Medsurge Week 6: Alterations in the Endocrine System

Endocrine Overview

-includes pituitary, hypothalamus, thyroid, parathyroids, adrenals, pancreas, testes/ovaries

-function: secrete hormones to help control overall body function and regulation

-disorders related to:

*deficiency/excess of specific hormone

*decreased responsiveness of target tissue

Posterior Pituitary Gland

-helps to maintain fluid and electrolyte balance with the release of the antidiuretic hormone (ADH)

*too much ADH= syndrome of inappropriate ADH

*not enough ADH= diabetes insipidus

Thyroid Gland

-controls metabolism through secretion of T3 and T4

-TSH released by anterior pituitary which stimulates the thyroid to secrete T3/T4

-iodine is essential for synthesis of hormones

-disorders:

*hyperthyroidism

*hypothyroidism

Parathyroid Gland

-maintains calcium and phosphate balance

-INCREASED parathyroid hormone (PTH) causes:

*INCREASE in calcium and DECREASE in phosphorus

-disorders:

*hyperparathyroidism

*hypoparathyroidism

Adrenal Gland

-Addison's disease

-Cushing syndrome

Syndrome of Inappropriate ADH (SIADH)

-excessive secretion of ADH causing fluid retention which leads to dilutional hyponatremia and fluid overload

SIADH Causes

-malignancies

*small cell lung cancer, thymoma, Hodgkin's/Non-Hodgkin's lymphoma

-pulmonary disorders

*PNA, TB, chronic lung diseases

-CNS disorders

*head injury, brain surgery or tumor, vascular, infection (meningitis, encephalitis, brain abscess)

-medications

*tricyclic antidepressants, thiazide diuretics, anticonvulsants, antidiabetic drugs, nicotine

SIADH Clinical Manifestations

-hyponatremia (<134 mEq/L)

-decreased serum osmolality

-increased urine specific gravity (concentrated)

-hypertension

SIADH Clinical Manifestations if Na+ <120 mEq/L

-lethargy

-headaches

-disorientation

-change in LOC

-generalized seizures

-coma r/t cerebral edema

SIADH Medical Management

-identify and treat underlying cause

-fluid restriction

*500-1000mL/24h

-medication therapy:

*diuretics: furosemide (Lasix)

*hypertonic saline (3% NaCl): sodium <120 mEq/L

SIADH Nursing Management

-measure I&O and daily weights

-asses sodium levels at regular intervals

-assess neurological status

-seizure precautions

Diabetes Insipidus (DI)

-deficiency of ADH

*3 D's: Diabetes Insipidus, Decreased ADH, Diuresis

Symptoms of Diabetes Insipidus

-neurogenic: acute onset, caused by destruction of posterior pituitary, leads to lack of ADH

-nephrogenic: damage to renal tubules, caused by a decrease in K+, increase in Ca+, leads to kidney impairment to reabsorb water

-psychogenic: excess water intake

DI Clinical Manifestations

-fluid volume deficit:

*weight loss

*poor skin turgor, increased thirst, dry mucous membranes

*increased HR, hypotension, weak pulses

*decreased urine specific gravity (diluted)

*increased urine output

*hypernatremia (>145 mEq/L)

DI Medical Management

-identify and treat underlying cause

-replace ADH

-desmopressin/DDAVP (synthetic ADH)

*oral, sublingual, or intranasal

-nephrogenic: thiazide diuretics and low-sodium diet

DI Nursing Management

-maintain adequate hydration

-measure I&O and check urine specific gravity

-administer DDAVP

-record daily weight

*teach pts. to weigh themselves

-medical alert bracelet

Hyperthyroidism

-hyperactivity of the thyroid gland

-overproduction of T3, T4, or both by the thyroid

*lab findings: decreased TSH, increased T3 and 4

Hyperthyroidism Causes

-grave's disease (autoimmune)

-thyroiditis (inflammation)

-overmedication with synthetic thyroid hormone

-thyroid nodules

Grave's Disease

-most common hyperthyroid etiology

-autoimmune

*antibodies bind to TSH causes overproduction of T3 and T4

-multisystem presentation:

*exophthalmos

*tachycardia

*proximal muscle weakness

*goiter

Hyperthyroidism Manifestations (SWEATING)

-Sweating

-Weight loss

-Emotional lability

-Appetite increased, but losing weight

-Tremor/Tachycardia

-Intolerance of heat, irregular menstruation, irritability

-Nervousness

-Goiter, GI problems (diarrhea)

Hyperthyroidism Nursing Management

-reduce stimulation and promote comfort

-monitor for complications:

*telemetry, 12-lead EKG

~thyroid storm- life threatening

*fever, tachycardia, systolic HTN

~immediately report temp. increase of even 1 degree

Hyperthyroid Medication Therapy

-antithyroid: methimazole (tapazole)

-beta-adrenergics: propranolol (Inderal)

-iodine preparations: short term use before surgery

-radioactive iodine: not used in pregnancy, radiation precautions

Hyperthyroid surgical management

-total thyroidectomy: lifelong HRT (hormone replacement therapy) needed

-subtotal thyroidectomy

Hyperthyroidism Surgical Complications

-hemorrhage

-resp. distress

-parathyroid gland injury

*hypocalcemia, tetany

-damage to laryngeal nerves

-thyroid storm

Thyroidectomy Postop Monitoring

-hoarseness and stridor: swelling at incision site

-suture line: check for hemorrhage with/in 24hrs

-vital signs: especially temp.

-hypocalcemia/tetany

-thyroid storm/thyroid crisis: triggered by stress

Hypothyroidism

-insufficient levels of thyroid hormones

-more common in women than men

*lab findings: increased TSH, and decreased T3 and 4

Hypothyroidism Causes

-Hashimoto disease (autoimmune)

-thyroid surgery

-post-radioactive iodine treatment

-radiation of head and neck cancers

Hypothyroidism Manifestations (MOM'S SO TIRED)

-Memory loss

-Obesity

-Menorrhagia

-Slowness (mentally and physically)

-Skin and hair dryness

-Onset is gradual

-Tiredness

-Intolerance to cold

-Raised BP

-Energy levels fall

-Depression/delayed relaxation

Myxedema

-mucinous edema from build up of proteins and sugar compounds inside of cells

Myxedema Clinical Manifestations

-non-pitting edema formed everywhere

*eyes, hands/feet, between shoulder blades, TONGUE, LARYNX

Hypothyroidism Medical Management

-lifelong hormone replacement

-synthetic hormone preparations

*Levothyroxine sodium (Synthroid)

~dosage determined by TSH blood levels, start low and go slow

~take on a empty stomach before breakfast

~monitor s/s of hypothyroidism

Hypothyroidism Nursing Management

-monitor for complications such as: resp and cardiac problems

-support cognition: cognition should improve with thyroid hormone treatment

-educate regarding drug therapy

Hyperparathyroidism

-excessive PTH causes

*hypercalcemia

*hypophosphatemia

Hyperparathyroidism Cause

-overactivity of more than 1 of four parathyroid glands by:

*adenoma (benign) or malignant tumor

*enlargement (hyperplasia)

-vitamin D deficiency

-CKD

Hyperparathyroidism Management

-goals: relieve symptoms and prevent complications caused by excess PTH

-hydration

-surgical removal of abnormal parathyroid tissue

-encourage mobility

-assess and monitor calcium levels

-IV hydration

asses for hypercalcemia

Hyperparathyroidism Mnemonic

-Painful BONES, renal STONES, abdominal GROANS, psychiatric MOANS

Hypoparathyroidism

-results from hyposecretion of PTH causing

*hypocalcemia

*hyperphosphatemia

Hypoparathyroidism Causes

-inadvertent removal of parathyroid gland during thyroidectomy, parathyroidectomy, or radical neck dissection

-other risks:

*radiation exposure

*genetic predisposition

*severe hypomagnesemia (<0.8mEq/L)

Hypoparathyroidism Manifestations

-tingling and numbness

-muscle cramps (

-spasms of hands/feet

-seizures

-ECG

-Trousseau's sign and Chvostek's sign

Hypoparathyroidism Medical Management

-Goal: increase calcium levels to 8-9mg/dL

-administer IV calcium gluconate

-diet high in calcium, low in phosphate

-vitamin D

Hypoparathyroidism Nursing Management

-assess for s/s hypocalcemia

-monitor ECG

-pt. education on diet and meds

Disorders of the Adrenal Gland

-made up of the adrenal cortex and the adrenal medulla

-Cushing Syndrome

-Addison's Disease

Adrenal Cortex

-mineralocorticoids

-glucocorticoids

-androgens

Mineralocorticoids

-sodium and water reabsorption

-potassium excretion

Glucocorticoids

-decreases inflammatory reaction

-decrease WBC migration to inflamed area

-raises serum glucose

Adrenal Medulla

-catecholamines

Catecholamines

-stress response

Cushing Syndrome

-disorder characterized by high levels of serum cortisol

-more common in women, ages 20-40yrs

-the normal feedback system is impaired

Cushing Syndrome Causes

-long term glucocorticoid pharmacologic therapy (latrogenic)

-pituitary or adrenal tumor that overproduces ACTH

Cushing Syndrome Clinical Manifestations

-truncal obesity

-'buffalo hump", "moon face"

-thin skin and fragile capillaries

-bone density loss leading to osteoporosis

-HTN

-increased risk for infection d/t decreased WBC production

-increased androgen production which causes:

*acne, Hirsutism (abnormal facial hair), Oligomenorrhea (infrequent menstrual cycle)

Cushing Syndrome Medical Management

-depends on cause

-surgery or radiation

-taper and discontinue corticosteroids if able

Cushing Syndrome Nursing Management

-decrease risk of injury and infection

-promote skin integrity

-monitor for adrenal insufficiency

Addison's Disease

-primary adrenocortical insufficiency

-occurs when adrenal cortex function is inadequate

-leads to decreased cortisol and aldosterone

Addison's Disease Causes

-autoimmune

-idiopathic atrophy

Addison's Clinical Manifestations

-skin: hyperpigmentation

-labs: low sodium, increased potassium, glucose and WBC

Addison's Disease Medical Management

-manage shock with IV fluids and vasopressors

-corticosteroid replacement

*"ADD hormone for ADDison's"

*IV hydrocortisone

-antibiotics, if infection caused the crisis

Addison's Disease Nursing Management

-restoring fluid status

-reducing stress

-medical alert bracelet

-single-dose corticosteroid injectable for emergencies