NRSE 320: Exam #3

Endocrine System

• ____________ glands produce hormones and secrete them into the bloodstream, where they circulate to other tissues

• Plays a role in

  • Reproduction

  • Growth and Development

  • Regulation of Energy

Endocrine System: 9 Glands

• Hypothalamus

• Pituitary Gland

• Thyroid Gland

• Parathyroid Glands

• Adrenal Glands (on top of kidneys)

• Pancreas

• Ovaries

• Testes

• Pineal Gland

Function and Regulation of Hormones

• Negative feedback system

  • Hormone feeds back to decrease its production. Helps bring things back to normal whenever they start to become too extreme (helps keep homeostasis in the body)

Hormone Imbalance: Health History

• Ask if the patient has experienced changed in the following:

  • Energy levels

  • intolerance to heat or cold

  • weight

  • thirst

  • frequency of urination
    bowel function

  • body proportion

  • muscle mass/fat/fluid distribution

  • memory, concentration

  • sleep patterns

  • mood

  • vision, joint pain and sexual dysfunction

Hormone Imbalance: Physical Assessment

• Vital signs

• Head-toe- assessment

• Palpation of skin/hair/thyroid

• Changes in physical characteristics

  • ex) facial hair in women

  • “moon face”

  • vision changes

  • exophthalmos (abnormal protrusion of one or both eyeballs)

  • edema

  • obesity of the trunk

• Changes in mood/behavior:

  • nervousness

  • lethargy

  • depression

  • fatigue

Hormone Imbalance: Diagnostic Tests

• Serum blood tests

  • HbA1C for diabetes (monitors success in diabetic treatment or when changes need to be made)

  • Serum hormone levels are specific

• Radiographic Studies

  • MRI, CT, ultrasound, scan

• Urine Analysis

  • Measures the amount of hormones excreted by the kidneys

• Suppression Testing/Stimulation Testing

  • Used to detect the hyperfunction of an endocrine organ

The Pituitary Gland

• The Master gland

• Helps control the rest of the glands

  • Tells when to secrete and when to stop

• Anterior Pituitary

  • Major hormones include:

    • FSH

    • Luteinizing hormone (LH)

    • Prolactin (PRL)

    • adrenocorticotropic hormone (ACTH)

    • thyroid stimulating hormone (TSH)

    • GH (somatotropin)

• 2. Posterior Pituitary

  • Antidiuretic hormone (ADH)

    • Controls the excretion of water by the kidneys

  • Oxytocin

    • Stimulated during pregnancy and childbirth

Diabetes Insipidus

• A deficiency of Antidiuretic Hormone (ADH) (vasopressin).

• Causes

  • Head trauma

  • surgery

  • Infection

  • brain tumors

  • inflammation

  • Cerebral vascular disease

  • Idiopathicc (unknown cause)

• Classic signs

  • Intense thirst

    • The patient tends to drink 2-20 L of fluid daily and craves cold water

  • Frequent urination

• Other signs

  • Maybe fatigued from nocturia

  • May experience generalized weakness.

Diabetes Insipidus: Testing

• Fluid deprivation test

  • Withholding fluids for 8-12 hours or until 3-5% of the body weight is lost

• Urine testing

• Monitoring specific gravity

Diabetes Insipidus: Medical Management

Hormone replacement with ADH derivatives: vasopressin (limits the amount of water eliminated in the urine)

Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

• The body makes too much Antidiuretic Hormone (ADH)

• Retaining too much fluid

• Causes

  • meningitis

  • brain tumors

  • head trauma

  • lung diseases

  • infection

  • certain medications

• Clinical Manifestations

  • Fluid retention

  • Dilutional hyponatremia

    • Causes muscle cramps and weakness

    • Low urinary output and increased body weight

    • Cerebral edema may lead to…

      • lethargy

      • confusion

      • headache

      • seizures or coma

  • Concentrated urine

  • Excess intravascular volume

Syndrome of Inappropriate Antidiuretic Hormone (SIADH): Testing

• Measuring urine osmolality (specific gravity)

• Serum osmolality

Syndrome of Inappropriate Antidiuretic Hormone (SIADH): Treatment

• Treat the underlying cause

• Restrict fluids

• Hypertonic IV solution (NaCl 3%) to raise sodium levels

• Diuretic therapy and electrolyte replacement

• Fluid restrictions can range from 500 ml per day to between 800 to 1000 mLs per day

The Thyroid Gland

• The largest endocrine gland, located in the lower neck

• Produces 3 hormones:

  1. Thyroxine (T4)

  2. Triiodothyronine (T3)

  3. Calcitonin

• Regulates…

  • weight

  • body temp

  • hair and nail growth

  • metabolism

  • Energy levels

Hypothyroidism

• Low levels of thyroid hormone

• Causes

  • Autoimmune disease

  • Medications

  • Radioactive iodine

  • Thyroidectomy

  • Radiation to head/neck

• Clinical Manifestations

  • Cold Intolerance

  • Hair loss

  • Muscle weakness

  • Extreme fatigue/lethargy

  • weight gain

  • dry skin

  • constipation

  • anemia

Hypothyroidism: Complications, Diagnostic testing & Treatment

• Complication

  • Myxedema Coma (medical emergency – hypotension, hypoventilation and subnormal temperatures)

• Diagnostic studies:

  • Thyroid Stimulating Hormone levels and free T4 levels

• Treatment:

  • Synthroid - Levothyroxine

    • Lifelong treatment

    • take in the morning

    • on empty stomach

Hyperthyroidism

• An increased secretion of thyroid hormone

• Causes your metabolism to speed up

• Graves disease

  • Autoimmune disorder that results in the overproduction of thyroid hormones

    • clinical manifestation: Big bulging eyes

Hyperthyroidism: Clinical manifestations

• Related to to increase in metabolic rate and increased oxygen consumption

  • Anxious/restless/irritable

  • Goiter (enlarged thyroid gland)

  • Fine tremors

  • Tachycardic/palpitations

  • Heat intolerance/ increased perspiration

  • Increase in appetite

  • Diarrhea

  • Weight loss

  • Thin skin

  • *Patients with Graves disease may present with exophthalmos

Hyperthyroidism: Diagnostic studies & Medical Management

• Testing

  • Increased serum calcium levels

  • Elevated PTH levels

• Medical Management:

  • Treat underlying cause

  • Radioactive iodine for Graves disease

The Parathyroid Glands

• Parathormone (parathyroid hormone)

  • Regulates Calcium and Phosphorus Metabolism

Hyperparathyroidism

• An overproduction of parathormone by the parathyroid glands

• Characterized by…

  • bone decalcification

  • The development of renal calculi (kidney stones) containing calcium

• Associated with increased serum calcium levels – leads to hypercalcemia and hypophosphatemia

• Symptoms

  • Most are asymptomatic

  • weakness

  • Loss of appetite

  • constipation

  • increased need for sleep

  • emotional disorders

  • shortened attention span

Hyperparathyroidism: Diagnostic Studies & Medical Management

• Diagnostic Studies:

  • Increased serum calcium levels, elevated PTH levels

• Management:

  • Parathyroidectomy (surgical removal of abnormal parathyroid tissue)

  • At risk for kidney stones, hydrate!!

  • Ambulation

The Adrenal Glands

• 2 glands, one attached to the upper portion of each kidney

• Regulates

  • Metabolism

  • Blood pressure

  • Respond to stress

• Hormones such as…

  • Cortisol

    • STRESS

  • Aldosterone

    • Sodium balance in the body

  • Adrenaline

    • Fight or flight

  • Estrogen/testosterone

Addison’s Disease

• Primary adrenal insufficiency:

  • adrenal glands make too little cortisol (helps with stress)

• Clinical Manifestations (happen slowly, often over a few months):

  • Hyponatremia

  • Hyperkalemia

  • Fatigue

  • Weight loss/anorexia

  • Hypoglycemic

  • Hypotension

  • Increased levels of ACTH (produced by the Pituitary gland, whose job is to tell the Adrenal gland to produce and when not to produce) result in hyperpigmentation of the skin and mucous membranes ( knuckles, knees, and skin folds)

Addison’s Disease: Assessment

• Confirmed by lab results (early morning serum cortisol and plasma ACTH)

• Increased ACTH (adrenocorticotropic hormone= regulated cortisol and androgen production)

• Decreased cortisol levels

• Abnormal electrolyte imbalances

Addison’s Disease: Management

• Monitor for signs of Addisonian crisis (shock, hypotension, rapid/weak pulse, weakness, rapid respiratory rate)

  • Treatment: Immediate treatment with IVF, glucose, and electrolytes

• Monitor…

  • Fluid imbalance

  • patient’s stress levels

  • Blood pressure

  • Skin

  • Changes in weight

  • Fatigue

Cushing’s Syndrome

• Your body produces too much cortisol

• Causes

  • The use of Corticosteroid medication

  • a tumor of the pituitary gland

• Clinical Manifestations

  • Buffalo hump (fat deposit in neck/shoulders)

  • Rounding of face “moon face”

  • Central type obesity

  • Heavy trunk

  • Thin extremities

  • Skin is thin and fragile

  • Weakness

  • Sleep disturbance

Cushing’s Syndrome: Assessment

• 24- hour urine for free cortisol

• CT Scan/MRI to visualize tumors of the pituitary and adrenal glands

• An overnight low-dose dexamethasone suppression tests

• Serum cortisol levels are usually higher in the morning (6-8am)

Cushing’s Syndrome: Medical Management

• The primary goal is to normalize hormone secretion

• Treatment depends on cause

  • Pituitary adenoma

    • Surgical removal of the tumor and/or radiation

  • Adrenal tumors or hyperplasia

    • Adrenalectomy

    • Drug therapy is indicated when surgery is contraindicated or as adjunct to surgery

Diabetes

• A group of metabolic diseases resulting from:

  • Deficiency of insulin

  • Resistance of tissue (e.g., muscle, liver) to insulin

  • OR both situations listed above

Type 1 diabetes

• is chronic, characterized by a lack of insulin production OR by production of defective insulin, which results in acute hyperglycemia

• Clients must take insulin

Type 2 diabetes mellitus

• Most common

• Caused by both insulin resistance and insulin deficiency, but there is no absolute lack of insulin as in type 1 diabetes

Fasting blood glucose level

70 to 100

Glucose tolerance test

Measures the body's response to glucose can be used to screen for type 2

Hemoglobin A1C test

Measures your average blood sugar levels over the last 3 months

Hemoglobin A1C test: Normal

Below 5.7%

Hemoglobin A1C test: Prediabetic

5.7% to 6.4%

Hemoglobin A1C test: Diabetes

• 6.5% or ABOVE

• an A1C of 13% or above is dangerously high!!

Complication of Diabetes: Hypoglycemia - KNOW THIS

• blood glucose less than 70 mg/dL

• Causes

  • Too much insulin/meds

  • Too little food

  • Excessive physical activity

• Signs & Symptoms

  • Shaking

  • Sweating

  • Tachycardia

  • Hunger

  • Dizziness

  • Confusion

  • Lethargy

  • Weakness

Complication of Diabetes: Diabetic ketoacidosis (DKA) - KNOW THIS

• The body can’t produce enough insulin

• Causes…

  • Missed insulin doses

  • Illness or infection

  • Undiagnosed/untreated diabetes

• Signs and Symptoms

  • Positive ketones in urine

  • Kussmaul's respirations

  • metabolic acidosis

  • Fruity smelling breath

  • Fast heart rate

  • Headache

  • Tired

  • Nausea/vomiting

  • extreme thirst

  • increased urination

  • Flushed face and stomach pain

• Treatments

  • IV regular insulin + 0.9% NS infusion

  • Correct dehydration/electrolyte loss and acidosis

  • Treating hyperglycemia

Complication of Diabetes: Hyperglycemic Hyperosmolar Syndrome (HHS) - KNOW THIS

• Blood glucose levels that are too high for a long period causing confusion and dehydration.

  • Infection causes 50-60% of cases

• Signs & Symptoms

  • Hypotension

  • Profound dehydration

  • Tachycardia

  • Seizures

  • LOC

• Treatments

  • Fluid/electrolyte replacement

  • Insulin

Type 2 Diabetes

• Disease that occurs when your blood glucose is too high

• Blood glucose is your main source of energy and comes mainly from the food you eat

• Insulin (a hormone made by the pancreas) helps glucose get into your cells to be used for energy.

• Your body doesn’t make enough insulin or doesn’t use insulin well

• Lifestyle changes are FIRST before insulin

  • Eat healthy

  • Regular exercise

  • Lose weight

Complication of Type 2 Diabetes: Diabetic Retinopathy

Microvascular damage to the retina (most common cause of new cases of blindness in people ages 20-74)

Complication of Type 2 Diabetes: Diabetic Neuropathy

• Nerve damage can affect hands and feet

• Causing…

  • Numbness

  • Tingling

  • Decreased sensitivity to temperature extremes and touch

Complications of Type 2 Diabetes: Foot and Leg Problems

• Causes

  • Neuropathy

  • PVD

  • Immunocompromised

• Gangrene (necrotic, black tissue) because of delayed treatment of foot injuries most likely related to diabetic neuropathy!!

Insulin

• Required in Type 1

• Main job is to move glucose from our bloodstream into the body’s cells to make energy

Insulin: Onset

The length of time before insulin reaches bloodstream and begins lowering blood glucose

Insulin: Peak

Time during which insulin is at maximum strength in terms of lowering blood glucose

Insulin: Duration

How long insulin continues to lower blood glucose

Rapid Acting Insulin: Names

• Lispro

• Aspart

Rapid Acting Insulin: Onset

About 15 Minutes​

Rapid Acting Insulin: Peak

1 hour

Rapid Acting Insulin: Duration

3 hours

Short-acting Insulin: Name

Regular

Short Acting Insulin: Onset

30 minutes

Short Acting Insulin: Peak

2 hours

Short Acting Insulin: Duration

8 hours

Intermediate Acting: Name

NPH

Intermediate Acting: Onset

2 hours

Intermediate Acting: Peak

8 Hours

Intermediate Acting: Duration

16 hours

Long Acting Insulin: Names

• Levemir

• Lantus

Long Acting Insulin: Onset

2 hours

Long Acting Insulin: Peak

NONE

Long Acting Insulin: Duration

24 Hours

Atelectasis

• Closure or collapse of alveoli

• Chest x-ray used to confirm

• Most commonly occurs after surgical procedures in the postoperative settings or in patients who are immobilized

Atelectasis: Signs and Symptoms

• Increasing SOB

• Cough

• Sputum production

• Hypoxemia

• Decreased breath sounds

Atelectasis: Nursing Mangement

• Prevention is KEY

• Frequent turning

  • Q 2 turns

• Early mobilization

• Incentive spirometry

• Coughing and deep breathing

Acute Bronchitis

• Acute inflammation of the mucous member of the trachea and bronchial tree

• Usually due to an upper respiratory infection

• Can be viral OR bacterial

• Chest X-rays can differentiate between bronchitis and pneumonia

Acute Bronchitis: Signs and Symptoms

• Most common symptom

  • Persistent, irritating cough (10 to 20 days)

• Can produce Sputum

• Fever

• Chills

• Headache

• Malaise

• SOB

Acute Bronchitis: Medical Management

• Antibiotic treatment depending on symptoms and bacterial infection

• Increasing fluids

• Suctioning

• Steam inhalations

• Mild analgesics

• Cough suppressants

• Bronchodilators

Acute Bronchitis: Nursing Mangement

• Increase fluid intake

• Sitting up frequently

• Completing course of antibiotic

• Rest

Pneumonia

• Inflammation of the lung parenchyma caused by various microorganisms, including bacteria, fungi and viruses

• Etiology:

  • Aspiration

  • Inhalation of microbes

  • Spread from another primary infection in body

Pneumonia: Risk Factors

• Aging

• Air pollution/Smoking

• Prolonged immobility

• Underlying disorders (heart failure, diabetes, COPD, AIDS)

• Decreased immune system

• Anesthesia

• Tracheal intubation

• Influenza

• Resident in a long term care facility

Community Acquired Pneumonia (CAP)

• Occurs either in the community setting or within the first 48 hours after hospitalization

• Rate of CAP increases with age

• S. pneumonia (pneumococcus) most common bacterial cause of CAP

• Until the COVID-19 pandemic, viruses were relatively uncommon causes of CAP in adults

• Treatment: Pneumococcal Vaccine

Hospital Acquired Pneumonia (HAP)

• Develops 48 hours or more after hospitalization

• Risk factors include:

  • Mechanical ventilation for > 48 hours

  • Prolonged hospital stay

  • Severity of underlying illness and presence of comorbidities

• Sputum culture is the gold standard to determining which type of organism is present

• Chest X to confirm

• Pseudomonas aeruginosa, Staphylococcus aureus, and Enterobacter are the most common organism causes of HAP

Aspiration Pneumonia

• Can occur in the community or hospital setting

• Usually follows aspirate from the mouth or stomach in the trachea and through the lungs (food, vomitus, water, or oral contents)

• Chest x-ray to confirm

• Monitor oxygen/airway

• Nursing intervention

  • Antibiotics

  • Supplemental oxygen

  • NPO until stable

  • Turn the patient to the side

Pneumonia: Clinical Manifestations

• Productive cough and chest pain

• **In elderly, signs/symptoms of hypoxia (confusion or lethargy) may be only findings

• Sudden onset of fever

• Shaking - chills

• Shortness of breath

• Pulmonary consolidation

• Adventitious breath sounds (crackles)

• Dullness upon percussion

• Increased fremitus (vibration of chest wall)

Complications: Pneumonia

• Pleurisy

  • Inflammation of pleura

• Pleural effusion

  • Fluid in pleural space

• Atelectasis

  • Collapsed alveoli

• Bacteremia

  • Bacterial infection of blood

• Septic shock

• Respiratory failure

Pneumonia: Assessment and Diagnostic Findings

• History and physical examination

• Chest X-ray

• Blood Culture to check for bacteremia

• Sputum sample with culture

• ABG’s

• Pulse oximetry

Pneumonia: Collaborative Management

• Prevention

• Pneumococcal vaccination

  • See CDC guidelines

• Appropriate antibiotics determined by results of sputum culture

• Monitor vital signs and hypoxemia

  • Administer oxygen if needed

• Nutritional therapy

  • Hydration, small, frequent meals to conserve energy

• Treatment of viral pneumonia is primarily supportive

Pneumonia: Overall Goals

• NO signs of hypoxia

• Clear breath sounds

• Normal breathing patterns

• Normal chest x ray

• No complications

Pneumonia: Nursing Implementation

• Health promotion

  • Hand hygiene

  • Cover mouth when coughing/sneezing

  • Adequate rest & regular exercise

• Acute intervention

  • Sterile technique – tracheal suctioning, monitoring O2 sats, hydration, response to treatment, and therapeutic positioning

• Ambulatory and home care

  • Drug therapy compliance and adequate rest

Tuberculosis

• Infectious disease that primarily affects the lung parenchyma

• Caused by Mycobacterium tuberculosis

• Usually involves the lungs but can be transmitted to other parts of the body including the meninges, kidneys, bones and lymph nodes

• Spreads from person to person by airborne transmission

• Begins when a susceptible person inhales myxobacteria and becomes infected

Tuberculosis: Signs and Symptoms

• Early stages- Can be asymptomatic

• Common sign:

  • Frequent cough with white, frothy sputum or hemoptysis

• Active TB may present with…

  • Fatigue

  • Malaise

  • Anorexia

  • Unexplained weight loss

  • Low-grade fevers

  • Night sweats

Tuberculosis: Complications

• Miliary TB (spreads to other organs in body via blood)

• Pleural effusion (fluid in the pleural cavity)

• Empyema (infection in pleural cavity)

• Tuberculosis pneumonia (an acute form of pneumonia)

• Other organ involvement (infection of the meninges of the CNS, bones, joints, kidneys, lymph nodes and genital tract)

• When TB is present, we must assess infectious status and promote adherence to long-term treatment.

Tuberculosis: Diagnostic Studies

• TB Skin test (Mantoux test)

  • Induration at injection site (not redness) indicates exposure/antibody production (>5mm typically indicates positive)

• Chest x-ray

• Microscopic examination of stained sputum smears for acid-fast bacilli – Best collected in the morning.

• Blood tests

Tuberculosis: Medical Management

• Treated primarily with anti-TB agents for 6-12 months (Isoniazid, rifampin, pyrazinamide, ethambutol)

• Liver enzymes, BUN/creatinine levels are monitored monthly

• Frequent sputum cultures to evaluate effectiveness of treatment

Tuberculosis: Nursing Management

• Promoting airway clearance

• Educating patient on compliance to treatment regimen

• Promoting activity and adequate nutrition

• Preventing transmission of TB infection.

• Staff and family to wear N-95 masks (if visitors allowed)

Pleural Effusion

• A collection of fluid in the pleural space

• It may be a complication of…

  • heart failure

  • TB

  • pneumonia

  • pulmonary infections

  • nephrotic syndrome

  • connective tissue disease

  • PE

  • neoplastic tumors

• Empyema

  • Collection of pus in the pleural cavity

Pleural Effusion: Clinical manifestation

progressive dyspnea

Pleural Effusion: Diagnostic

Chest x-ray, CT scan, and thoracentesis to confirm the presence of fluid

Pleural Effusion: Treatment

• Relieve discomfort

• Treat underlying cause

• Prevent reaccumulation of fluid

• Thoracentesis= removes fluid

• Some patients may need a chest tube

Pulmonary Hypertension

• Elevated pulmonary arterial pressure greater than 25 mm Hg at rest and greater than 30 mm Hg with exercise (measured by an echocardiogram and cardiac catheterization)

• Sign and Symptom

  • Commonly presents with shortness of breath and fatigue

• Can occur due to…

  • primary disease or secondary to respiratory

  • cardiac, autoimmune

  • hepatic or connective tissue disorder

• Treatments

  • Medications to surgical intervention depending on the underlying cause (may need lung transplant)

Cor Pulmonale

• Condition that results from pulmonary hypertension

• Causes the right side of the heart to enlarge which causes right-sided heart failure

• Treat the underlying condition

Cor Pulmonale: Nursing Management

• Mange dyspnea by admin oxygen

• Admin medication to treat right ventricular hypertrophy & pulmonary hypertension

• Preventative measure

  • encourage smoking cessation

• Avoid exposure to second hand smoking and respiratory pollutants

Pulmonary Embolism

• Obstruction of the pulmonary artery or one of its branches by a thrombus

• Clinical Manifestations

  • Dyspnea

  • Chest pain

  • Hemoptysis

• Most common causes

  • Anxiety and sudden onset of unexplained dyspnea

  • Chest pain

  • Tachycardia

• To diagnose…

  • D-Dimer blood test and/or

  • VQ scan

Pulmonary Embolism: Complications

• Pulmonary infarction

  • Death of lung tissue

• Pulmonary hypertension can lead to hypertrophy of the right ventricle

Tension Pneumothorax

• When air is drawn into the pleural space from a lacerated lung or through a small opening or wound in the chest wall

• The trapped air causes pressure on the heart and lung limiting venous return causing a decrease in cardiac output

Simple Pneumothorax

• Occurs when air enters the pleural space through a breach of either the parietal or visceral pleura

• Can occur in an healthy person in the absence of trauma due to…

  • rupture of an air-filled bleb, or blister, on the surface of the lung, allowing air to enter the pleural cavity