrombin time, tests ( prothrombin time, partial thromboplastin time, partial thromboplastin time, platelet count)platelet count)

c.c. Administer a sedative as Administer a sedative as prescribedprescribed

d.d. Position: Supine or left lateral Position: Supine or left lateral

Post procedure:Post procedure:

a.a. Assess vital signsAssess vital signsb.b. Assess biopsy site for bleedingAssess biopsy site for bleedingc.c. Monitor peritonitisMonitor peritonitisd.d. Maintain bedrest for several Maintain bedrest for several

hourshourse.e. Position: Right side with pillow Position: Right side with pillow

under the coastal margin to under the coastal margin to decrease hemorrhagedecrease hemorrhage

f. Instruct to avoid coughing and f. Instruct to avoid coughing and straining.straining.

g. Instruct to avoid heavy lifting g. Instruct to avoid heavy lifting and strenuous exercise x 1 and strenuous exercise x 1 week.week.

Other Dx Tests: Ultrasonography, Other Dx Tests: Ultrasonography, computed tomography, MRI, computed tomography, MRI, Laparoscopy.Laparoscopy.

Significant Symptoms of Liver Significant Symptoms of Liver DiseaseDisease

1.1. JaundiceJaundice- sclerae and skinsclerae and skin yellow yellow

tinged/ greenish yellow.tinged/ greenish yellow.Bilirubin level elevation- Bilirubin level elevation- 2- 2.5mg/dl2- 2.5mg/dl

4 Major Causes of Jaundice:4 Major Causes of Jaundice:1. Excessive destruction of RBC.1. Excessive destruction of RBC.

2. Impaired uptake of bilirubin by the liver 2. Impaired uptake of bilirubin by the liver cellscells

3. Decrease conjugation of bilirubin3. Decrease conjugation of bilirubin

4. Obstruction of bile flow in the canaliculi4. Obstruction of bile flow in the canaliculi

Types of jaundice:Types of jaundice:1.1. Hemolytic JaundiceHemolytic Jaundice- increase destruction of RBCincrease destruction of RBC increase bilirubin concentration increase bilirubin concentration

in the blood. in the blood. - is encountered in pt. with - is encountered in pt. with

hemolytic transfusion reactions hemolytic transfusion reactions and other hemolytic disorders.and other hemolytic disorders.

2. Hepatocellular Jaundice2. Hepatocellular Jaundice - inability of damaged liver cells - inability of damaged liver cells

to to clear normal amounts of clear normal amounts of bilirubin bilirubin from the blood. from the blood.- viral infection ( hepa A, B,C or - viral infection ( hepa A, B,C or E), E), yellow fiver virus, Epstein – yellow fiver virus, Epstein – Barr Barr virus, medication or virus, medication or chemical chemical toxicity toxicity ( phosphorus) or from ( phosphorus) or from alcohol alcohol intake.intake.

- - AST & ALT levels increasedAST & ALT levels increased: : indicate cellular necrosis. indicate cellular necrosis.- - serum bilirubin and urine serum bilirubin and urine urobilinogen elevate urobilinogen elevate..- Liver Cirrhosis is a form of - Liver Cirrhosis is a form of hepatocellular disease. hepatocellular disease.

33. Obstructive Jaundice. Obstructive Jaundice

- occlusion of the bile duct by a - occlusion of the bile duct by a gallstone, an inflammatory process, gallstone, an inflammatory process, tumor or pressure. tumor or pressure.- caused by “intrahepatic obstruction” - caused by “intrahepatic obstruction” - stool: light/ clay colored- stool: light/ clay colored- skin: itchy- skin: itchy- Dyspepsia- Dyspepsia

- - bilirubin and alkaline bilirubin and alkaline phosphatase level s are phosphatase level s are

elevated. elevated.4. Hereditary Hyperbilirubinemia4. Hereditary Hyperbilirubinemia

- Increase serum bilirubin - Increase serum bilirubin levels resulting from levels resulting from

inherited inherited disorders which disorders which produce produce jaundice. jaundice.

- normal liver histology and liver- normal liver histology and liver function test results.function test results.

Portal HypertensionPortal Hypertension- - is characterized by increaseis characterized by increase

resistance to flow in the portalresistance to flow in the portal venous system. ( prehepatic,venous system. ( prehepatic, posthepatic and intrahepatic posthepatic and intrahepatic obstruction to the liver lobules).obstruction to the liver lobules).

- portal vein pressure: 12 mm Hg- portal vein pressure: 12 mm Hg- PVP normal: 5-10 mm Hg- PVP normal: 5-10 mm Hg

1.1. PrehepaticPrehepatic- caused by portal vein thrombosis- caused by portal vein thrombosis and compression by cancer or and compression by cancer or

enlarged lymph nodes.enlarged lymph nodes.2. 2. PosthepaticPosthepatic

- is located at the between the - is located at the between the junction of the left and right junction of the left and right hepatic duct to the point where hepatic duct to the point where duct opens into the intestine.duct opens into the intestine.

Eg. Eg. Budd- Chiari SyndromeBudd- Chiari Syndrome

3. 3. Intrahepatic Intrahepatic - obstruction occur within the - obstruction occur within the Liver.Liver.

Major cause of Portal Major cause of Portal Hypertension:Hypertension:

Alcoholic cirrhosisAlcoholic cirrhosis

AscitesAscites

Several factors that contribute to fluid Several factors that contribute to fluid accumulation are:accumulation are: Increase capillary pressure caused Increase capillary pressure caused

by portal hypertensionby portal hypertension Obstruction of the venous flow Obstruction of the venous flow

through the liverthrough the liver Salt & water retention by the kidneySalt & water retention by the kidney Decrease colloidal osmotic pressure.Decrease colloidal osmotic pressure.

Clinical Manifestations:Clinical Manifestations:

1.1. Increased abdominal girthIncreased abdominal girth2.2. Rapid weight gain***Rapid weight gain***3.3. Striae and distended veins in Striae and distended veins in

the abdominal wall.the abdominal wall.4.4. Fluid & Electrolyte imbalances Fluid & Electrolyte imbalances

are common.are common.

Diagnostic Findings:Diagnostic Findings:

- Percussion of the abdomen- Percussion of the abdomen

- Assessing for abdominal fluid wave.- Assessing for abdominal fluid wave.

- Abdominal girth measurement- Abdominal girth measurement

- - body weight measurement***body weight measurement***

Medical Management:Medical Management:1.1. Dietary ModificationDietary Modification:: Strict sodium restrictionStrict sodium restriction

Table saltsTable salts Salty foodsSalty foods Salted butter and margarineSalted butter and margarine Canned and frozen foodsCanned and frozen foods Commercial salt substitutes should Commercial salt substitutes should

be approved: contains ammonia be approved: contains ammonia which precipitate to which precipitate to hepatic hepatic comacoma..

2. 2. DiureticsDiuretics Spironolactone ( Aldactone)- Spironolactone ( Aldactone)-

prevents potassium lossprevents potassium loss AldosteroneAldosterone Furosemide ( lasix)- hyponatremiaFurosemide ( lasix)- hyponatremia Ammonium chloride and Ammonium chloride and

acetazolamide ( Diamox) are acetazolamide ( Diamox) are contraindicated: hepatic comacontraindicated: hepatic coma

Complications of diuretic Complications of diuretic therapy:therapy: Fluid & Electrolyte Fluid & Electrolyte

disturbances: hypovolemia, disturbances: hypovolemia, hypokalemia, hyponatremia, hypokalemia, hyponatremia, encephalopathy.encephalopathy.

3.3. BedrestBedrest

4. Paracentesis4. Paracentesis- is the removal of fluid from the - is the removal of fluid from the peritoneal cavity through a small peritoneal cavity through a small surgical incision or puncture surgical incision or puncture made through the abdominal wall made through the abdominal wall under sterile conditions.under sterile conditions.

- - In Paracentesis, use a large In Paracentesis, use a large volume ( 5-6 liters) is safe to volume ( 5-6 liters) is safe to treat with severe ascites. This is treat with severe ascites. This is in combination with IV infusion of in combination with IV infusion of salt poor albumin or other salt poor albumin or other colloid.colloid.

HEPATITISHEPATITIS- Inflammation of the liver - Inflammation of the liver

caused by a virus, bacteria, or caused by a virus, bacteria, or exposure to medications or exposure to medications or hepatotoxins.hepatotoxins.

Types :Types :•Hepa A, B, C ,D , E, G.Hepa A, B, C ,D , E, G.

Medical & Nursing Medical & Nursing Management: Management:

HEPA AHEPA A1. Bed rest during acute stage and 1. Bed rest during acute stage and

diet.( small frequent meals)diet.( small frequent meals)

2. Environmental Sanitation and 2. Environmental Sanitation and hygiene measures ( hand washing).hygiene measures ( hand washing).

3. Abstain alcohol intake.3. Abstain alcohol intake.

Medical & Nursing Medical & Nursing Management: HEPA BManagement: HEPA B

1.1. Alpha interferon-Alpha interferon- 5 million u- 5 million u- 10million u 3x weekly for 4-6 10million u 3x weekly for 4-6 months.months.- administered by injection.- administered by injection.

Side effectsSide effects:: fever, chills, fever, chills, anorexia, nausea, myalgias and anorexia, nausea, myalgias and fatigue.fatigue.

Late side effectsLate side effects: bone marrow : bone marrow suppression, thyroid dysfunction, suppression, thyroid dysfunction, alopecia, and bacterial infection.alopecia, and bacterial infection.

2 antiviral agents:2 antiviral agents:

1.1. Lamivudine ( Epvir)Lamivudine ( Epvir)2.2. Adefovir ( Hepseral)Adefovir ( Hepseral)

• BedrestBedrest• Avoid protein intakeAvoid protein intake

HEPATIC CIRRHOSISHEPATIC CIRRHOSIS3 Types of Cirrhosis:3 Types of Cirrhosis:

1.1. Alcoholic cirrhosis-Alcoholic cirrhosis- scar tissue scar tissue surrounds the portal areas.surrounds the portal areas.- most common type of - most common type of

cirrhosis.cirrhosis.- due to chronic alcoholism.- due to chronic alcoholism.

2. 2. Post necrotic cirrhosis-Post necrotic cirrhosis- broad broad bands of scar tissue cause bybands of scar tissue cause by acute viral hepatitis.acute viral hepatitis.3. Biliary cirrhosis- 3. Biliary cirrhosis- scarring around scarring around

the bile ducts.the bile ducts.- result from chronic biliary- result from chronic biliary obstruction & infection.obstruction & infection.

Clinical Manifestations:Clinical Manifestations:EmaciationEmaciationAscitesAscitesSpider angiomas: nose, cheeks, Spider angiomas: nose, cheeks,

upper thorax, and shoulder.upper thorax, and shoulder.HepatomegalyHepatomegalyFetor hepaticusFetor hepaticusAsterixis ( liver flap)Asterixis ( liver flap)

PeritonitisPeritonitisGastrointestinal varicesGastrointestinal varicesEdemaEdemaVitamin deficiency and anemiaVitamin deficiency and anemiaMental deteriorationMental deterioration

Diagnostic Findings:Diagnostic Findings:Serum Albumin- decreaseSerum Albumin- decreaseSerum globulin- increaseSerum globulin- increaseAST, AST, GGT- increaseAST, AST, GGT- increaseBilirubin test- elevateBilirubin test- elevateProthrombin time- prolongProthrombin time- prolongLiver biopsy-Liver biopsy- gives gives

confirmation of diagnosis.confirmation of diagnosis.

Nursing Management for Nursing Management for cirrhosiscirrhosis::

Elevate the head of the bed to Elevate the head of the bed to minimize SOB.minimize SOB.

Provide supplemental vitamins ( B Provide supplemental vitamins ( B complex, Vitamin A,C, and K, folic complex, Vitamin A,C, and K, folic acid and thiamine) as prescribed.acid and thiamine) as prescribed.

Restrict Sodium & fluid intakeRestrict Sodium & fluid intakeAdminister Diuretics as prescribed.Administer Diuretics as prescribed.

Monitor I & O and electrolyte Monitor I & O and electrolyte balance.balance.

Weight and measure abdominal Weight and measure abdominal girth daily.girth daily.

Monitor LOC, assess for precoma Monitor LOC, assess for precoma state ( tremors, delirium)state ( tremors, delirium)

Monitor for asterixisMonitor for asterixis

Maintain gastric intubation to Maintain gastric intubation to assess bleeding and assess bleeding and esophagogastric balloon esophagogastric balloon tamponade to control bleeding tamponade to control bleeding varices.varices.

Administer blood productsAdminister blood productsMonitor coagulation lab. results; Monitor coagulation lab. results;

administer Vit K if prescribedadminister Vit K if prescribed

Administer Lactulose ( Chronulac), Administer Lactulose ( Chronulac), which decreases the pH of the which decreases the pH of the bowel, decreases production of bowel, decreases production of ammonia by bacteria in the bowel, ammonia by bacteria in the bowel, and facilitates the excretion of and facilitates the excretion of ammonia.ammonia.

Administer neomycin ( mycifradin) Administer neomycin ( mycifradin) to inhibit protein synthesis in to inhibit protein synthesis in bacteria and decrease the bacteria and decrease the production of ammonia.production of ammonia.

Avoid medications: narcotics, Avoid medications: narcotics, sedatives and barbiturates and sedatives and barbiturates and any hepatotoxic medications.any hepatotoxic medications.

Instruct about the restriction of Instruct about the restriction of alcohol intakealcohol intake

Prepare for paracentesis and Prepare for paracentesis and surgical shunting procedures.surgical shunting procedures.

Anatomy of GallbladderAnatomy of GallbladderGallbladderGallbladder

- a pear shaped, hollow saclike - a pear shaped, hollow saclike organ.organ.- 7.5- 10 cm long.- 7.5- 10 cm long.- lies in the shallow depression on - lies in the shallow depression on

the inferior surface of the liver.the inferior surface of the liver.- stores 30- 50 ml of bile.- stores 30- 50 ml of bile.

Function:Function: Storage and concentrate bile.Storage and concentrate bile. Cholecystokinin- pancreozymin Cholecystokinin- pancreozymin ( CCK- PZ)- hormone, major ( CCK- PZ)- hormone, major stimulus for digestive enzyme stimulus for digestive enzyme secretion; stimulates contraction secretion; stimulates contraction

of of the gallbladder.the gallbladder.

Bile is composed of:Bile is composed of:SodiumSodiumPotassiumPotassiumCalciumCalciumChloride and bicarbonateChloride and bicarbonateLecithin, fatty acids, Lecithin, fatty acids, cholesterolcholesterol, , bilirubinbilirubin, , bile saltsbile salts

Functions of Pancreas:Functions of Pancreas:1.1. Exocrine Pancreas-Exocrine Pancreas- the secretion the secretion

influences by the vagus nerveinfluences by the vagus nerve-digestive enzyme that secrete:-digestive enzyme that secrete:

amylase- aids in digestion of amylase- aids in digestion of carbohydratescarbohydrates

Trypsin- aids in digestion of Trypsin- aids in digestion of proteinsproteins

Lipase- digestion of fatsLipase- digestion of fats Secretin- major stimulus for Secretin- major stimulus for

increase bicarbonate secretion increase bicarbonate secretion from the pancreas, major from the pancreas, major stimulus for digestive enzyme stimulus for digestive enzyme secretion is the hormone CCK- secretion is the hormone CCK- PZ.PZ.

2. Endocrine pancreas2. Endocrine pancreasIslets of Langerhans- Islets of Langerhans-

composed of alpha, beta & delta composed of alpha, beta & delta cells.cells.• Beta- InsulinBeta- Insulin• Alpha- GlucagonAlpha- Glucagon• Delta- SomatostatinDelta- Somatostatin

A.A. Insulin ( Beta cells)Insulin ( Beta cells)- lower blood glucose by - lower blood glucose by

permitting entry of glucose into permitting entry of glucose into the cell of the liver, muscle & the cell of the liver, muscle & other tissues as glycogen and other tissues as glycogen and used for energy.used for energy.

- promotes storage of fat in - promotes storage of fat in adipose tissue and synthesis of adipose tissue and synthesis of proteins.proteins.

NoteNote******If absent:If absent:

- glucose can’t enter into the cells - glucose can’t enter into the cells and excreted in the urine ( DM)and excreted in the urine ( DM)

- fats & proteins are used for - fats & proteins are used for energy instead of glucose.energy instead of glucose.

B. Glucagon ( alpha cells)B. Glucagon ( alpha cells)- used to raise blood glucose by - used to raise blood glucose by converting glycogen to glucose converting glycogen to glucose in the liver.in the liver.- is secreted by the pancreas in - is secreted by the pancreas in response to decrease in level of response to decrease in level of blood glucose.blood glucose.

C. Somatostatin C. Somatostatin - exerts a hypoglycemic - exerts a hypoglycemic

effect.effect.

Disorders of the Gallbladder:Disorders of the Gallbladder:1.1. CholecystitisCholecystitis

- acute inflammation is- acute inflammation is associated with gallstones.associated with gallstones.(Chronic) - cause gallbladder (Chronic) - cause gallbladder contraction due to inefficient contraction due to inefficient emptying of bile.emptying of bile.Calculus- bacterial invasionCalculus- bacterial invasion

Clinical Manifestations:Clinical Manifestations:Nausea & VomitingNausea & Vomiting IndigestionIndigestionBelchingBelchingFlatulenceFlatulenceEpigastric Pain radiates to Epigastric Pain radiates to

scapula- scapula- 2- 4 hrs.2- 4 hrs.

Right Upper Quadrant PainRight Upper Quadrant Pain

Guarding, rigidity, and Guarding, rigidity, and rebound tendernessrebound tenderness

Mass @ RUQMass @ RUQMurphy’s signMurphy’s signTachycardiaTachycardia

2. Cholelitiasis, or gallstone2. Cholelitiasis, or gallstone, , - is caused by precipitation of- is caused by precipitation of

substances contained in bile, substances contained in bile, mainly cholesterol and mainly cholesterol and

bilirubin.bilirubin.

Clinical Manifestations:Clinical Manifestations:• Indigestion and biliary colicIndigestion and biliary colic• JaundiceJaundice• Steatorrhea & Clay colored stoolSteatorrhea & Clay colored stool• Dark orange and foamy urineDark orange and foamy urine• JaundiceJaundice• Vitamin deficiencyVitamin deficiency• PruritusPruritus

Diagnostic Findings:Diagnostic Findings:1.1. Abdominal X rayAbdominal X ray2.2. UltrasonographyUltrasonography3.3. Radionuclide imagingRadionuclide imaging4.4. CholecystographyCholecystography5.5. Endoscopic Retrograde Endoscopic Retrograde

cholangiopancreotography ( ERCP)cholangiopancreotography ( ERCP)6.6. Percutaneous Transhepatic Percutaneous Transhepatic

CholangiographyCholangiography

Nursing Management:Nursing Management:1.1. Maintain NPO status during Maintain NPO status during

nausea & vomiting.nausea & vomiting.2.2. Maintain nasogastric Maintain nasogastric

decompression/ suctioning for decompression/ suctioning for severe vomiting or anti emetics.severe vomiting or anti emetics.

3.3. Administer analgesic and Administer analgesic and antibiotic agents. Note: Morphine antibiotic agents. Note: Morphine & codeine should not be given.& codeine should not be given.

4. Administer antispasmodic 4. Administer antispasmodic agents.agents.

5. Avoid fatty foods ( cream, pork, 5. Avoid fatty foods ( cream, pork, fried foods), egg, gas forming fried foods), egg, gas forming vegetables and alcohol.vegetables and alcohol.

6. Ursodeoxycholic ( UDCA) & 6. Ursodeoxycholic ( UDCA) & chenodeoxycholic acid ( CDCA) chenodeoxycholic acid ( CDCA) - dissolve small, radiolucent - dissolve small, radiolucent gallstones composed of cholesterol.gallstones composed of cholesterol.

Not applicable:Not applicable:- cystic duct occlusion, pigment - cystic duct occlusion, pigment stones.stones.

Non surgical implementation:Non surgical implementation:1.1. Dissolution therapyDissolution therapy remove cholesterol stonesremove cholesterol stones Direct contact with repeated Direct contact with repeated

injections and aspirations of injections and aspirations of dissolution agent via dissolution agent via percutaneous catheterpercutaneous catheter

2. Extracorporeal shock wave 2. Extracorporeal shock wave lithotripsylithotripsy

Shock waves are administered Shock waves are administered that disintegrate stones in the that disintegrate stones in the biliary systembiliary system

Oral dissolution followsOral dissolution follows

Surgical Implementation:Surgical Implementation:

1.1. Cholecystectomy- removal of Cholecystectomy- removal of the gallbladderthe gallbladder

2.2. Choledochotomy- incision into Choledochotomy- incision into the common bile duct to the common bile duct to remove the stoneremove the stone

Post operative Post operative Implementation:Implementation:

Monitor for respiratory Monitor for respiratory complications secondary to pain at complications secondary to pain at the incision sitethe incision site

Encourage deep breathing & Encourage deep breathing & coughingcoughing

Encourage early ambulationEncourage early ambulationEncourage splinting during Encourage splinting during

coughingcoughing

Administer anti emetic, analgesic Administer anti emetic, analgesic as prescribedas prescribed

Maintain NPO status and NG tube Maintain NPO status and NG tube suctionsuction

Advance from clear liquids to solidsAdvance from clear liquids to solidsMaintain and monitor drainage Maintain and monitor drainage

from the T tubefrom the T tube

PancreasPancreas lies transversely in the posterior lies transversely in the posterior

part of the upper abdomen.part of the upper abdomen. head part is @ the right of the head part is @ the right of the

abdomenabdomenBody lies beneath the stomachBody lies beneath the stomach

2 Types of Pancreatic 2 Types of Pancreatic Disease:Disease:

1. Acute Pancreatitis1. Acute Pancreatitis

2. Chronic Pancreatitis2. Chronic Pancreatitis

Acute PancreatitisAcute Pancreatitis severe, life-threatening severe, life-threatening

disorder associated with disorder associated with escape of activated pacreatic escape of activated pacreatic enzymes into the pancreas enzymes into the pancreas and surrounding tissues.and surrounding tissues.

Clinical Manifestations of Clinical Manifestations of Acute Pancreatitis:Acute Pancreatitis:

• Initial sign: severe midepigastric Initial sign: severe midepigastric or periumbilical pain radiates to or periumbilical pain radiates to the backthe back

• Ominous sign: rigid board like Ominous sign: rigid board like abdomenabdomen

• Severe pancreatitis: EcchymosisSevere pancreatitis: Ecchymosis• Common: Abdominal distentionCommon: Abdominal distention• Tachycardia, hypotension, cool & Tachycardia, hypotension, cool &

clammy skin, fever.clammy skin, fever.

HypocalcemiaHypocalcemiaCommon:Nausea & vomitingCommon:Nausea & vomitingShock in severe episodes, with Shock in severe episodes, with

respiratory distress and acute respiratory distress and acute renal failure.renal failure.

Turner’s sign or cullen’s signTurner’s sign or cullen’s sign

Diagnostic Findings:Diagnostic Findings: Serum amylase level- increase for Serum amylase level- increase for

the 24 hrs to 48- 72 hrs.the 24 hrs to 48- 72 hrs.Serum lipase- increase for 24- 48 Serum lipase- increase for 24- 48

hrs to 5- 14 days.hrs to 5- 14 days.WBC increase- 16,000 cells/ micro WBC increase- 16,000 cells/ micro

literslitersElevated Blood glucose- 200 mg/dlElevated Blood glucose- 200 mg/dl

Serum lactate dehydrogenase- Serum lactate dehydrogenase- moremore

350 IU/L350 IU/LAST ( increase 250 IU/L)AST ( increase 250 IU/L)Serum albumin, Ca, Na, Serum albumin, Ca, Na,

Magnesium and K is low because Magnesium and K is low because of dehydration and vomitingof dehydration and vomiting

Abdominal X ray detect Abdominal X ray detect pancreatic calcifications or pancreatic calcifications or gallstones suggest an alcohol or gallstones suggest an alcohol or biliary obstruction.biliary obstruction.

CT is most definitive in CT is most definitive in determining pancreatic changesdetermining pancreatic changes

Nursing Interventions:Nursing Interventions: Oral foods and fluids are withheldOral foods and fluids are withheldRest the GI tractRest the GI tract

a. Gastric suctioning is instituted a. Gastric suctioning is instituted to treat distention of the bowel to treat distention of the bowel and prevent further stimulation of and prevent further stimulation of the pancreatic enzymes.the pancreatic enzymes.

b. Withhold oral feedings to b. Withhold oral feedings to decrease pancreatic secretions.decrease pancreatic secretions.

IV fluids & electrolytes are IV fluids & electrolytes are administered for shock & administered for shock & hypotension.hypotension.

relief such as Meperidine relief such as Meperidine rather than Morphine.rather than Morphine.

Anticholinergic drugs to provide Anticholinergic drugs to provide smooth muscle relaxationsmooth muscle relaxation

Maintenance of alkaline gastric Maintenance of alkaline gastric pH with H2 receptor antagonists pH with H2 receptor antagonists and antacidsand antacids

Antibiotic therapy for Antibiotic therapy for infection or sepsisinfection or sepsis

Maintenance of adequate Maintenance of adequate oxygenationoxygenation

Surgical Interventions:Surgical Interventions:Incision & drainage of infection & Incision & drainage of infection &

pseudocysts.pseudocysts.Debridement or pancreatectomy Debridement or pancreatectomy

to remove necrotic pancreatic to remove necrotic pancreatic tissue.tissue.

Cholecystectomy for gallstone Cholecystectomy for gallstone pancreatitis.pancreatitis.

Complications:Complications:1.1. Pancreatic ascites, abscess, or Pancreatic ascites, abscess, or

pseudocystpseudocyst2.2. Acute respiratory distress syndromeAcute respiratory distress syndrome3.3. Hemorrhage with hypovolemic Hemorrhage with hypovolemic

shockshock4.4. Acute renal failureAcute renal failure5.5. Sepsis and multiple organ Sepsis and multiple organ

dysfunction syndromedysfunction syndrome

Nursing Diagnosis:Nursing Diagnosis: Acute Pain r/t disease processAcute Pain r/t disease process

Deficient Fluid Volume r/t Deficient Fluid Volume r/t vomiting, fever and fluid shiftsvomiting, fever and fluid shifts

Ineffective Breathing Pattern Ineffective Breathing Pattern r/t severe pain and pulmonary r/t severe pain and pulmonary complicationcomplication

Chronic PancreatitisChronic Pancreatitis

- progressive destruction of the - progressive destruction of the pancreas.pancreas.

- persistence of pancreatic - persistence of pancreatic cellular damage after acute cellular damage after acute inflammation and decreased inflammation and decreased pancreatic endocrine and pancreatic endocrine and exocrine function.exocrine function.

Clinical Manifestations:Clinical Manifestations:Pain located in the epigastrium or Pain located in the epigastrium or

left upper quadrant radiating to the left upper quadrant radiating to the back more constantly and occurring back more constantly and occurring at unpredictable intervals.at unpredictable intervals.

Weight loss, nausea & vomiting, Weight loss, nausea & vomiting, anorexiaanorexia

Malabsorption and steatorrheaMalabsorption and steatorrheaDiabetes MellitusDiabetes Mellitus

Diagnostic Findings:Diagnostic Findings: Serum amylase & lipase- normal Serum amylase & lipase- normal

to low to low Fecal fat analysis determines Fecal fat analysis determines

need for pancreatic need for pancreatic Bilirubin & alkaline phosphatase- Bilirubin & alkaline phosphatase-

elevatedelevated

Secretin and cholecystokinin Secretin and cholecystokinin stimulatory test- abnormalstimulatory test- abnormal

Plain abdominal X rayPlain abdominal X rayCT scanCT scanERCPERCP

Nursing Management:Nursing Management: Pain managementPain managementCorrection of nutritional deficiencies.Correction of nutritional deficiencies.Pancreatic enzyme replacementPancreatic enzyme replacementTreatment of DMTreatment of DMEndoscopic placement of pancreatic Endoscopic placement of pancreatic

stent allowing free flow of pancreatic stent allowing free flow of pancreatic juices through distorted and juices through distorted and irregular/ narrowed pancreatic duct.irregular/ narrowed pancreatic duct.

Surgical Interventions:Surgical Interventions: PancreaticojejunostomyPancreaticojejunostomySphincteroplastySphincteroplastyDrain pancreatic pseudocyst into Drain pancreatic pseudocyst into

external drainexternal drainWhipple procedureWhipple procedureAutotransplantation of islet cellsAutotransplantation of islet cells

Complications:Complications:Pancreatic pseudocystPancreatic pseudocystPancreatic ascites and pleural Pancreatic ascites and pleural

effusionseffusionsGI hemorrhageGI hemorrhageBiliary Tract obstructionBiliary Tract obstructionPancreatic fistulaPancreatic fistula

Nursing Diagnosis:Nursing Diagnosis: Acute and chronic Pain r/t Acute and chronic Pain r/t

chronic and unrelenting insult chronic and unrelenting insult to pancreasto pancreas

Imbalanced Nutrition: Less Imbalanced Nutrition: Less than Body Requirements r/t than Body Requirements r/t glucose intoleranceglucose intolerance

Anxiety r/t surgical interventionAnxiety r/t surgical intervention

Diabetes MellitusDiabetes MellitusMetabolic disorder Metabolic disorder

characterized by increase characterized by increase glucose level in the blood glucose level in the blood ( hyperglycemia) resulting ( hyperglycemia) resulting from defects in insulin from defects in insulin secretion.secretion.

Function of Insulin:Function of Insulin: hormone produced by the hormone produced by the

pancreaspancreasControls the glucose level in the Controls the glucose level in the

blood thru regulating the blood thru regulating the production and storage of production and storage of glucose.glucose.

Risk factors:Risk factors: Family historyFamily historyObesityObesityRace/ ethnicityRace/ ethnicityAgeAgeHypertension 140/ 90 mmHgHypertension 140/ 90 mmHgHDL cholesterol < 35 mg/dlHDL cholesterol < 35 mg/dlHistory of gestational diabetesHistory of gestational diabetes

Types of Diabetes Types of Diabetes Mellitus:Mellitus:

1. Type I – Insulin- 1. Type I – Insulin- dependent DMdependent DM

2.2. Type II- Non- insulinType II- Non- insulin dependent dependent

DMDM

Criteria for diagnosis of Criteria for diagnosis of DM:DM:

1. 1. Symptoms of diabetes plus casual Symptoms of diabetes plus casual plasma glucose concentration plasma glucose concentration > 200mg/dl.> 200mg/dl. 2. Fasting Plasma glucose > 1262. Fasting Plasma glucose > 126 mg/dl.mg/dl.

3. 2-h postload glucose > 200mg/dl 3. 2-h postload glucose > 200mg/dl during oral glucose tolerance test during oral glucose tolerance test ( OGTT)( OGTT)

Diabetes Management:Diabetes Management:1.1. NutritionalNutritionalObjective: Objective:

- to control total caloric intake to - to control total caloric intake to attain or maintain a reasonable attain or maintain a reasonable body weight and control bloodbody weight and control blood glucose levels.glucose levels.

Incorporate diet into Incorporate diet into individuals client needs, individuals client needs, lifestyle and cultural and lifestyle and cultural and socio economic patterns.socio economic patterns.

According to ADA ( American diet According to ADA ( American diet Association) recommend all Association) recommend all levels of caloric intake:levels of caloric intake:

• 50%- 60% carbohydrates50%- 60% carbohydrates• 20%- 30% fats20%- 30% fats• 10%- 20% protein10%- 20% protein

A.A. CarbohydratesCarbohydrates - should be eaten in - should be eaten in moderation –moderation –

to prevent postprandial blood glucose to prevent postprandial blood glucose levels.levels.

Carbohydrate countingCarbohydrate counting- a tool for blood glucose - a tool for blood glucose management.management.1. counting grams of carbohydrates1. counting grams of carbohydrates

Eg. 15 g of carbo- 1 serving of apple 2 inches or 1 slice bread.Eg. 15 g of carbo- 1 serving of apple 2 inches or 1 slice bread.

B. FatsB. Fats10% saturated fats10% saturated fats- less than 300mg/day dietary- less than 300mg/day dietary

cholesterol.cholesterol.- encourage the use of - encourage the use of legumeslegumes & &

whole grainswhole grains to help reduce to help reduce saturated fats and cholesterol.saturated fats and cholesterol.

3. Fiber3. Fibersolublesoluble: legumes, oats and some : legumes, oats and some

fruitsfruits helps blood glucose. helps blood glucose.InsolubleInsoluble: whole grain breads : whole grain breads

and cereals and some and cereals and some vegetables.vegetables.

Food classification Systems:Food classification Systems:1.1. Exchange ListsExchange Lists

2.2. Food guide PyramidFood guide Pyramid

Other dietary concerns:Other dietary concerns:Alcohol Intake- main danger isAlcohol Intake- main danger is Hypoglycemia. Esp. takingHypoglycemia. Esp. taking insulin.insulin.

- when taking diabinese is- when taking diabinese is disulfiram ( atabuse) type disulfiram ( atabuse) type reaction. S/E: facial flushing,reaction. S/E: facial flushing, warmth,headache, n/v, sweating,warmth,headache, n/v, sweating, thirsty.thirsty.

2. Exercise2. Exercisebenefits:benefits:

lower blood glucose levellower blood glucose levelReduces cardiovascular risksReduces cardiovascular risksImproves circulation and Improves circulation and muscle tonemuscle tone

Decreases total cholesterol Decreases total cholesterol and triglycerides levelsand triglycerides levels

Encourage weight lossEncourage weight loss

Instruct the pt. to check blood Instruct the pt. to check blood glucose level before, during, and glucose level before, during, and after exerciseafter exercise

Initially, pt. who requires insulin Initially, pt. who requires insulin should be instructed to eat 15g should be instructed to eat 15g carbohydrate snack ( a fruit carbohydrate snack ( a fruit exchange) or snack of complex exchange) or snack of complex carbo. With protein before carbo. With protein before exercise to prevent exercise to prevent hypoglycemia.hypoglycemia.

If the blood glucose level is greater If the blood glucose level is greater than 250 mg/dl and urinary ketones than 250 mg/dl and urinary ketones are present, the pt. is instructed not are present, the pt. is instructed not to exercise until blood glucose is to exercise until blood glucose is nearly normal and urinary ketones nearly normal and urinary ketones are negative.are negative.

Self Monitoring of blood Self Monitoring of blood glucose:glucose:

Provide the client with the Provide the client with the current blood glucose level current blood glucose level and information to maintain and information to maintain good glycemic control.good glycemic control.

A cornerstone of insulin A cornerstone of insulin therapy.therapy.

- - it requires a finger prick to obtainit requires a finger prick to obtain a drop of bood for testing.a drop of bood for testing.- caution with clients with- caution with clients with

retinopathy & neuropathy.retinopathy & neuropathy.- Stress the importance of - Stress the importance of followingfollowing

the manufacturer’s instructionthe manufacturer’s instruction

- - Stress the importance of Stress the importance of HandwashingHandwashing

- the strip is place in the meter - the strip is place in the meter first before the blood is applied.first before the blood is applied. Once the blood is placed on the Once the blood is placed on the strip, the meter automatically strip, the meter automatically

displaysdisplays the blood glucose level less than the blood glucose level less than 1 minute.1 minute.

Glycosylated hemoglobin- used to Glycosylated hemoglobin- used to describe hgb into which glucose has describe hgb into which glucose has been incorporated.been incorporated.

A1C - an index of blood glucose level A1C - an index of blood glucose level over 6- 12 weeksover 6- 12 weeks

- 6.0 % normal- 6.0 % normal- is a blood test that reflects- is a blood test that reflects

average blood glucose levels average blood glucose levels overover

a period of 2- 3 months.a period of 2- 3 months.

Urine Testing Urine Testing - a less reliable indicator for- a less reliable indicator for

blood glucose monitoring.blood glucose monitoring.-teach the client that the -teach the client that the

second voided urinesecond voided urine specimen is most accurate.specimen is most accurate.

- presence of ketones may indicate- presence of ketones may indicate ketoacidosisketoacidosis..

- urine ketone testing should be- urine ketone testing should be performed during illness and performed during illness and whenever the client with DM typewhenever the client with DM type I has glycosuria greater than 240I has glycosuria greater than 240 mg/dl for 2 consecutive testingmg/dl for 2 consecutive testing periods.periods.

Complication of Insulin Complication of Insulin therapy:therapy:Local Allergic ReactionsLocal Allergic Reactions

redness, swelling, tenderness and redness, swelling, tenderness and induration 1-2 h after injection.induration 1-2 h after injection.

Insulin LipodystrophyInsulin LipodystrophySlight dimpling or pitting of Slight dimpling or pitting of subcutaneous fat.subcutaneous fat.

Insulin ResistanceInsulin Resistance administration of purer insulin prep.administration of purer insulin prep. prednisone is prescribedprednisone is prescribed

Dawn PhenomenonDawn Phenomenon release of growth hormone, release of growth hormone, cause blood glucose to rise @ cause blood glucose to rise @ 3 am.3 am.• administration of administration of intermediate acting insulin @ intermediate acting insulin @ 10 pm.10 pm.

Somogyi’s phenomenonSomogyi’s phenomenon a rebound phenomenon that a rebound phenomenon that occurs during the initial occurs during the initial period of blood glucose period of blood glucose control.control.

develop at peak insulin develop at peak insulin times and during nighttimes and during night

elevated at bedtime, decrease elevated at bedtime, decrease at 2 am to 3 am.at 2 am to 3 am.

Treatment include decreasing Treatment include decreasing evening dose of intermediate evening dose of intermediate acting insulin, increasing the acting insulin, increasing the bedtime snack.bedtime snack.

Insulin WaningInsulin Waning A progressive rise of bld. A progressive rise of bld. Glucose from bedtime to Glucose from bedtime to morning.morning.

treatment is increasing the treatment is increasing the evening dose of intermediate evening dose of intermediate or long acting insulin.or long acting insulin.

Endocrine System:Endocrine System: Functions:Functions:1.1. Maintenance and regulation of vital Maintenance and regulation of vital

functionsfunctions2.2. Response to stress and injuryResponse to stress and injury3.3. Growth & developmentGrowth & development4.4. Energy metabolismEnergy metabolism5.5. ReproductionReproduction6.6. Fluid, electrolyte and acid- base Fluid, electrolyte and acid- base

balancebalance

Endocrine SystemEndocrine SystemA.A. PituitaryPituitary

- commonly referred as “- commonly referred as “mastermaster gland”gland”

- located @ the base of the brain- located @ the base of the brain- controlled by the hypothalamus- controlled by the hypothalamus- influences water absorption by- influences water absorption by

the kidney.the kidney.- controls sexual development &- controls sexual development &

functionfunction

A. Posterior PituitaryA. Posterior Pituitary Vasopressin ( ADH & Oxytocin)Vasopressin ( ADH & Oxytocin)

- important hormones,- important hormones, secreted by the posteriorsecreted by the posterior lobe of the pituitary gland.lobe of the pituitary gland.

- synthesized in the - synthesized in the hypothalamus for storage.hypothalamus for storage.

- controls the excretion of water by- controls the excretion of water by the kidney.the kidney.

- secretion is stimulated by an- secretion is stimulated by an increase osmolality of the increase osmolality of the

bloodblood or by decrease in BP.or by decrease in BP.

OxytocinOxytocin- facilitates milk ejection- facilitates milk ejection

during lactation.during lactation.- increases the force of - increases the force of

uterine contraction uterine contraction duringduring

labor & deliverylabor & delivery

B. Anterior PituitaryB. Anterior PituitaryMajor Hormone:Major Hormone:

A.A. FSH ( Follicle Stimulating FSH ( Follicle Stimulating Hormone)Hormone)

B.B. LH ( Luteinizing Hormone)LH ( Luteinizing Hormone)C.C. ProlactinProlactinD.D. ACTHACTHE.E. TSHTSHF.F. Growth HormoneGrowth Hormone

Disorders of Pituitary Disorders of Pituitary GlandGland

A. A. Diabetes InsipidusDiabetes Insipidus - hyposecretion of ADH and - hyposecretion of ADH and

deficiency of vasopressin.deficiency of vasopressin.- results in failure of tubular- results in failure of tubular

reabsorption of water in reabsorption of water in thethe

kidneys.kidneys.

Clinical Manifestations:Clinical Manifestations:Water- like urine with no albumin Water- like urine with no albumin

& glucose& glucoseClassic signs: Hypernatremia, Classic signs: Hypernatremia,

hypokalemia, hypercalcemiahypokalemia, hypercalcemiaDecrease urine specific gravity- Decrease urine specific gravity-

1.001- 1.0051.001- 1.005Polyuria( 4- 24 L), polydipsia, Polyuria( 4- 24 L), polydipsia,

dehydrationdehydration

FatigueFatigueDecrease skin turgor, dry Decrease skin turgor, dry

mucous membranesmucous membranesPostural hypotensionPostural hypotensionTachycardiaTachycardia

Diagnostic Findings:Diagnostic Findings: Fluid deprivation testFluid deprivation test

- withholding fluids for 8-12 hours- withholding fluids for 8-12 hours- weighing frequently- weighing frequently- plasma and urine osmolality- plasma and urine osmolality

studies are performed @ studies are performed @ beginning and end of the test.beginning and end of the test.

24 hour urine output24 hour urine outputplasma level of ADH, plasma and plasma level of ADH, plasma and

urine osmolality, desmopressin urine osmolality, desmopressin therapy and IV of hypotonic therapy and IV of hypotonic saline solutionsaline solution

skull x ray & MRI- indicates skull x ray & MRI- indicates bright spotbright spot

Medical Management:Medical Management:1.1. To replace ADHTo replace ADH2.2. To ensure adequate fluid To ensure adequate fluid

replacementreplacement3.3. To identify and correct the To identify and correct the

underlying intracranial underlying intracranial pathologypathology

Pharmacologic TherapyPharmacologic Therapy1.1. Desmopressin acetate Desmopressin acetate

( DDAVP)( DDAVP)- a synthetic vasopressin, - a synthetic vasopressin,

administered intranasallyadministered intranasally- 1- 2 administration every - 1- 2 administration every

12- 24 hours12- 24 hours

2. 2. Vasopressin tannate Vasopressin tannate ( Pitressin Tannate)( Pitressin Tannate)

- IM, every 12- 96 hours- IM, every 12- 96 hours- given @ night, rotation - given @ night, rotation

of of injection site injection site

- S/E: abdominal cramps- S/E: abdominal cramps

Other drugs:Other drugs:• ClofibrateClofibrate• chlorpropamide ( Diabinese)- chlorpropamide ( Diabinese)-

hypoglycemiahypoglycemia• Thiazide diuretics- increases Na Thiazide diuretics- increases Na

excretionexcretion

Nursing Interventions:Nursing Interventions:1. 1. Monitor VS and neurologic and Monitor VS and neurologic and

cardiovascular status.cardiovascular status.2. Provide a safe environment esp. 2. Provide a safe environment esp.

in pt with change of LOC.in pt with change of LOC.3. 3. Monitor electrolyte values Monitor electrolyte values

and signs of dehydrationand signs of dehydration4. Monitor I & O, weights, specific 4. Monitor I & O, weights, specific

gravity of urinegravity of urine5. 5. Maintain adequate fluid intake.Maintain adequate fluid intake.

B. Syndrome of B. Syndrome of Inappropriate Anti diuretic Inappropriate Anti diuretic

Hormone Secretion Hormone Secretion ( SIADH)( SIADH)- Excessive ADH secretionExcessive ADH secretion

- Cannot excrete a dilute urineCannot excrete a dilute urine- Retain fluids & develop a sodium Retain fluids & develop a sodium

deficiency known as “dilutional deficiency known as “dilutional hyponatremia”hyponatremia”

- Occurred in severe pneumonia, Occurred in severe pneumonia, pneumothorax and other pneumothorax and other disorder of the lungs.disorder of the lungs.

Clinical Manifestations:Clinical Manifestations:1. Fluid volume overload.1. Fluid volume overload.2. Change in LOC and mental 2. Change in LOC and mental

status changes.status changes.3. Weight gain3. Weight gain4. Hypertension4. Hypertension5. Tachycardia5. Tachycardia6. Dilutional hyponatremia6. Dilutional hyponatremia7. Anorexia, nausea & vomiting7. Anorexia, nausea & vomiting

Nursing Management:Nursing Management:1.1. Close monitoring of fluid intake Close monitoring of fluid intake

& output.& output.2.2. Daily weightDaily weight3.3. Urine & blood chemistriesUrine & blood chemistries..4.4. Monitor fluid and electrolyte Monitor fluid and electrolyte

balance.balance.5.5. Administer demeclocycline Administer demeclocycline

(Declomycin)(Declomycin)

C. HypopituitarismC. Hypopituitarism

Description: Description: - hyposecretion of growth - hyposecretion of growth hormonehormone

by the anterior pituitary.by the anterior pituitary.

Clinical Manifestations:Clinical Manifestations:1.1. Retarded physical growthRetarded physical growth2.2. Premature agingPremature aging3.3. Low intellectual developmentLow intellectual development4.4. Poor development of secondary Poor development of secondary

sex characterisitcssex characterisitcs

Nursing Interventions:Nursing Interventions:1.1. Provide emotional support.Provide emotional support.2.2. Encourage client to express Encourage client to express

feelings related to altered body feelings related to altered body imageimage

3.3. Prepare to administer human Prepare to administer human growth hormone ( hGH)growth hormone ( hGH)

D. HyperpitiutarismD. Hyperpitiutarism

Hypersecretion of GH which Hypersecretion of GH which results in gigantism and results in gigantism and acromegalyacromegaly

Clinical Manifestations:Clinical Manifestations:1.1. Large hands and feetLarge hands and feet2.2. Arthritic changesArthritic changes3.3. Visual disturbancesVisual disturbances4.4. DiaphoresisDiaphoresis5.5. Oily, rough skinOily, rough skin6.6. OrganomegalyOrganomegaly7.7. HypertensionHypertension8.8. Deepening of the voiceDeepening of the voice

Nursing interventions:Nursing interventions:1.1. Prepare the client for Prepare the client for

hypophysectomy.hypophysectomy.

Hypophysectomy- Hypophysectomy- removal of removal of the pituitary gland.the pituitary gland.

Complications: increased Complications: increased intracranial pressure ( ICP), intracranial pressure ( ICP), bleeding & meningitis.bleeding & meningitis.

Thyroid glandThyroid gland- - butterfly- shaped organ located inbutterfly- shaped organ located in

the lower neck anterior to thethe lower neck anterior to the trachea.trachea.

- about 5x the blood flow to the - about 5x the blood flow to the liverliver- controls the rate of body - controls the rate of body

metabolism and growth.metabolism and growth.

Hormones:Hormones:1. Thyroxine ( T4)1. Thyroxine ( T4)2. Triiodothyronine ( T3)2. Triiodothyronine ( T3)3. Thyrocalcitonin3. Thyrocalcitonin4. Iodine4. Iodine

Role of Iodine: Role of Iodine: - essential to the thyroid gland for - essential to the thyroid gland for

synthesis of its hormones.synthesis of its hormones.

A. HypothyroidismA. HypothyroidismHyposecretion of thyroid hormoneHyposecretion of thyroid hormoneCharacterized by decrease rate of Characterized by decrease rate of

body metabolismbody metabolismSubclinical form: Subclinical form: myxedemamyxedemaMost common cause: Most common cause:

autoimmune thyroiditis autoimmune thyroiditis ( Hashimoto’s disease)( Hashimoto’s disease)

Clinical Manifestations:Clinical Manifestations:1.1. FatigueFatigue2.2. Intolerance to coldIntolerance to cold3.3. Weakness, muscle aches, Weakness, muscle aches,

paresthesiaparesthesia4.4. WeightWeight5.5. gaingain6.6. Dry skin and hairDry skin and hair7.7. Loss of body hairLoss of body hair

8. Bradycardia8. Bradycardia9. 9. ConstipationConstipation10. 10. Generalized puffiness and Generalized puffiness and

edema around the eyes and faceedema around the eyes and face11. Forgetfulness & loss of memory11. Forgetfulness & loss of memory12. Menstrual disturbances12. Menstrual disturbances13. Cardiac disorders13. Cardiac disorders

Pharmacologic therapyPharmacologic therapy1.1. Synthetic levothyroxine Synthetic levothyroxine

( Synthroid or Levothroid)( Synthroid or Levothroid)- used in treating - used in treating hypothyroidism hypothyroidism and and suppressing nontoxic goiter.- suppressing nontoxic goiter.- hormone replacement is given hormone replacement is given depends on TSH concentrationdepends on TSH concentration

Nursing interventions:Nursing interventions:1.1. Monitor VS, HR and rhythmMonitor VS, HR and rhythm2.2. Administer thyroid replacement; Administer thyroid replacement;

Levothyroxine sodium ( Synthroid) Levothyroxine sodium ( Synthroid) commonly prescribed.commonly prescribed.

3.3. Instruct about thyroid Instruct about thyroid replacement therapyreplacement therapy

4.4. Low calorie, cholesterol and low Low calorie, cholesterol and low saturated fat dietsaturated fat diet

5. Assess for constipation, provide 5. Assess for constipation, provide roughage and fluidsroughage and fluids

6. Provide warmth environment6. Provide warmth environment7. Avoid sedatives and narcotics7. Avoid sedatives and narcotics8. Monitor for overdose of thyroid 8. Monitor for overdose of thyroid

medication: tachycardia, medication: tachycardia, restlessness, nervousness and restlessness, nervousness and insomniainsomnia

9. Report for chest pain immediately.9. Report for chest pain immediately.

B. HyperthyroidismB. Hyperthyroidism Hypersecretion of thyroid hormoneHypersecretion of thyroid hormoneIncrease rate of body metabolismIncrease rate of body metabolismGrave’s diseaseGrave’s disease: most common : most common

type of hyperthyroidismtype of hyperthyroidismMost common causeMost common cause: thyroiditis, : thyroiditis,

excessive ingestion of thyroid excessive ingestion of thyroid hormonehormone

Clinical Manifestations:Clinical Manifestations:1.Thyrotoxicosis: nervousness1.Thyrotoxicosis: nervousness2. Cardiac dysrhytmias, such as 2. Cardiac dysrhytmias, such as

tachycardia and palpitationstachycardia and palpitations3. Protruding eyeballs ( exophthalmos)3. Protruding eyeballs ( exophthalmos)4. Weight loss4. Weight loss5. Diarrhea5. Diarrhea6. irritable6. irritable

7. Pulse rapid7. Pulse rapid8. Heat intolerance8. Heat intolerance9. Flushed skin, moist & soft9. Flushed skin, moist & soft10. Increase appetite10. Increase appetite11. Osteoporosis & fracture11. Osteoporosis & fracture

Nursing Interventions:Nursing Interventions:1. Provide adequate rest.1. Provide adequate rest.2. Provide cool and quiet environment2. Provide cool and quiet environment3. Obtain daily weights.3. Obtain daily weights.4. Provide high calorie diet.4. Provide high calorie diet.5. Administer iodine preparation that 5. Administer iodine preparation that

inhibit the release of thyroid inhibit the release of thyroid hormone.hormone.

6. 6. Use of radioisotope 123 I or 131 Use of radioisotope 123 I or 131 I, anti thyroid hormone, and I, anti thyroid hormone, and levothyroxinelevothyroxine

7. Administer Propanolol ( Inderal) 7. Administer Propanolol ( Inderal) for tachycardiafor tachycardia

Parathyroid glandParathyroid gland- Located near the thyroid.Located near the thyroid.

- Controls Ca and phosphorus Controls Ca and phosphorus metabolismmetabolism

- Produces parathyroid hormone Produces parathyroid hormone ( PTH)( PTH)

A. HypoparathyroidismA. Hypoparathyroidism caused by parathyroid hormone caused by parathyroid hormone

deficiencydeficiencyPrecipitating factors: Precipitating factors:

thyroidectomy, thyroidectomy, parathyroidectomy, radical neck parathyroidectomy, radical neck dissectiondissection

Clinical Manifestations:Clinical Manifestations:1.1. Hypocalcemia and Hypocalcemia and

HyperphosphatemiaHyperphosphatemia2.2. Numbness and tingling in the faceNumbness and tingling in the face3.3. + Trousseau’s sign & + Trousseau’s sign &

Chvostek’s signChvostek’s sign4.4. HypotensionHypotension5.5. Anxiety, irritability and depressionAnxiety, irritability and depression

6. 6. Signs of overt tetany, such as Signs of overt tetany, such as bronchospasm, laryngospasm, bronchospasm, laryngospasm, carpopedal spasm, dysphagia, carpopedal spasm, dysphagia, photophobia, cardiac photophobia, cardiac dysryhthmias, seizures dysryhthmias, seizures

Nursing Interventions:Nursing Interventions:1.1. Monitor VSMonitor VS2.2. Monitor signs of tetany and Monitor signs of tetany and

hypocalcemiahypocalcemia3.3. Initiate seizure precautionsInitiate seizure precautions4.4. Place tracheostomy set, oxygen Place tracheostomy set, oxygen

and suction at bedsideand suction at bedside

5. 5. Prepare to administer Ca Prepare to administer Ca gluconate IV or Ca chloridegluconate IV or Ca chloride

6. Provide high Ca and low 6. Provide high Ca and low phophorus dietphophorus diet

7. Instruct client in the 7. Instruct client in the administration of Vit D administration of Vit D supplements it enhances Ca supplements it enhances Ca absorption from the GI tractabsorption from the GI tract

8. Administer phosphate binders 8. Administer phosphate binders to enhance excretion of to enhance excretion of phosphate through the GI tractphosphate through the GI tract

B. HyperparathyroidismB. HyperparathyroidismHypersecretion of theparathyroid Hypersecretion of theparathyroid

hormonehormone characterized by bone characterized by bone

decalcification and development decalcification and development of renal calculi ( Kidney stone)of renal calculi ( Kidney stone)

Clinical Manifestations:Clinical Manifestations:1.1. Hypercalcemia and Hypercalcemia and

hypophosphatemiahypophosphatemia2.2. Fatifue and muscle weaknessFatifue and muscle weakness3.3. Skeletal pain and tendernessSkeletal pain and tenderness4.4. Bone deformitiesBone deformities5.5. Anorexia, N/V, epigastric painAnorexia, N/V, epigastric pain6.6. Weight lossWeight loss

7. 7. ConstipationConstipation8. Hypertension8. Hypertension9. Cardiac dysrhythmias9. Cardiac dysrhythmias10. Renal stone10. Renal stone

Nursing Interventions:Nursing Interventions:1.1. Monitor VS, esp BPMonitor VS, esp BP2.2. Monitor for dysrhyhmiasMonitor for dysrhyhmias3.3. Monitor I & O and for signs of Monitor I & O and for signs of

renal stonesrenal stones4.4. Encourage fluidsEncourage fluids5.5. Administer Lasix to lower Ca Administer Lasix to lower Ca

absorptionabsorption

6. 6. Administer IV normal saline sol’nAdminister IV normal saline sol’n7. Administer phosphate7. Administer phosphate8. Administer calcitonin ( Calcimar) 8. Administer calcitonin ( Calcimar)

to decrease skeletal Ca release to decrease skeletal Ca release and increase renal clearance of Caand increase renal clearance of Ca

9. Administer Ca chelators9. Administer Ca chelators10. Monitor Ca & phosphorus level.10. Monitor Ca & phosphorus level.

11. Assess for tingling and 11. Assess for tingling and numbness innumbness in

the muscles and signs of the muscles and signs of hypocalcemiahypocalcemia12. Prepare patient for12. Prepare patient for parathyroidectomyparathyroidectomy

Adrenal glandAdrenal gland- rest upon each kidney- rest upon each kidney- regulates sodium and electrolyte- regulates sodium and electrolyte

balancebalance- Affects carbohydrate, fat, and - Affects carbohydrate, fat, and

protein metabolismprotein metabolism- influences the development of - influences the development of

sexual characteristics.sexual characteristics.

- - 2 parts: 1. 2 parts: 1. adrenal cortex, adrenal cortex, outerouter shell, synthesizes glucocorticoidsshell, synthesizes glucocorticoids and mineralocorticoids and secretes and mineralocorticoids and secretes small amounts of sex hormonessmall amounts of sex hormones ( androgens & estrogens) ( androgens & estrogens) 2. 2. adrenal medullaadrenal medulla, inner core , inner core

andand works as part of SNS, producesworks as part of SNS, produces epinephrine & norepinephrine.epinephrine & norepinephrine.

Addison’s DiseaseAddison’s Disease idiopathic atrophy of the adrenal idiopathic atrophy of the adrenal

glandglandAdrenal cortex is inadequate due Adrenal cortex is inadequate due

to surgical removal of both to surgical removal of both adrenal glandadrenal gland

Caused by infection: TB & Caused by infection: TB & histoplasmosishistoplasmosis

Inadequate ACTH secretionInadequate ACTH secretion

Clinical Manifestations:Clinical Manifestations:1. 1. Major problem: fatigue, Major problem: fatigue,

weakness and dehydrationweakness and dehydration2. Decrease blood glucose, sodium 2. Decrease blood glucose, sodium

and increase in potassium.and increase in potassium.3. Emaciation3. Emaciation4. 4. Addisonian crisis: hypotension, Addisonian crisis: hypotension,

dehydration and cyanosisdehydration and cyanosis5. apathy5. apathy

6. 6. ConfusionConfusion7. Circulatory shock: pallor, rapid weak 7. Circulatory shock: pallor, rapid weak

pulse, rapid respiration, decrease BPpulse, rapid respiration, decrease BP8. Headache8. Headache9. Nausea9. Nausea10. Abdominal pain10. Abdominal pain11. Diarrhea and restlessness11. Diarrhea and restlessness

Medical Management:Medical Management:1.1. Administering fluids and Administering fluids and

corticosteroidscorticosteroids2.2. Hydrocotisone IV 5%normal Hydrocotisone IV 5%normal

saline- gives 170 caloriessaline- gives 170 calories3.3. Vasopressor Amines- Vasopressor Amines-

hypotension persistshypotension persists4.4. Glucocorticoids taken 2/3 @ Glucocorticoids taken 2/3 @

8am remaining is 4pm8am remaining is 4pm

Nursing Interventions:Nursing Interventions:1.1. Monitor VS, BP, weight and I & OMonitor VS, BP, weight and I & O2.2. Monitor blood glucose and Monitor blood glucose and

potassium levelspotassium levels3.3. Administer mineralocorticoids Administer mineralocorticoids

and glucocorticoids medicationsand glucocorticoids medications4.4. Observe for addisonian crisis Observe for addisonian crisis

secondary to stress, infection, secondary to stress, infection, trauma and surgerytrauma and surgery

Cushing’s SyndromeCushing’s SyndromeCaused by excessive corticoid Caused by excessive corticoid

production secondary to hyperplasiaproduction secondary to hyperplasia

Benign or malignant adrenal tumorBenign or malignant adrenal tumor

Ectopic production of ACTH by Ectopic production of ACTH by malignancymalignancy

Clinical Manifestations:Clinical Manifestations:1.1. Truncal obesity with thin extremitiesTruncal obesity with thin extremities2.2. MoonfaceMoonface3.3. Classic picture: buffalo humpClassic picture: buffalo hump

neck and supraclavicular neck and supraclavicular areasareas

Heavy trunkHeavy trunk Thin extremitiesThin extremities

4. Increase Na retention & water, 4. Increase Na retention & water, hyperglycemia, WBC and hyperglycemia, WBC and decrease Potassium and Cadecrease Potassium and Ca

5. Ecchymoses ( bruises)5. Ecchymoses ( bruises)6. Reddish purple striae on the 6. Reddish purple striae on the

abdomen and upper thighsabdomen and upper thighs7. Hirsutism7. Hirsutism

8. Hypertension8. Hypertension9. Increased susceptibility to 9. Increased susceptibility to

infectioninfection

Diagnostic Findings:Diagnostic Findings:

Overnight dexamethasone Overnight dexamethasone suppression test-suppression test- screening screening test for diagnosis of cushing’s test for diagnosis of cushing’s syndromesyndrome

Nursing Interventions:Nursing Interventions:1.1. Monitor BPMonitor BP2.2. Monitor I & O, weightMonitor I & O, weight3.3. Monitor lab. Values: glucose, Monitor lab. Values: glucose,

WBC, sodium, K and CaWBC, sodium, K and Ca4.4. Provide good skin careProvide good skin care5.5. Administer aminoglutethimide Administer aminoglutethimide

( Elipten, cytadren, an adrenal ( Elipten, cytadren, an adrenal enzyme inhibitorenzyme inhibitor

6. Prepare client for 6. Prepare client for Transpphenoidal Transpphenoidal hypophysectomy – treatment of hypophysectomy – treatment of choice , and adrenalectomychoice , and adrenalectomy