NPTE Endocrine and Electrolyte conditions

Hyperthyroidism

• Thyroid gland secretes excessive amounts of thyroid hormone, Low TSH

  • Graves’ disease- excessive thyroid activity, enlargement of the gland, protruding eyes (retraction of eyelids and inflammation of ocular muscles)

• Clinical presentation

  • elevation in body metabolism → high BMR

  • S/s- Tachycardia, fatigue, weight loss, hyperreflexia, increased sweating, heat intolerance, tremor, nervousness, polydipsia, weakness, increased appetite, dyspnea, weight loss

  • Decreased DBP

  • Chronic periarthritis w/ calcification

  • Proximal muscle weakness (pelvic/ thigh)

• Can have potential contraindication with aquatic therapy

Hypothyroidism- Hashimoto’s disease

• Results from insufficient thyroid hormone → more common than hyper

• Types

  • Primary- results from reduced functional thyroid tissue mass or impaired hormonal synthesis or release

  • Secondary- result of inadequate stimulation of the gland b/c of anterior pituitary gland dysfxn

• Clinical Presentation

  • Generalized depression of body metabolism

  • S/s- intolerance of cold, excessive fatigue, drowsiness, headaches, and weight gain, brittle nails, dry skin, and hair, decreased perspiration.

    • In women: irregular menstrual bleeding, premenstrual syndrome may worsen, dry skin, thin and brittle hair, and nails

  • Increased DBP

• Can result in exercise intolerance, weakness, and exercise-induced myalgia

Hyperparathyroidism

• Excessive secretion of PTH- dirupts calcium, phosphate and bone metabolism → release of calcium by the bone and accumulation of calcium in the bloodstream

• Clinical presentations

  • Mild/ severe proximal muscle weakness, muscle atrophy, bone decalcification, bone pain esp in spine, pathologic fractures, bone cysts, joint hypermobility, hyperactive DTR

  • Loss of appetite, weight loss, nausea and vomiting, depression, increased thirst/ urination, GI problems, pancreatitis, peptic ulcers

Hypoparathyroidism

• Insufficient secretion of PTH- results from accidental removal or injury of the PTG during thyroid/ anterior neck surgery

• Clinical presentations

  • hypocalcemia- neuromuscular excitability and muscular tetany, especially involving flexion of the UE

    • Trousseau sign- tetany of carpopedal muscles

  • Spasm of intercostal m. and diaphragm compromising breathing

  • Positive Chvostek’s sign → twitching of facial muscles w/ taping of the facial nerve in front of the ear

  • Cardiac arrhythmias, dry scaly skin, thin hair/ brittle nails

Adrenal insufficiency- Addison’s Disease

• Causes: infections, neoplasms, hemorrhage, autoimmune process

• Adrenal insufficiency- decreased cortisol and aldosterone

• Decreased BP, dehydration, hyponatremia

• Hyperkalemia

• Decreased glucose

• Bronze pigmented skin- increased MSH (melanocyte stimulating hormone)

• Weight loss, anorexia, GI disturbances

• Generalized weakness (Asthenia)

• Intolerance to cold and stress, anxiety, and depression

Adrenal hyperfunctioning- Cushing’s disease

• Causes: pituitary tumor with increased ACTH secretion

• Elevated cortisol and aldosterone

• Increased BP, and water retention

• Hypokalemia

• Increased glucose

• Ruddy appearance, striae on skin

• Weight gain, centripetal obesity, round moon face

• Proximal muscle weakness and atrophy

• Increased susceptibility to infection, Osteoporosis (buffalo hump), poor wound healing

Diabetes Mellitus

• Type 1

  • pancreas produces no insulin → insulin dependent DM

  • Diagnosed mostly at childhood, can be any age (d/t viral infection)

  • S/s: polyphagia, weight loss, ketoacidosis, polyuria, polydipsia, blurred vision, dehydration

• Type 2

  • Body’s resistance to insulin → insulin resistant DM

  • Occurs secondary to other dysfxns

  • S/s: similar to type 1 with rare occurence of ketoacidosis

Dx of Diabetes Mellitus

• Fasting blood glucose: >126 mg/dL

• Random blood glucose level > 200 mg/dL

• HbA1C levels - avg over 2-3 months

  • Glycosylated Hemoglobin normal reference range 4-6%

  • A1C level over 10% requires immediate insulin therapy

Hypoglycemia → cold and clammy give them candy

• Glucose: < 70 mg/dL

• Early signs: palor, sweating, shakiness, poor coordination and unsteady gait, tachycardia & palpitations, dizziness, fainting, excessive hunger

• Late signs: slurred speech, drowsiness, confusion, loss of consciousness & coma

Hyperglycemia- Hot and dry, sugar high

• Glucose: >300 mg/dL

• Early signs: weakness, dry mouth, frequent, scant urination, Kussmaul respirations (deep/ rapid breathing), dull senses, confusion, diminished reflexes, excessive thirst

• Late signs: breath has fruity odor (acetone breath), Hyperglycemic coma

Exercise and Diabetes

• Blood Glucose levels

  • Below 70: NEVER EXERCISE

  • 70-100: give them a carb snack and wait till 100, then exercise

  • 100-250: safe to exercise

  • 250-300 w/o ketones: exercise with caution

  • 250-300 w/ ketones: EMERGENCY

  • Above 300: NEVER EXERCISE

Potassium- normal fxn

• 3.5-5 mEq/L

• necessary to maintain fxn of sodium-potassium membrane pumps, which are essential for the normal muscle contraction- relaxation

Hypokalemia

• <3.5 mEq/L

• Causes

  • Dietary deficiency/ intestinal/ urinary loss (diarrhea, vomiting, gastric suction)

  • Trauma

  • Metabolic alkalosis

  • DKA

  • integumentary loss/ severe magnesium deficiency

• Symptoms

  • Dizziness, hypotension, arrhythmias, ECG charges (flattened T waves and depressed ST segments)

  • Nausea and vomiting, anorexia, constipation, abdominal distension

  • Muscle weakness, fatigue, leg cramping

  • irritability, confusion, mental depression, speech changes, diminished reflexes, pulmonary hyperventilation

  • metabolic alkalosis

Hyperkalemia

• >5 mEq/ L

• Causes:

  • Conditions that alter kidney function or decrease its ability to excrete potassium (chronic renal disease or renal failure)

  • Addison's disease

  • Chronic heparin therapy, lead poisoning, insulin deficit, NSAIDs, ACE inhibitors

  • Trauma- crush injuries, burns

  • Metabolic acidosis

  • Rhabdomyolysis, Hyperglycemia, Digitalis toxicity

• Symptoms:

  • Tachycardia and later bradycardia, ECG changes- Tall T waves, prolonged P-R interval, and QRS duration

  • Muscle weakness, flaccid paralysis, Areflexia progressing to weakness, numbness, tingling, and flaccid paralysis

  • Metabolic acidosis

Sodium- normal

• 135-145 mEq/L

• Affects the osmolarity of blood and therefore influences blood volume and pressure retention or loss of interstitial fluid

• Sodium imbalance affects the osmolarity of the ECF and is often associated w/ fluid volume imbalances

Hyponatremia

• <135 mEq/L

• Causes

  • Inadequate sodium intake

  • Excessive intake or retention of water (kidney failure and heart failure)

  • Excessive water loss and electrolytes (vomiting, excessive perspiration, tap water, enemas, suctioning, use of diuretics, diarrhea)

  • Trauma (loss of sodium through burn wounds, wound drainage from surgery)

  • Adrenal gland insufficiency (Addison disease) or hypoaldosteronism

  • Neoplasm with ADH production

  • Hypothyroidism

  • Nephrotic syndrome

• S/s

  • Anxiety, headaches, muscle twitching and weakness, confusion, seizures

  • Hypotension; tachycardia; with severe deficit, vasomotor collapse, thready pulse

  • Nausea, vomiting, abdominal cramps

  • Cold clammy skin, decreased skin turgor

Hypernatremia

• >145 mEq/L

• Causes

  • Decreased water intake (comatose, mentally contused, or debilitated client)

  • Water loss (excessive sweating, osmotic diarrhea), Fever, heat exposure, burns

  • Hyperglycemia

  • Excess adrenocortical hormones (Cushing syndrome)

• S/S

  • Agitation, restlessness, seizures, ataxia, confusion

  • Hypertension, tachycardia, pitting edema, excessive weight gain

  • Rough, dry tongue; intense thirst; severe hypotension

  • Dyspnea, respiratory arrest

  • Flushed skin; dry, sticky mucous membranes

Calcium- normal

• 9-11 mEq/L

• Influences the permeability of cell membranes and regulates neuromuscular release

• Plays a role in the electrical excitation of cardiac cells and in the mechanical contraction of the myocardial and vascular smooth muscle cells

Hypocalcemia

• <9 mEq/L

• Causes

  • Inadequate dietary intake of calcium and inadequate exposure to sunlight (Vitamin D necessary for calcium use)

  • Impaired absorption of calcium and Vitamin D from intestinal tract (severe diarrhea, overuse of laxatives, and enemas containing phosphates; phosphorus tends to be more readily absorbed from the intestinal tract than calcium and suppresses calcium retention in the body)

  • Hypoparathyroidism (injury, disease, surgery)

  • Overcorrection of acidosis

  • Renal failure

  • Hypomagnesemia (especially with alcoholism)

• S/S

  • Anxiety, irritability, twitching around mouth, laryngospasm, seizures, Chvostek, and Trousseau sign, apathy, irritability, and confusion

  • Paresthesia (tingling and numbness of the fingers), tetany or painful tonic muscle spasms, facial spasms, abdominal cramps, muscle cramps, spasmodic contractions

  • Arrhythmias, hypotension

Hypercalcemia

• >11 mEq/L

• Causes

  • Hyperparathyroidism, hyperthyroidism, adrenal insufficiency

  • Multiple fractures

  • Excess intake of calcium (excessive antacids), excess intake of vitamin D)

  • Osteoporosis, immobility, multiple myeloma

  • Thiazide diuretics

• S/S

  • Drowsiness, lethargy, headaches, depression

  • Weakness, muscle flaccidity, bone pain, pathologic fractures

  • Cardiac arrhythmias

  • Anorexia, nausea, vomiting, constipation, dehydration, polyuria

Magnesium- normal

• 1.5-2.5 mEq/L

• Important intracellular activator for more than 300 enzymatic processes, exerts physiologic effects on the nervous system that resemble the effects of calcium

• Plays a role in maintaining the correct level of electrical excitability in the nerves and muscles

Hypomagnesemia

• <1.5 mEq/L

• Causes

  • Decreased magnesium intake or absorption (chronic malnutrition, chronic diarrhea, bowel resection, chronic alcoholism, prolonged gastric suction)

  • Excessive loss of magnesium (diabetic ketoacidosis, severe dehydration, hyperaldosteronism, and hypoparathyroidism)

  • Vitamin D deficiency

  • Impaired renal absorption

  • Hyperthyroidism

  • Metabolic acidosis

• S/S

  • Muscle tremors and weakness; athetoid movements

  • Hyperirritability, tetany, leg and foot cramps

  • Confusion, apathy, depression, delusions

  • Arrhythmias

Hypermagnesemia

• > 2.5 mEq/L

• Causes

  • Chronic renal failure or renal insufficiency

  • Overuse of antacids and laxatives containing magnesium

  • Severe dehydration (resulting oliguria can cause magnesium retention)

  • Diabetic ketoacidosis

  • Hypothyroidism

  • Addison's disease (adrenal insufficiency)

  • Shock, sepsis

• S/S

  • Diminished reflexes, muscle weakness, flaccid paralysis, respiratory muscle paralysis that may cause respiratory impairment and even respiratory arrest

  • Drowsiness, flushing, lethargy, confusion, diminished sensorium

  • Bradycardia, weak pulse, hypotension, heart block, cardiac arrest

Changes in DTR- Hyperactive

• Hypocalcemia

• Hypomagnesemia

• Hypernatremia

• Alkalosis

Changes in DTR- Hypoactive

• Hypercalcemia

• Hypermagnesemia

• Hyponatremia

• Acidosis