1 UNIVERSITY OF SAN CARLOS COLLEGE OF NURSING ENDOCRINE NOTES Endocrine glands and its hormones: PITUITARY PITUITA RY GLAND – master gland since it controls all the other glands of the endocrine system 1.) Anterior Pituitary Gland ( adenohypophysis) – outgrowth of the pharynx G H (somatotropine) - stimulation of somatic growth SH - stimulates synthesis and release of thyroid hormones T SH ROLACTIN - regulation of milk production P ROLACTIN ACTH - stimulates the adrenal cortex to secrete adrenal hormones LH - in women stimulate ovarian follicular development and ovulation, LH stimulates testosterone biosynthesis in men SH – female egg cell production or male sperm production F SH SH - cause hyperpigmentation of skin M SH
2.) Posterior Pituitary Gland ( neurohypophysis) – extension of the hypothalamus Oxytocin - stimulates contraction of uterine smooth muscle cells, stimulates milk delivery from the breast during lactation. ADH ( Vasopressin) - promotes water conservation by the kidney ADRENAL GLANDS – a pair of glands located on top of the kidney poles
1.)adrenal cortex – outer part of the adrenal gland Sugar – – glucocorticoids ( cortisone) Salt – mineralocortic mineralocorticoids oids ( aldosterone) Sex – gonadal gonadal hormones ( androgen, estrogen) 2.) adrenal medulla – inner part of the adrenal gland CATECHOLAMINES CATECHO LAMINES – fight or flight response of the body Epinephrine ( adrenalin) Norepinephrine ( noradrenalin) THYROID GLAND
T3 ( TRIIDOTHYRONINE) – metabolically active form of T4 T4 (THYROXINE) – contains iodine essential for normal growth and metabolism THYROCALCITONI THYROCA LCITONIN N – decreases calcium concentration in the blood PARATHYROID GLAND
PARATHYROID HORMONE( PARATHORMONE, PTH) -
incre inc rease asess calc calcium ium con concen centra tratio tion n in in the blo blood od
PANCREAS
2 FUNCTIONS: 1. EXOCRINE – Produces pancreatic juices which are used in the duodenum as an important part in the digestive system 2. ENDOCRINE – ISLETS OF LANGERHANS ALPHA CELLS (GLUCAGON) – increases blood glucose by glycogenolysis
2 BETA CELLS (INSULIN) – decreases blood glucose by glycogenesis, transports glucose into cells for utilization DELTA CELLS (SOMATOSTATIN) – inhibits the secretion of glucagon and insulin insulin
Disorders of the Pituitary Gland
DEFINITION
S/S
HYPOPITUITARISM ( dwarfism) Hyposecretion of GH
HYPERPITUITARISM ( gigantism, acromegaly) Hypersecretion of GH gigantism – – before before closure of epiphyseal plate acromegaly – after closure of epiphyseal plate
Retarded physical growth Premature aging Low intellectual devt Poor devt of secondary sex characteristics
Coarse facial features Large hands and feet Thickening and protrusion of the jaw Arthritic changes Organomegaly
provide emotional support
provide emotional support r/t altered body image
MANAGEMENT encourage expression of feelings r/t altered body image prepare to administer human growth hormone(hGH)
provide frequent skin care provide pharmacological and nonpharmacological interventions for joint pain prepare the client for radiation of the pituitary gland as prescribe
HYPOPHYSECTOMY
SURGERY
COMPLICATION/S Increase ICP Bleeding CSF leakage Temporary DI
DIABETES INSIPIDUS (DI)
SYNDROME OF INAPPROPRIATE SECRETION OF ADH (SIADH) Hypersecretion of ADH
DEFINITION
Hyposecretion of ADH
LAB/DX
(+) fluid deprivation test
S/S
Polyuria of 4 to 24 L/day Polydipsia Dehydration Inability to concentrate urine A low urinary specific gravity:1.006 or less Postural hypotension
Signs of fluid overload • Weight gain • Hypertension Dilutional Hyponatremia • Changes in LOC and mental status changes
MANAGEMENT
monitor electrolyte values for signs of dehydration
provide a safe envt, particularly for the client with changes in LOC
and
monitor I&O, weights, specific gravity of urine
monitor I&O and obtain daily weights
3 instruct the client to avoid foods or liquids with a diuretic type action(e.g caffeinated beverages) administer vasopressin tannate( Pitressin Tannate), desmopressin acetate(DDV acetate(DDVAP, AP, Stimate) or lypressin(Diapid) as prescribed
monitor fluid and electrolyte balance restrict fluid intake as prescribed administer diuretics and IV fluids as prescribed; monitor IV fluids carefully because of the risk for water intoxication
administer chlorpropamide(Diabenese) chlorpropamide (Diabenese) or clofibrate(Atromid-S) clofibrate(A tromid-S) as prescribed – augments the action of ADH if partial deficit of ADH exists
Disorders of the Adrenal Gland DEFINITION
ADDISON’S DISEASE Hyposecretion of adrenal hormones
CUSHING’S SYNDROME Hypersecretion of adrenal hormones
Hypoglycemia Hyperkalemia Hyponatremia Postural hypotension Emotional disturbances Lethargy, fatigue, and muscle weakness Dark pigmentation
Elevated blood glucose Hypokalemia Hypernatremia Hypertension Truncal obesity with thin extremities Moonface Buffalo hump Supraclavicularr fat pads Supraclavicula Fragile skin that easily bruises Hirsutism
monitor v/s, particularly BP, weight, and I&O
monitor v/s particularly BP monitor I&O monitor lab values provide good skin care allow the client to discuss feelings r/t body appearance
S/S
MANAGEMENT
monitor blood glucose and potassium levels administer glucocorticoids or mineralocorticoid mineralocor ticoid meds as prescribed low potassium, high sodium diet
administer aminoglutethimide(Elipten, Cytadren)- an adrenal enzyme inhibitor as prescribed low sodium, high potassium diet
Patient Education:
avoid individuals with infection avoid stress avoid strenuous exercise Hypophysectomy – if the Hypophysectomy condition results from increase ACTH secretion by the pituitary gland
SURGERY
Adrenalectomy – if the condition results from adrenal adenoma COMPLICATION
ADDISONIAN CRISIS acute adrenal insufficiency precipitated by stress, illness and infection S/S: hyponatremia, hyperkalemia hypoglycemia
4 shock Mgt: administer IV glucocorticoids as prescribed - hydrocortisone sodium succinate(Solu- cortef)
PHEOCHROMOCYTOMA DEFINITION S/S
MANAGEMENT
Catecholamine- producing tumor in the adrenal medulla HPN Severe headaches Palpitations Pain in the chest or abdomen with n & v monitor v/s (BP)
avoid stimuli (increased abdominal pressure, micturition, and vigorous abdominal palpation) instruct the client not to smoke, drink caffeinated beverages promote rest and a nonstressful envt provide a diet high in calories, vitamins and minerals avoid tyramine- rich foods ( e. g. aged cheese, ripe banana, wine, gravies) COMPLICATION SURGERY
HYPERTENSIVE CRISIS DOC : phentolamine(Regitine) ADRENALECTOMY •
lifelong glucocorticoid replacement is necessary with a bilateral adrenalectomy
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temporary glucocorticoid replacement replacement,, up to 2 years is necessary for a unilateral adrenalectomy
POST OP: monitor for signs of shock and hemorrhage, particularly during first 24 to 48 hours
DISORDERS OF THE THYROID GLAND HYPOTHYROIDISM
DEFINITION Normal lab values: T3 = 80 to 230 ng/dL T4 = 5 to 12 ug/dL
S/S
MANAGEMENT
hyposecretion of thyroid hormone
HYPERTHYROIDISM (GRAVE’S DSE) hypersecretion of thyroid hormone
decreased rate of body metabolism
increased rate of body metabolism Enlarged thyroid gland (goiter) Intolerance to cold Weight gain Protruding eyeballs Bradycardia (exophthalmos) Constipation Heat intoleranc intolerancee Generalized Generalize d puffiness and edema Diaphoresis around the eyes and face Weight loss Forgetfulness Forgetfulne ss and loss of memory Diarrhea Dry skin and hair Smooth, soft skin and hair Personality changes tachycardia and palpitations monitor vital signs provide adequate rest provide a warm environmen environmentt for the client
provide a cool and quiet environment
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instruct the client in low calorie, low cholesterol, low saturated fat diet assess the client for constipation; provide roughage and fluids to prevent constipation
administer thyroid replacement replacement;; levothyroxine sodium (Synthroid) is most commonly prescribed S/E: tachycardia, restlessness, nervousness and insomnia NSG RESPONSIBILITY: Administer in the morning to prevent insomnia Instruct the client about thyroid replacement therapy for a lifetime
provide a high calorie diet avoid the administration of stimulants administer antithyroid medications that block thyroid synthesis as prescribed e.g. propylthiouracil(PTU) methimazole(( Tapazole) methimazole A/R: agranulocytosis administer iodine preparations that inhibit the release of thyroid hormone as prescribed
e.g. SSKI (Lugol’s Solution) - given preop to decrease vascularity of thyroid gland prepare the client for radioactive iodine therapy as prescribed, to destroy thyroid cells administer propanolol (Inderal) for tachycardia
COMPLICATION
Myxedema Coma - results from persistently low thyroid production
- can be precipitated by acute illness, rapid withdrawal of thyroid medications, anesthesia and surgery, hypothermia or the use of sedatives and narcotics S/S: Hypotension Bradycardia Hypothermia Hyponatremia Hypoglycemia Respiratory failure
MGT: maintain a patent airway administer levothyroxine sodium(Synthroid) sodium(Synt hroid) IV as prescribed keep client warm
Thyroid Storm - occurs in a client with uncontrollable hyperthyroi hyperthyroidism dism
- occurs from manipulation manipulation of the the thyroid gland during surgery and the release of thyroid hormone into the bloodstream S/S: Fever Tachycardia Systolic hypertension Agitation, tremors and anxiety Delirium and coma MGT: maintain a patent airway and adequate ventilation administer antithyroid medications, sodium iodide solution, propanolol (Inderal) and glucocorticoids as prescribed monitor continually for cardiac dysrhythmias use a cooling blanket to decrease temperature
SURGERY
THYROIDECTOMY PRE- OP: instruct the client in how to perform coughing and deep breathing exercises by supporting the neck POST OP: monitor for respiratory distress
have a tracheostomy set, oxygen, and suction at the bedside
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monitor surgical site for edema and for signs of bleeding(anteriorly bleeding(anterio rly and posteriorly) monitor for laryngeal nerve damage: (dysphonia, high pitched voice, stridor, dysphagia, and restlessness) monitor for signs of hypocalcemia and tetany: ( Positive Positive chvostek’s sign, Positive trousseau’s sign)
DISORDERS OF THE PARATHYROID GLAND
DEFINITION S/S
HYPOPARATHYROIDISM (HYPOCALCEMIA, HYPERPHOSPHATEMIA) hyposecretion of of pa parathyroid ho hormone
(+) trousseaus’s sign – carpal spasm induced by arterial occlusion of the arm with a BP cuff
HYPERPARATHYROIDISM (HYPERCALCEMIA)
hypersecretion of of pa parathyroid ho hormone Fatigue and muscle weakness Skeletal pain and tenderness
(+) chvostek’s sign – facial nerve irritability elicited by tapping the nerve
MGT
Bone deformities that result in pathological fractures
bronchospasm laryngospasm carpopedal spasm dysphagia photophobia cardiac dysrhythmi dysrhythmias as seizures
Renal stones
prepare to administer IV calcium gluconate or calcium chloride for hypocalcemia
monitor for cardiac dysrhythm dysrhythmias ias cmonitor for I&O and for signs of renal stones
place a tracheostomy set, oxygen, and suctioning at the bedside
monitor for skeletal pain; move client slowly and carefully encourage fluids
provide a high calcium and low phosphorus diet(milk and dairy products) instruct client in the administration of calcium supplements as prescribed instruct client in the administration of vitamin D supplements as prescribed instruct the client in the administration of phosphate binders – promotes excretion of phospate SURGERY
administer furosemide (Lasix) as prescribed to lower calcium levels administer phosphates as prescribed, which interfere with calcium absorption administer calcitonin ( Calcimar) as prescribed, to decrease skeletal calcium release and increase renal clearance of calcium administer calcium chelators(calc chelators(calcium ium EDTA) as prescribed to lower calcium levels HYPERPARATHYROIDECTOMY PRE – OP: ensure that calcium levels are decreased to near normal inform the client that talking may be painful for the first day or two after surgery POST OP: place a tracheostomy set, oxygen, and suctioning at the bedside assess neck dressing for bleeding monitor for hypocalcemic crisis as evidenced by
7 tingling and twitching in the extremities and face monitor for laryngeal nerve damage
DISORDERS OF THE PANCREAS DIABETES MELLITUS DEFINITION
Impaired carbohydrate, carbohydrate, protein, and lipid metabolism
TYPES
TYPE 1 – INSULIN DEPENDENT DM ( IDDM) • also referred to as juvenile diabetes •
S/S
characterized by no insulin production by the islets of langerhands caused by autoimmune disease
TYPE 2 – NON – INSULIN DEPENDENT DIABETES MELLITUS • common among obese • characterized by insulin resistance or impaired insulin receptors Polyuria Polydipsia Polyphagia Weight loss Blurred vision Slow wound healing Vaginal infections Weakness and paresthesias Signs of inadequate circulation to the feet
LAB/DX FINDINGS: NORMAL FINDINGS: Blood glucose level = 60 – 120 mg/dl
RANDOM BLOOD SUGAR > 200 mg/dl FBS = 70 – 110 mg/dl FASTING BLOOD SUGAR(FBS) > 110 mg/dl but < 126 mg/dl Postprandial glucose = 70 – 110 mg/dl POSTPRANDIAL GLUCOSE > 140 mg/dl but < 200 mg/dl OGT – glucose returns to normal in 2 – 3 hours and urine is negative for glucose HbA1c:
ORAL GLUCOSE TOLERANCE(OGT) - blood glucose level returns to normal slowly and urine is positive for glucose
diabetic with good control: 7.5% or less diabetic with fair control:7.6% to 8.9% diabetic with poor control: 9% or greater
GLYCOSYLATED HEMOGLOBIN (HbA1c) - used to assess the effectiveness of treatment regimen and client’s compliance for 3 months > 7.0 %
MANAGEMENT
D - iet 50 - 60 % CHO, 20 - 30 % FATS, 10 - 20% CHON I - nsulin A - ntidiabetic agents B - blood sugar monitoring E - xercise T - transplant of the pancreas E - nsure adequate food intake S - crupulous foot care A. CX OF INSULIN THERAPY 1. INSULIN LIPODYSTROPHY - caused by repeated use of an injection site 2. DAWN PHENOMENON • Results in the nocturnal release of growth hormone, which may cause the blood glucose to begin to rise at about 3 AM • TX :evening dose of intermediate acting
COMPLICATIONS
8 insulin at 10 PM 3. SOMOGYI’S PHENOMENON normal or elevated blood glucose levels are present at bedtime, a decrease occurs at about 2 AM to 3 AM to hypoglycemic levels and a subsequent increase occurs as a result of the production of counterregulatory counterregulat ory hormones •
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Tx: decrease intermediate insulin at suppertime, moving the intermediate insulin dose to bedtime or increasing bedtime snack
B. ACUTE COMPLICATION OF DM 1. Hypoglycemia - occurs when the blood glucose level falls to less than 50 to 60 mg/Dl fast acting simple carbohydrate: three or four commerciall commercially y prepared glucose tablets 4 to 6 ounces of fruit juice or regular soda 6 to 10 life savers or hard candy 2 to 3 teaspoons of sugar or honey. 2. Diabetic Ketoacidosis Common in type 2 DM S/S include hyperglyce hyperglycemia, mia, dehydration and electrolyte loss, and acidosis Tx : fluids, insulin ( IV Regular ), and electrolyte replacement replacement ( K) 3. Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) Common in type 2 DM extreme hyperglycemia without ketosis and acidosis Tx: same with DKA •
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C. CHRONIC COMPLICATIONS OF DM 1. Diabetic Retinopathy permanent vision changes and blindness can occur •
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Mgt : maintain safety
2. Diabetic nephropathy • a progressive decrease in kidney function Mgt: • monitor I & O • monitor BUN and creatinine levels and for albuminuria
3. Diabetic neuropathy general deterioration of the nervous system development of ulcers Mgt: cut toenails straight across apply moisturizing lotion to the feet but not between the toes • •
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INSULIN PREPARATIONS
Short Acting e. g. regular insulin (Humulin R, Novolin R) Intermediate Acting e. g. isophane insulin ( NPH, Humulin N, Novolin N) Long Acting e. g. zinc suspension (Ultralente,
ONSET(HR) 30 min – 1 hr
PEAK ( HR) 2-4
DURATION(HR) 6 -12
2-4
6 - 12
18 - 24
6 - 12
18 - 24
48 - 72
9 Humulin U)
MYRAY 04/07/08 Lean 03
