Endocrine abnormalities

PN4

Winter 2008

Common Key Features of Hormones

• All hormones exert their effect at low blood concentrations

• Receptors on or within target tissues are needed for all hormones to exert an effect

• Most hormones (except for thyroid and adrenal medullary hormones) are not stored to any great extent and must be produced as needed

• Hormones in the blood are bound to plasma proteins• Only free hormones can bind to their receptor sites

Common Key Features of Hormones

• Most hormones cause target tissues to increase or decrease their activity

• The activity of hormones is of short duration• Continued hormone activity requires continued

production and secretion• Clearance of secreted hormones occurs through

cellular uptake, enzymatic breakdown, GI excretion or urinary excretion

General Assessment

Often present as problems associated with:• Nutrition-metabolic• Elimination• Sleep-rest• Sexuality-reproduction

Review assessment questions from sem 2 and Iggy pg1452

Physical Assessment

• Inspection

• Palpation

• Auscultation

• Psycho-social

Diagnostic Test

• Stimulation/suppression tests

• Assays

• Urine tests

• Test for glucose (look up Hgb A1C)

• CAT scan; MRI

• Needle biopsy

Hypopituitarism

• Deficiency in one or more hormone

• Rarely all of the hormones

• Results in metabolic abnormalities and sexual dysfunction

• Deficiencies of ACTH and TSH are life threatening because they result in decrease of secretions from adrenal and thyroid glands

Deficiencies of Gonadotropins

• LH and FSH causes ?????

• GH causes ?????

Etiology

• Benign or malignant pituitary tumor

• Malnutrition or rapid loss of body fat, i.e. AN

• Idiopathic cause

• Postpartum hemorrhage

• Infection

• trauma

Disorder of the Anterior Pituitary

• Can be primary or secondary

• One or more hormones are under or over secreted

Treatment

• Testosterone

• Hormone therapy combinations e + p

• Clomid for pregnancy

• GH therapy

Hyperpituitarism

• Often caused by hormone secreting tumor

• Causes gigantism or acromegaly

Figure 63-1The clinical features of GH excess

Figure 63-2The progression of acromegaly

Pathophysiology

• Often caused by a benign tumor

• As tumor gets larger, in addition to extra hormone, client suffers from visual disturbances, headache, increased IP

• Usually prolactin (PRL) and GH hypersecretion

Nursing Diagnosis

• Disturbed body image r/t altered physical appearance

• Sexual dysfunction r/t actual limitation imposed by disease ( loss of libido, infertility, impotence)

Addition ND

• Acute/chronic pain

• Fear

• Anxiety

• Activity intolerance

• Disturbed sensory perception

• Knowledge deficit

Treatment

• Non-surgical

• Drugs

• Radiation

• Surgical

Figure 63-3The transsphenoidal surgical approach to the pituitary gland

Disorders of the posterior pituitary gland

• Also called neurohypophysis

• Deficiency or excess of vasopressin (ADH)

• Results in either diabetes insipidus or SIADH (syndrome of inappropriate antidiuretic hormone)

Diabetes Insipidus

• Disorder of water metabolism caused by a deficiency of ADH

• Results in the excretion of large volumes of dilute urine. Kidneys do not concentrate

• Polyuria

• Dehydration causes thirst

• Either insufficient production or kidneys inability to respond to ADH

DI

• Can be caused by Lithium or demeclocycline (Declomycin)

• Key symptoms are excessive urination and thirst

• Cardiovascular Sx

• Renal/urinary Sx

• Integumentary Sx

• Neurologic Sx

Treatment

• Meds: Diabinese, Nova-Propamide which increase the action of existing ADH

• Nrs Care: early detection, I = O,

• Administer vasopressin transnasally

• Medic alert

SIADH

• Increased ADH causes water retention resulting in dilution hyponatremia and fluid volume overload

• Causes: malignancies, pulmonary causes, CNS disorders, medications

• Diagnosis: blood and urine tests that relate to osmolarity and concentration

Interventions

• Fluid restriction

• Drug therapy: diuretics, hypertonic IV,

Adrenal Gland hypofunction

• Acute adrenal insufficiency is called Addisonian Crisis and is life threatening

• Affects electrolytes Na low, K+ high; and glucose levels

• Tx: replacement therapy

Adrenal hypersecretion

• Cushings Syndrome (hyper cortisolism)

• Increase in body fat, “buffalo hump”, “moon face”, decreased muscle mass, atrophic skin and bone density, hirsutism, oligomenorrhea

Figure 63-6Appearance of a client with Cushing’s disease or syndrome

Endocrine System Problems:Thyroid and Para-thyroid

PN 1V

Overview

• Hormones from the thyroid and para thyroid affect general metabolism, electrolyte balance and excitable membrane activity.

• Disturbances usually have widespread clinical symptoms

• Sometimes life threatening

Hormonal Pathway

Figure 62-6Anatomic location of the thyroid gland

Figure 62-9Palpation of the thyroid gland

Hyperthyroidism

• Called thyroidtoxicosis

• State of hypermetabolism

• Increased heart rate

• Elevated protein, carb and lipid metabolism

• Glucose tolerance is decreased=hyperglyciemic

• Fat metabolism increased = fat loss

Hyperthyroidism

• Over secretion of thyroid changes the secretions of hormones from the hypothalamus and anterior pituitary glands

• Influence sex hormone production

Etiology

• Graves’ Disease or Goiter (auto immune)

• Sx of GD: Exophthalmos, pretibial myxedema,

• Can also be caused by overmedication of thyroid hormone

• Thyroid Storm, Thyroid Crisis

Figure 64-2Exophthalmos

Figure 64-3Goiter

Symptoms

• Wt. loss

• Heat intolerance, diaphoresis

• Palpitations, chest pain, dyspnea

• Changes in vision, look of eyes

• Change of energy, weakness, insomnia, F

• Irritable or depressed

• Menstrual changes, increase libido

Diagnostic and Lab findings

• Elevated T3, T4, free T4, decreased TSH, positive RAI uptake scan and thyroid scan

Interventions

• Monitor cardiovascular sytem

• Environmental

• Drugs: Tapazole, iodine, Atenolol

• Surgery: total or subtotal thyriodectomy– Pre op– Post op– Post discharge

Hypothyroidism

• Decreased metabolism due to low levels of the thyroid hormone

• Can occur at any age/stage

• Sx depend on length of time of disease

Symptoms

• Goiter

• Lethargy, diminished reflexes, periorbital edema, bradycardia, dysrhythmia, hypotension, reproductive problems, coarse dry hair that falls out, coarse dry skin, signs of slowed metabolism, anemia, elevated serum lipids

Symptoms

• Assess for myxedema

• Decreased T4 , free T4, normal T3, increased TSH

• Managed by giving T4 replacement (Synthroid, Cytomel)

Nsg Diagnosis

• Decreased cardiac output• Constipation• r/f impaired skin integrity• R/f activity intolerance• r/f sexual dysfunction• Disturbed body image• Hypothermia• Knowledge deficit

Nsg Interventions

• Meds given in a.m. before or after meals (taken for life) Must use same brand

• Adjust environment

• Pace activities

• Encourage fluid intake and fibre

• Medic alert

• What to report to MD?

Thyroiditis

• Inflammation of the thyroid gland

• Acute, chronic, subacute

• Chronic more common (Hasimotos’s disease)

Thyroiditis

Acute: bacterial, uncommon– Pain, neck tenderness, malaise, increase Temp;

Sub acute: viral, sometimes follows URI

- fever, chills, difficulty swallowing, muscle and joint pain, pain that radiates to jaw and ears

- lymph nodes hard and enlarged

- thyroid function is normal, but may go up or down

TX: rest fluids ASA, sometimes c-steroids

Thyroiditis

Chronic: low thyroidism, males more than females, 30’s to 50’s

Autoimmune

• Thyroid gland is invaded with antibodies and lymphocytes and gland is destroyed

• The more tissue destroyed the more hypo they become and the more TSH increases

Chronic con’t

• DX: blood test• Needle bx• Scan• RAIU

• TX: thyroid hormone to decrease TSH which will decrease size of gland

• Surgery• Life long meds

Thyroid CA

4 types:

• Papillary

• Follidular

• Medulllary

• Anaplastic

Types

Papillary: most common, females under 40, slow growing, progresses for years before spreading to LN’s. Good cure if confined to gland

Follicular: 25% over age 50yrs, invades blood vessels and spreads to bone and lung, rarely spreads to lymph G, prognosis fair

Types

Medullary: 5-10 % over age 50 yrs, mets via lymphatic

Anaplastic: rapid, aggressive tumor invades, poor prognosis, die within 1 yr, surgery palliative

Hyperparathyroidism• Occurs in older adults; 2x’s more common

in womenEtiology:

– Primary: hyperplasia or tumor of one of the PT glands, increasing the absorption of calcium from GI tack

– Secondary: enlargement d/t chronic hypocalcemia in the presence of elevated PTH

– Tertiary; PT glands are enlarged and do not respond to changes in serum C+ usually associated with CRF

Assessment findings

• Polyuria and renal calculi, anorexia, constipation, nausea, vomiting, abdominal pain, generalized bone pain, pathologic fractures, muscle weakness and atrophy, CNS depression

Diagnostic findings & Tx

• Elevated serum levels of total calcium; increased PTH; decreased phosphate; possible bone changes on xray and CT

• Treatment: decrease serum calcium with NS diuretics and phosphate replacement, surgery to remove involved PT glands

Nsg Diagnosis

• Risk for injury

• Pain

• Impaired physical mobility

• r/f altered urinary elimination

• r/f constipation

• Knowledge deficit

Nsg Interventions

• Comfort and safety; pace activity etc

• Strain all urine

• 2 to 3 lts of fluid and fiber in diet

• Daily wt, nutrition,

• Chvostec and Trousseau signs, tetany (post surgery of aggressive tx)

• Client education and assess their understanding

Hypoparathyroidism

• Low PTH levels causing hypocalcemia, usually caused by surgical removal of all or part of gland

• Hypocalcemia raises the threshold for excitability in nerve and muscle fibers causing the fibers to be easily stimulated; could lead to life threatening tetany.

Manifestations

• GI symptoms (pain, n, v, d, anorexia)

• Signs of hypocalcemia (anxiety, headache, paresthesia, neuromuscular irritability with tremors and muscle spasm)

• Difficulty swallowing, (possibly laryngospasms!) hoarse voice, sensation of tightness in throat, dry hair, patch hair loss, ridged finger nails

Diagnostic findings & Tx

• Decreased PTH, total calcium, free calcium, increased serum phosphate

• Tx: supplemental calcium and Vit D.

Nursing education

• Instruct ct. about diet high in calcium and Vit D,

• identify minimum daily intake,

• foods high in calcium such as cheese, milk, turnip greens, almonds, collard greens, beans, peanuts, frankfurters and bologna