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endocrine system
regulation of hormones:
negative feedback mechanism
o if the client is healthy, the concentration or hormones is maintained at
a constant level.
disorders of the
anterior pituitary
gland
hypopituitarism
hyperpituitarism
hypopituitarism
o caused by low levels of one or more anterior pituitary hormones.
o lack of the hormone leads to loss of function in the gland or organ
that it controls.
causes of primary hypopituitarism
o pituitary tumors
o inadequate blood supply to pituitary gland
o sheehan syndrome
o infections and/or inflammatory diseases
o sarcoidosis
o amyloidosis
o radiation therapy
o surgical removal of pituitary tissue
o autoimmune diseases
o congenital absence
causes of secondary hypopituitarism (affecting the hypothalamus):
hyperpituitarism
o hyperfunction of the anterior pituitary gland → oversecretion of one or
more of the anterior pituitary hormones
o usually caused by a benign pituitary adenoma
o most common hormones affected:
o prolactin
o growth hormone
pituitary tumor:
prolactinoma
growth hormone hypersecretion
0 25 50 years
acromegaly
epiphyseal closure
occur at normal times
treatment
o medication
o bromocriptine and cabergoline (dopamine agonist) for prolactinoma and gh hypersecretion
o octreotide (somatostatin) for gh hypersecretion
o surgery
o transsphenoidal hypophysectomy
o radiation therapy for large tumors
o diet
nursing interventions
o provide emotional support → striking body change can cause
psychological stress
o perform or assist with range of motion exercises to promote
maximum joint mobility and prevent injury
o evaluate muscle weakness
nursing interventions
o keep the skin dry
question
o what is the medication of choice in the treatment of gh hypersecretion
and prolactinoma?
o bromocriptine
o cabergoline
o octreotide
o vasopressin
question
o as a nurse which of the following is the most important nursing
consideration?
o adrenal gland
o thyroid gland
o kidneys
o ovaries
o prostate
disorders of the
posterior pituitary
gland
diabetes insipidus
siadh
vasopressin or antidiuretic hormone
diabetes insipidus
diabetes insipidus
o central diabetes insipidus: deficiency of vasopressin
o primary diabetes insipidus
o maybe familial, occurring as a dominant trait, or sporadic (“idiopathic”)
o secondary diabetes insipidus
o due to damage to the hypothalamus or pituitary stalk by tumor, surgical or accidental
trauma, infection
diabetes insipidus
diabetes insipidus
signs and symptoms
o polyuria
o intense thirst
o dehydration
o inadequate water replacement
o hyperosmolality
o hypovolemia
diabetes insipidus
diagnostics
o fluid deprivation test
o administration of desmopressin
o 24 hour urine collection for volume,
glucose, and creatinine
o serum for glucose, urea nitrogen, calcium, uric acid, potassium,
sodium
diabetes insipidus
medications
o for central di
o desmopressin; intranasal
o lypressin; intranasal
o vasopressin tannate in oil; im
o for nephrogenic di
o indomethacin-hydrochlorothiazide
o indomethacin-desmopressin
o indomethacin-amiloride
o clofibrate, chlorpropamide
o psychotherapy
hyperthyroidism: management
o radioactive iodine (¹³¹i), potassium or sodium iodide, strong iodine solution
(lugol’s solution)
o adjunct with other antithyroid drugs in preparation for thyroidectomy
o treatment for thyrotoxic crisis
o mechanism of action
o inhibits the release and synthesis of thyroid hormones
o decreases vascularity of the thyroid gland
o decreases thyroidal uptake of rai
hyperthyroidism: nursing management
potassium or sodium iodide, strong iodine solution
o dilute oral doses in water or fruit juice and give with meals to prevent gastric irritation, to
hydrate the patient, and to mask the very salty taste
o warn the patient that sudden withdrawal may precipitate thyrotoxicosis
o store in light resistant container
o give iodides through a straw to avoid teeth discoloration
o force fluids to prevent fluid volume deficit
hyperthyroidism: nursing management of rai treatment
o radioactive iodine
o food may delay absorption. the patient should fast overnight before administration
o after dose for hyperthyroidism, the patients urine and saliva are slightly radioactive for 24
hours; vomitus is highly radioactive for 6 to 8 hours
o institute full radiation precautions during this time
o instruct the patient to use appropriate disposal methods when coughing and expectorating
hyperthyroidism: nursing management of rai treatment
o after dose for thyroid cancer, isolate the patient and observe the following
precautions:
o pregnant personnel shouldn’t take care of the patient
o disposable eating utensils and linens should be used
o instruct the patient to save all urine in lead containers for 24 to 48 hours so amount of
radioactive material excreted can be determined
o or flush the toilet twice after urination
hyperthyroidism: nursing management of rai treatment
o the patient should drink as much fluid as possible for 48 hours after
drug administration to facilitate excretion
o limit contact with the patient to 30 minutes per shift per person the 1st
day; may increase time to 1 hour on 2nd day and longer on 3rd day
hyperthyroidism: nursing management of rai treatment
o if the patient is discharged less than 7 days after ¹³¹i dose for thyroid
cancer, warn patient
o to avoid close, prolonged contact with small children
o not to sleep in the same room with his spouse for 7 days after treatment →
increase risk of thyroid cancer in persons exposed to ¹³¹i.
hyperthyroidism: management
o b-blockers, digoxin, anticoagulation
o prednisone for ophthalmopathy
o treatment for thyroid storm
o ptu
o i.v. propanolol to block sympathetic effects
o corticosteroids to replace depleted cortisol levels
o iodide to block release of thyroid hormone
hyperthyroidism: management
o surgery: thyroidectomy
o preop: give lugol’s iodide to prevent thyroid storm
o care of post-thyroidectomy client
o monitor for respiratory distress
o have tracheotomy set, oxygen, and suction at bedside
o semi-fowlers position
o monitor for laryngeal nerve damage
o monitor for signs of hypocalcemia and tetany
o monitor for thyroid storm
hyperthyroidism: nursing management
o record vital signs and weight
o monitor serum electrolyte levels, and check periodically for hyperglycemia and glycosuria
o monitor cardiac function
o check levels of consciousness and urine output
o if patient is in her 1st trimester of pregnancy: report for signs of spontaneous abortion
o diet
o high protein, high calorie, vitamin supplements
o low sodium diet for patients with edema
o no stimulants like coffee, tea
hyperthyroidism: nursing management
o for exophthalmos
o suggest sunglasses or eye patches to protect eyes from light
o moisten the conjunctivae with artificial tears
o warm the patient with severe lid retraction to avoid sudden physical movement that might cause the
lid to slip behind the eyeball
o elevate the head of the bed to reduce periorbital edema
o stress the importance of regular medical follow-up after discharge because hypothyroidism may
develop
o drug therapy and rai therapy require careful monitoring and comprehensive teaching
hypothyroidism
hypothyroidism
o a state of low serum thyroid hormone levels or cellular resistance to thyroid hormone
o causes:
o may result from thyroidectomy
o radiation therapy
o chronic autoimmune thyroiditis
o inflammatory conditions
o pituitary failure to produce tsh
o hypothalamic failure to produce thyrotropin-releasing hormone (trh)
o inborn errors of thyroid hormone synthesis
o antithyroid medications such as ptu
o inability to synthesize thyroid hormone because of iodine deficiency
hypothyroidism: diagnostics
o radioimmunoassay tests: ↓ t3 t4
o ↑ tsh level with primary hypothyroidism
o ↓ tsh level with secondary hypothyroidism
o serum cholesterol and triglyceride levels are increased
o in myxedema coma
o low serum sodium levels
o respiratory acidosis because of hypoventilation
hypothyroidism: management
o prevention: prophylactic iodine supplements to decrease the
incidence of iodine deficient goiter
o symptomatic cases:
o hormonal replacement: synthroid (synthetic hormone (levothyroxine))
o dosage is increased q 2-3 weeks esp. if the patient is an elderly
nursing management of replacement therapy
o different brands of levothyroxine may not be bioequivalent
o warn the patient to tell the doctor if
o chest pain, palpitations, sweating, nervousness, or their signs or symptoms
of overdosage
o signs and symptoms of aggravated cardiovascular disease (chest pain,
dyspnea, tachycardia)
nursing management of replacement therapy
o instruct the patient to take thyroid hormones at the same time each
day to maintain constant hormone levels
o suggest a morning dosage to prevent insomnia
o monitor apical pulse and blood pressure. if pulse is >100, withhold
the drug. assess for tachyarrhytmias and chest pain.
nursing management of replacement therapy
o thyroid hormones alter thyroid function test results
o for ¹²³i uptake studies
o d/c levothyroxine 4 wks before the test
o d/c liothyronine 7 to 10 days before the test
o monitor prothrombin time
o wof: unusual bleeding and bruising
hypothyroidism: nursing interventions
o diet: high-bulk, low calorie diet
o encourage activity
o maintain warm environment
o administer cathartics and stool softeners
o to prevent myxedema coma, tell the patient to continue course of thyroid medication event if
symptoms subside
o maintain patent airway
o administer medications – synthroid, glucose, corticosteroids
o iv fluid replacement
o wrap patient in blanket
o treat infection or any underlying illness
disorders of the
pancreas
diabetes mellitus
hormones of the pancreas
o insulin
o decreases blood sugar by:
o stimulating active transport of glucose into muscle and adipose tissue
o promoting the conversion of glucose to glycogen for storage
o promoting conversion of fatty acids into fat
o stimulating protein synthesis
o secreted in response to high blood sugar
o found in β cells of the islets of langerhans
hormones of the pancreas
o glucagon
o increases blood glucose by
o causing gluconeogenesis and glycogenolysis in the liver
o secreted in response to low blood sugar
o found in the α-cells of the islets of
langerhans
diabetes mellitus
o chronic disease characterized by hyperglycemia
o it is due to total or partial insulin deficiency or insensitivity of the cells
to insulin
o characterized by disorders in the metabolism of cho, fats, chon as
well as changes in the structure and function of blood vessels
types of diabetes mellitus
o type 1 or iddm
o usually occurs in children or in non-obese adults
o type 2 or niddm
o usually occurs in obese adults or over age 40
o gestational dm
o secondary dm
o induced by trauma, surgery, pancreatic disease or medications
o can be treated as either type 1 or type 2
pathophysiology
o lack of insulin causes hyperglycemia (insulin is necessary for the transport of
glucose across the membrane)
o body excretes excess glucose through kidneys → osmotic diuresis → polyuria
→
dehydration → polydipsia
o cellular starvation → polyphagia
o the body turns to fats and proteins for energy; but in the absence of glucose in
the cell, the fats cannot be completely metabolized and ketones are produced
chronic complications
o microangiopathy: retinopathy, nephropathy
o macroangiopathy: peripheral vascular diseae, atherosclerosis, cad
o neuropathy
instruction in the care of the feet
o hygiene of the feet
o wash feet daily with mild soap and lukewarm water. dry thoroughly between the toes by
pressure. do not rub vigorously, as this is apt to break the delicate skin.
o rub well with vegetable oil to keep them soft, prevent excess friction, remove scales, and
prevent dryness.
o if the feet become too soft and tender, rub them with alcohol abut once week.
instruction in the care of the feet
o hygiene of the feet
o when rubbing the feet, always rub upward from the tips of the toes. if varicose veins are
present, massage the feet very gently; never massage the legs.
o of the toenails are brittle and dry, soften them by soaking for 1 ½ hour each night in
lukewarm water containing 1 tbsp of powdered sodium borate (borax) per quart. clean
around the nails with an orangewood stick. if the nails become too long, file them with an
amery board. file them straight across and no shorter than the underlying soft tissue of the
toes. never cut the corner of the nails.
instruction in the care of the feet
o wear low heeled shoes of soft leather that fit the shape of the feet
correctly. the shoes should have wide toes that will cause no
pressure, fit close in the arch, and grip the heels snugly. wear new
shoes one-half hour only on the first day and increase by 1 our each
day following. wear thick, warm, loose stockings.
instruction in the care of the feet
o treatment of corns and calluses
o corns and calluses are due to friction and pressure, most often from improperly fitted shoes
and stockings. wear shoes that fit properly and cause no friction or pressure.
o to remove excess calluses or corns, soak the feet in lukewarm water, using a mild soap, for
about 10 minutes and then rub off the excess tissue with a towel or file. do not tear it off.
under no circumstances must the skin be irritated.
instruction in the care of the feet
o treatment of corns and calluses
o do not cut corns or calluses. if they need attention it is safer to see a
podiatrist.
o prevent callus formation under the ball of the foot (a) by exercise, such as
curling and stretching the toes several times a day; (b) by finishing each step
on the toes and not on the ball of the foot; and (c) by wearing shoes that are
not too short and that do not have high heels.
diagnostics: fbs and ogtt
diagnostics: glycosylated hemoglobin
pheochromocytoma
pheochromocytoma: signs and symptoms
o think sympathetic!
o persistent or paroxysmal hypertension
o palpitations, tachycardia, headache, visual disturbance, diaphoresis, pallor,
warmth or flushing, paresthesia, tremor, excitation
o anxiety, fright, nervousness, feelings of impending doom, abdominal or chest
pain, tachypnea, nausea and vomiting, fatigue, weight loss, constipation
pheochromocytoma:
o diagnostic tests:
o increased plasma levels of catecholamines, elevated blood sugar, glucosuria
o elevated urinary catecholamines and urinary vanilymandelic acid levels
o avoid coffee, nuts, chocolates, banana
o tumor on ct scan
pheochromocytoma: treatment
o surgical removal of the tumor with sparing of normal adrenals
o wof: hypo or hypertension post-op
o antihypertensives
o alpha-adrenergic blocker
o beta-adrenergic blocker
o calcium channel blockers
o metyrosine may be used to block catecholamine synthesis
adrenalectomy
o resection or removal of one or both adrenal glands
o the treatment of choice:
o for adrenal hyperfunction and hyperaldosteronism
o adrenal tumors, such as adenomas and pheochromocytomas
adrenalectomy: pre-op
o correct electrolyte imbalance
o potassium
o sodium
o calcium
o manage hypertension
adrenalectomy: post-op
o monitor vital signs
o wof: shock from hemorrhage
o keep in mind that post-op hypertension is common because of
handling of the adrenal glands stimulate catecholamine release
o wof: adrenal crisis – hypotension, hyponatremia, hyperkalemia
hyperparathyroidism
o effect of pth secretion: ↑ calcium
o through increased bone resorption, increased gi and renal absorption of
calcium
o complications
o renal calculi → renal failure
o osteoporosis
o pancreatitis
o peptic ulcer
hyperparathyroidism: signs and symptoms
o think of hypercalcemia:
o cns; psychomotor and personality disturbances, loss of memory for recent
event, depression, overt psychosis, stupor and, possibly coma
o gi: anorexia, nausea, vomiting, dyspepsia, and constipation
o neuromuscular: fatigue, marked muscle weakness and atrophy, particularly
in the legs
hyperparathyroidism: signs and symptoms
o renal: symptoms of recurring nephrolithiasis → renal insufficiency
o skeletal and articular: chronic lower back pain and easy fracturing from bone
degeneration, bone tenderness, joint pain
o others: skin pruritus, vision impairment from cataracts, subcutaneous
calcification
hyperparathyroidism:diagnostics
o ↑ serum pth levels
o ↑ serum calcium and ↓ phosphorus levels
o x-rays may show diffuse demineralization of bones
o elevated alkaline phosphatase
hyperparathyroidism: treatment
o surgery to remove adenoma
o force fluids: limiting dietary calcium intake
o for life threatening hypercalcemia: promote sodium and calcium excretion, using
normal saline solution, furosemide; and administering oral sodium or potassium
phosphate, calcitonin
o postmenopausal women: estrogen supplements
hypoparathyroidism
o a deficiency of parathyroid hormone (pth)
o pth primarily regulates calcium balance; hypoparathyroidism leads to
hypocalcemia and produces neuromuscular symptoms ranging from
paresthesia to tetany
hypoparathyroidism: causes
o congenital absence or malfunction of the parathyroid glands
o autoimmune destruction
o removal or injury to one or more parathyroid glands during neck
surgery
o massive thyroid radiation therapy
o ischemic infarction of the parathyroids during surgery
o neuromuscular irritability
o increased deep tendon reflexes
o dysphagia
o paresthesia
o tetany seizures
o psychosis
hypoparathyroidism: treatment
o vitamin d with supplemental calcium
o lifelong therapy, except for patient with the reversible form of the disease
o acute life-threatening tetany calls for immediate iv administration of calcium
o sedatives and anticonvulsants are given to control spasms until calcium levels
rise
o seizure precautions