Adult Health 2 - Endocrine 8.1

Addison's Disease

Cortisol & Aldosterone are low

Addison's s/s (STEROID)

S: Sodium & Sugar are low, Salt cravings

T: Tired & weak

E: Electrolyte imbalance (HyperK, HypoNa)

R: Reproductive changes

O: lOw BP

I: Increased pigmentation

D: Diarrhea & nausea, Depression

Other s/s: weight loss, postural hypotension, excess body hair

Addison's NI

Monitor for hypoglycemia & hyperkalemia

Hormone replacement

Education

Addison's Education

Increases doses with extra stress

Never abruptly stop meds

Take adequate salt

Medical alert bracelet

Warning signs of adrenal crisis (change in symptoms)

Addisonian/Adrenal Crisis (Acute Adrenal Insufficiency)

Low ACTH

Life-threatening emergency

Caused by insufficient adrenocortical hormones or sudden sharp decrease in these hormones

Severe glucocorticoid and mineralocorticoid deficiencies

Addisonian/Adrenal Crisis (Acute Adrenal Insufficiency) Triggers:

1. Stress

2. Sudden withdrawal from steroid hormone therapy

3. Adrenal surgery

4. Sudden pituitary destruction

Addisonian/Adrenal Crisis (Acute Adrenal Insufficiency) s/s

Hypotension

Tachycardia

Dehydration

Hyponatremia

Hyperkalemia

Hypoglycemia

Fever

Weakness

Confusion

Addisonian/Adrenal Crisis (Acute Adrenal Insufficiency) Complications

May lead to hypovolemic shock

Addisonian/Adrenal Crisis (Acute Adrenal Insufficiency) Tx

Aggressive management

Shock management (NS & D5)

High dose hydrocortisone replacement

How to know if a px is going into a Addisonian/Adrenal Crisis

Worsening of baseline

Notice a change

Cushing's disease

Elevated ACTH causing overproduction of cortisol

Cushing's s/s (STRESSED)

S: Skin fragile

T: Truncal obesity, thin extremities

R: Round moon shaped face

E: Ecchymosis, elevated blood pressure

S: Striae on extremities and abdomen, purple

S: Sugar is high (hyperglycemia)

E: Excessive body hair (hirsutism)

D: Dorsocervical fat pad (buffalo hump), Depression

Other s/s: personality changes, red face, gynecomastia, GI distress, petechiae, osteoporosis, amenorrhea, increased risk of infection

Cushing's NI

- Removal of pituitary or adrenalectomy --> Lifetime hormone replacement therapy

- Monitor BG

- Infection control

- Skin breakdown monitoring

- Emotional support

SIADH

Increased ADH

ADH: produced in hypothalamus, stored in posterior pituitary, acts on kidneys to retain water

SIADH Dx

Serum Na < 135

Serum Osmolarity < 280

Specific Gravity > 1.030

SIADH NI

Assess for LOC changes & seizures (brain swelling)

Accurate daily weights

Strict Is/Os

Monitor fluid overload, edema

Fluid restrictions

Monitor HTN & Hyponatremia

Loop diuretic: lasix (watch for hypoK)

Assess for pulmonary edema

diabetes insipidus (DI)

Decreased ADH

Pure water Loss

DI 3 main causes

head injury

pituitary tumor

craniotomy

DI Dx

2-20L urine output/day

Specific gravity < 1.005

Urine osmolarity < 100

Serum osmolarity > 295

DI s/s

Excessive thirst & micturition

Dehydration

Disrupted sleep patterns

Central (neurogenic) DI

Interference with ADH synthesis, transport, or release

head injury

pituitary tumor

craniotomy

Nephrogenic DI

Kidney's aren't responding to ADH

Primary DI

Excess water intake

DI Tx

Accurate daily weights

Strict Is/Os

Monitor specific gravity and for dehydration

Rehydrate/fluid resuscitation

Monitor for hypotn

Hypernatremia

Restrict foods that promote diuresis

Tx with pituitary hormone

Uncorrected Hypernatremia

Can cause brain shrinkage and intracranial bleeding

foods that promote diuresis

Caffeine

Lemons

Watermelons

Grapes

Hyperpituitarism (acromegaly & gigantism)

Over production of GH produced by anterior pituitary

Acromegaly

Growth after fusion of growth plates

Thicker bones

Large hands, feet, lips, nose

Acromegaly s/s

HA

Visual changes

wide spaced teeth

hyperpigmentation

Acanthosis Nigricans

Gigantism

Growth before bones are fused

Tall stature

Large hands & feet

Gigantism s/s

HA

Visual changes

coarse facial features

Frontal bossing

Obesity

Hypopituitarism

Pituitary glands fail to produce hormones

Selective Hypopituitarism

Deficiency of only one pituitary hormone

Panhypopituitarism

Total failure of pituitary gland w/ deficiency in all pituitary hormones

Sex hormone replacement therapy NC

Promotes growth and spread of cancer

Hyperthyroidism

Most commonly Graves Disease

Excess T3 & 4, low TSH

Hyperthyroidism s/s

Everything is running fast (except periods)

Tachycardia

HTN

N/V/D

Thirst, hunger

Tremors, nervousness

Increased metabolism (heat intolerance, thin, increased metabolism of meds)

Exophthalmos

Goiter

Oligomenorrhea

Muscle weakness

Hyperthyroidism NI

Relief of symptoms: control room temp, beta blockers

Well balanced meals: high Cals and vitamins

Anti-thyroid meds to stop T3/4 overproduction

Thyrotoxicosis/Thyroid storm

Hypermetabolism from excess circulating T3/4

Hypothyroidism

elevated TSH, low T3/4

Most commonly hashimoto's disease

Hypothyroidism s/s

Everything is low

Bradycardia

Constipation, poor appetite

Decreased metabolism (weight gain, cold intolerance, tired and fatigued, slow)

Extreme Depression

Can lead to myxedema coma

Myxedema Coma

Elevated TSH, Low T3/4

Decompensated metabolic state and mental status change

Nonpitting edema (myxedema)

Amiodarone NC

contains iodine and lithium which blocks hormone production and can cause hypothyroidism

DM T1

Lack of insulin

Prone to hyperglycemia

DM T1 s/s

Hyperglycemia

Polyphagia (cells are starving from lack of glucose = huge appetite)

Polydipsia (excess thirst)

Polyuria

Weight loss

DM T2

Insulin Resistance

Progressive DM T2

Body tries to compensate with pancreas pumping out more insulin

Pancreas slowly loses the ability to produce enough insulin

DKA s/s

Kussmaul respirations

Nausea/vomiting

Occasional abdominal pain

Fatigue

Thirst

Fruit breath

Confusion/drowsiness

Hypotension

Tachycardia

Rapid onset

BG >300 (average)

Main probs with DKA

Hyperglycemia

Ketosis

Acidosis

DKA causes

No insulin

Present illness

Undiagnosed diabetes

Noncompliant

Inadequate tx

Pump malfunction

HHS s/s

Dehydrated

Unconscious

Hypotension (later)

Tachycardia

Polyuria (several weeks)

Gradual onset

High osmolarity

BG >600 (average)

HHS Causes

Illness

cells not receptive to insulin

Main problems with HHS

hyperglycemia

dehydration

DKA & HHS Similarities

hyperglycemia

dehydration

hyperosmolarity

hypokalemia

caused by illness

tx: insulin, electrolyte replacement, IV fluids

All criteria must be met before switching from IV insulin to subQ

Glucose 250 or less

HCO3: 15 or more

pH >7.3

Anion gap 12 or less (normal range = 3-10)

Anion gap equation

(Na + K) - (Cl + HCO3)