endocrine system. endocrine system maintains homeostasis: –growth, maturation, reproduction,...
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ENDOCRINE SYSTEMENDOCRINE SYSTEM
ENDOCRINE SYSTEMENDOCRINE SYSTEM Endocrine system maintains homeostasis:Endocrine system maintains homeostasis:
– Growth, maturation, reproduction, energy, Growth, maturation, reproduction, energy, metabolism (metabolism (physical and chemical changes physical and chemical changes that takes place w/i an organism),that takes place w/i an organism), behavior behavior
Composed of glands or glandular tissue:Composed of glands or glandular tissue:– Synthesize, store, and secrete hormonesSynthesize, store, and secrete hormones
Exocrine- secretions passed along ducts Exocrine- secretions passed along ducts that empty outside body or lumen of that empty outside body or lumen of organorgan
Endocrine- glands &/or cells are ductless Endocrine- glands &/or cells are ductless but highly vascular; secretion hormones but highly vascular; secretion hormones into bloodstreaminto bloodstream
HORMONESHORMONES
Hormones: natural chemical Hormones: natural chemical substances secretedsubstances secreted
Carried in bloodstream to “target” Carried in bloodstream to “target” cells/tissuescells/tissues
Effects are direct or indirectEffects are direct or indirect– Trophic/tropic- stimulate another Trophic/tropic- stimulate another
endocrine glandendocrine gland Cells response to hormone depends Cells response to hormone depends
on genetic make-upon genetic make-up
HORMONESHORMONES
Characteristics:Characteristics:– Circulate in blood at low concentrationsCirculate in blood at low concentrations– Secreted in minute amounts at variable Secreted in minute amounts at variable
ratesrates– Bind to specific receptors/cellsBind to specific receptors/cells– Variable effects on rates of responsesVariable effects on rates of responses– Most not stored, must be produced as Most not stored, must be produced as
neededneeded– Activity is of short durationActivity is of short duration
HORMONESHORMONES
Classifications:Classifications:– Polypeptides: proteins with genetic code; Polypeptides: proteins with genetic code;
bind at cell membrane; stimulates cellular bind at cell membrane; stimulates cellular adenyl cyclase (AMP); adenyl cyclase (AMP); FASTFAST CHANGECHANGE (anterior/posterior pituitary)(anterior/posterior pituitary)
– Steroids: derived from cholesterol; diffuse Steroids: derived from cholesterol; diffuse thru cell membrane; enzyme synthesis; thru cell membrane; enzyme synthesis; SLOW CHANGESLOW CHANGE (aldosterone, sex hormones) (aldosterone, sex hormones)
– Amino acids: derived from tyrosine; act on Amino acids: derived from tyrosine; act on cell membrane; ( thyroid, dopamine, cell membrane; ( thyroid, dopamine, epinephrine)epinephrine)
HORMONESHORMONES
Steroid and thyroid hormones are not Steroid and thyroid hormones are not water soluble; bound to protein, but water soluble; bound to protein, but only unbound portion is activated only unbound portion is activated and can be used.and can be used.
Peptides and catecholamine are Peptides and catecholamine are water soluble; not bound to protein water soluble; not bound to protein and can circulate freely in bloodand can circulate freely in blood
Lab tests measure both bound and Lab tests measure both bound and unbound (free) hormonesunbound (free) hormones
SECRETIONSECRETION
Pituitary-target gland axisPituitary-target gland axis: pituitary : pituitary gland regulates endocrine glands gland regulates endocrine glands thru tropic hormones. Tropic thru tropic hormones. Tropic hormones get feedback about hormones get feedback about specific target glands by constant specific target glands by constant monitoring of levels of hormone.monitoring of levels of hormone.
Works by stimulation or inhibition of Works by stimulation or inhibition of hormoneshormones
SECRETIONSECRETION
Hypothalamic-pituitary-target-gland axisHypothalamic-pituitary-target-gland axis: : hypothalamus in brain’s di-encephalon hypothalamus in brain’s di-encephalon produces tropic hormones; in particular produces tropic hormones; in particular the pituitary gland. In turn, pituitary the pituitary gland. In turn, pituitary controls other target glands to produce controls other target glands to produce hormones. Therefore works hormones. Therefore works indirectlyindirectly
Hypothalamus secretes releasing factors Hypothalamus secretes releasing factors and inhibiting factorsand inhibiting factors
FEEDBACK MECHANISMSFEEDBACK MECHANISMS NegativeNegative- increased levels of substance inhibit - increased levels of substance inhibit
hormone synthesis and secretion; decreased hormone synthesis and secretion; decreased levels stimulate production and release (heat levels stimulate production and release (heat thermostat)thermostat)
PositivePositive-- increased levels stimulate hormone increased levels stimulate hormone production and release; decreased levels inhibit production and release; decreased levels inhibit synthesis and secretionsynthesis and secretion
ComplexComplex- - thyroid stimulating hormone (TSH) in thyroid stimulating hormone (TSH) in pituitary is activated by thyroid releasing pituitary is activated by thyroid releasing hormone (TRH) and inhibited by somatostatin (in hormone (TRH) and inhibited by somatostatin (in hypothalamus). Decreased Thypothalamus). Decreased T3 3 & T& T4 4 leads to leads to increased TSH release. Increased levels lead to increased TSH release. Increased levels lead to inhibit TSH secretion inhibit TSH secretion
OTHER REGULATORY OTHER REGULATORY MECHANISMSMECHANISMS
Nervous system- central nervous system Nervous system- central nervous system innervates hypothalamusinnervates hypothalamus
Hypoxia, pain, stress, RX affect ADH and Hypoxia, pain, stress, RX affect ADH and oxytocin levelsoxytocin levels
Hypothalamus helps to control autonomic Hypothalamus helps to control autonomic nervous systemnervous system
Can be used to modify other hormonesCan be used to modify other hormones If secreted and transported by blood- If secreted and transported by blood-
HORMONEHORMONE If secreted across synaptic junction- If secreted across synaptic junction-
NEUROTRANSMITTERNEUROTRANSMITTER
REGULATORY MECHANISMSREGULATORY MECHANISMS
RHYTHMS- hormonal levels fluctuate RHYTHMS- hormonal levels fluctuate in a 24 hour periodin a 24 hour period
Related to sleep-wake periods; dark-Related to sleep-wake periods; dark-lightlight– Diurnal- cortisol rises early in day, falls Diurnal- cortisol rises early in day, falls
toward eveningtoward evening– Circadian- growth hormone, prolactin Circadian- growth hormone, prolactin
peak during sleeppeak during sleep– Ultradian- menstrual cycleUltradian- menstrual cycle
DYSFUNCTIONSDYSFUNCTIONSDEFINITIONSDEFINITIONS
HYPERFUNCTIONHYPERFUNCTION:: excessive hormone excessive hormone production/functionproduction/function
HYPOFUNCTIONHYPOFUNCTION:: deficient hormone deficient hormone function/productionfunction/production
HYPERTROPHYHYPERTROPHY: increase in size of organ, : increase in size of organ, in bulk not in # of cells or tissue elements in bulk not in # of cells or tissue elements as a result of increased functionas a result of increased function
HYPERPLASIAHYPERPLASIA:: excessive proliferation of excessive proliferation of normal cells in normal tissue arrangement normal cells in normal tissue arrangement of an organof an organ
DYSFUNCTIONSDYSFUNCTIONSCLASSIFICATIONSCLASSIFICATIONS
PRIMARYPRIMARY:: disease within endocrine disease within endocrine glandgland
FUNCTIONALFUNCTIONAL: hormonal imbalances : hormonal imbalances resulting from disease in an organ or resulting from disease in an organ or tissue other than endocrine glandtissue other than endocrine gland
SECONDARYSECONDARY:: disease in a target disease in a target glandgland
GLANDSGLANDS
HYPOTHALAMUS:HYPOTHALAMUS:– Size of sugar cubeSize of sugar cube– Autonomic NS and endocrine functionsAutonomic NS and endocrine functions– Works thru releasing/inhibiting factorsWorks thru releasing/inhibiting factors– Hypothalamic-hypophysial portal systemHypothalamic-hypophysial portal system– Functions are visceral, somatic, Functions are visceral, somatic,
behavioral/emotional; temp. regulation, behavioral/emotional; temp. regulation, perspiration, GI secretion/motility, appetite, perspiration, GI secretion/motility, appetite, thirst, B/P, respiration, sexual behavior, thirst, B/P, respiration, sexual behavior, fear, rage, sleep,& menstrual cyclesfear, rage, sleep,& menstrual cycles
GLANDSGLANDS
PITUITARY:PITUITARY:– Size of pea (hypophysis); 1 cm diameterSize of pea (hypophysis); 1 cm diameter– Located in sella turcicaLocated in sella turcica– AnteriorAnterior- largest lobe; growth hormone, - largest lobe; growth hormone,
thyroid stimulating, thyroid stimulating, adrenocorticortrophic, follicle stimulating, adrenocorticortrophic, follicle stimulating, leutinizing, prolactin leutinizing, prolactin
– PosteriorPosterior- lies behind anterior; anti-- lies behind anterior; anti-diuretic, oxytocindiuretic, oxytocin
– Connected to hypothalamus by Connected to hypothalamus by hypophyseal stalkhypophyseal stalk
GLANDSGLANDS
THYROID:THYROID:– Located in front of trachea; two lobes Located in front of trachea; two lobes
connected by isthmus (“H” shaped)connected by isthmus (“H” shaped)– HIGHLY VASCULARHIGHLY VASCULAR– Secretes thyroxine (TSecretes thyroxine (T44); triiodothyronine ); triiodothyronine
(T(T33); thyrocalcitonin (calcitonin)); thyrocalcitonin (calcitonin)– Can store large quantities of hormonesCan store large quantities of hormones– 99%+ is bound to protein; INACTIVE99%+ is bound to protein; INACTIVE
THYROIDTHYROID
Increase in oxygen use and heat Increase in oxygen use and heat productionproduction
Requires iodine and protein to Requires iodine and protein to produce hormoneproduce hormone
Is able to store some hormoneIs able to store some hormone
GLANDSGLANDS
PARATHYROID:PARATHYROID:– Oval shaped arranged in pairs behind Oval shaped arranged in pairs behind
thyroid (4 total glands)thyroid (4 total glands)– Regulates blood levels of calcium and Regulates blood levels of calcium and
phosphorusphosphorus– Free from pituitary and hypothalamus Free from pituitary and hypothalamus
controlcontrol
GLANDSGLANDS
ADRENAL GLANDS:ADRENAL GLANDS:– Flat, pyramid-shaped structures lying on top of Flat, pyramid-shaped structures lying on top of
kidneys, surrounded by thick capsule; crucial kidneys, surrounded by thick capsule; crucial to metabolism, stress response, and fluid & e-to metabolism, stress response, and fluid & e-lytes balancelytes balance
– Cortex- firm, yellow, outer portion; 3 specific Cortex- firm, yellow, outer portion; 3 specific layerslayers
Outer layer secretes Outer layer secretes mineralocorticoidsmineralocorticoids Middle layer secretes Middle layer secretes glucocorticoidsglucocorticoids Inner layer secretes Inner layer secretes androgensandrogens
– Medulla- reddish brown; produces and secretes Medulla- reddish brown; produces and secretes catecholaminescatecholamines
ADRENAL GLANDADRENAL GLAND
MINERALOCORTICOIDS- MINERALOCORTICOIDS- aldosterone, aldosterone, maintains extracellular fluid volume; maintains extracellular fluid volume; acts on renal tubule to promote renal acts on renal tubule to promote renal re-absorption of Na+ & excretion of re-absorption of Na+ & excretion of K+; stimulated by angiotension II, K+; stimulated by angiotension II, hyponatremia, hyperkalemiahyponatremia, hyperkalemia
ADRENAL GLANDADRENAL GLAND
GLUCOCORTICOIDS- cortisolGLUCOCORTICOIDS- cortisol,,– most abundant,most abundant,– is necessary to maintain life;is necessary to maintain life;– secreted in diurnal pattern;secreted in diurnal pattern;– facilitates hepatic gluconeogenesis; converts facilitates hepatic gluconeogenesis; converts
protein to glucose, decrease glucose use in protein to glucose, decrease glucose use in fasting statefasting state
– critical in body’s response to stress;critical in body’s response to stress;– anti-inflammatory response;anti-inflammatory response;– maintains vascular integritymaintains vascular integrity
ADRENAL GLANDADRENAL GLAND
ANDROGENS:ANDROGENS:– Steroids secreted in small amountsSteroids secreted in small amounts– Stimulate pubic and axillary hair growthStimulate pubic and axillary hair growth– Stimulate sex drive in femalesStimulate sex drive in females– In post-menopausal women, primary In post-menopausal women, primary
source of estrogensource of estrogen
Easily remembered Easily remembered 3 S’s: 3 S’s: SALT, SUGAR, SEXSALT, SUGAR, SEX
EFFECTS OF AGINGEFFECTS OF AGING
General changes include:General changes include:– Increased connective tissue in glandsIncreased connective tissue in glands– Decreased blood supplyDecreased blood supply– Decreased metabolism resulting in increased Decreased metabolism resulting in increased
half-life of medicationshalf-life of medications– Changed:Changed:
basal levelbasal level response to stimuliresponse to stimuli TransportTransport Target organ responsivenessTarget organ responsiveness catabolismcatabolism
ASSESSMENTSASSESSMENTS Hormones affect Hormones affect ALLALL body tissues body tissues Great diversity in sign/symptomsGreat diversity in sign/symptoms s/s are often s/s are often vaguevague
– FatigueFatigue– DepressionDepression– Energy levelEnergy level– AlertnessAlertness– Sleep patternsSleep patterns– MoodMood– AffectAffect– WeightWeight– SkinSkin– HairHair– Personal appearancePersonal appearance– Sexual functionSexual function
PHYSICAL ASSESSMENTPHYSICAL ASSESSMENT
INSPECTIONINSPECTION: use head to toe approach: use head to toe approach PALPATION:PALPATION: only thyroid and testes can only thyroid and testes can
be palpatedbe palpated AUSCULTATION:AUSCULTATION: cardiac baseline; bruits cardiac baseline; bruits PSYCHOSOCIAL:PSYCHOSOCIAL: coping skills, support coping skills, support
systems; health-related beliefs; perception systems; health-related beliefs; perception of self; need for social servicesof self; need for social services
DYSFUNCTIONSDYSFUNCTIONS
Hypo-functioning:Hypo-functioning: requires hormone requires hormone replacement daily; transplants??, diet, etc.replacement daily; transplants??, diet, etc.– Purified vs. synthetic: Purified vs. synthetic: synthetic is a moresynthetic is a more
precise dosageprecise dosage Hyper-functioningHyper-functioning: generally harder to : generally harder to
treat; usually tumors removed by surgery, treat; usually tumors removed by surgery, radiation, or hormone antagonistradiation, or hormone antagonist– Inhibits action of hormone; Inhibits action of hormone; propylthiouricil propylthiouricil
(PTU)(PTU) and methimazole (Tapezole) to treat and methimazole (Tapezole) to treat hyperthyroidismhyperthyroidism
AdjunctiveAdjunctive:: patient education patient education
QUESTIONS TO ASK??QUESTIONS TO ASK?? General state of health: any noticeable changesGeneral state of health: any noticeable changes Past historyPast history MedicationsMedications Past surgeriesPast surgeries Growth and developmentGrowth and development Trauma (head/neck)Trauma (head/neck) Size of extremitiesSize of extremities Secondary sex characteristicsSecondary sex characteristics Visual changesVisual changes MenstruationMenstruation Changes in: hair, skin, nails, weight, appetite, memory, sleep, Changes in: hair, skin, nails, weight, appetite, memory, sleep,
nervous systemnervous system Family historyFamily history Stressors and coping patternsStressors and coping patterns System reviews: only endocrine gland that can be palpated is System reviews: only endocrine gland that can be palpated is
THYROID;THYROID; must be experienced to do this must be experienced to do this
DIAGNOSTIC TESTSDIAGNOSTIC TESTS
Specific for each hormoneSpecific for each hormone Measure absolute levels, estimate Measure absolute levels, estimate
production, transport, production, transport, catabolism-complex catabolism-complex substances converted to simpler substances converted to simpler substances- energy releasesubstances- energy release
May need multiple samplesMay need multiple samples Time of sample must always be includedTime of sample must always be included Patient should be fasting, free from Patient should be fasting, free from
stressors, no smoking, NPOstressors, no smoking, NPO Some samples need preservativesSome samples need preservatives
DIAGNOSTIC TESTSDIAGNOSTIC TESTS
DIRECT:DIRECT:– Most common; measures as hormone Most common; measures as hormone
appears in blood or urineappears in blood or urine– Since minute amounts, special Since minute amounts, special
techniquestechniques– May due 24-hour testing (24May due 24-hour testing (2400 urine) urine)– Radioimmunoassay RIA: radioactively Radioimmunoassay RIA: radioactively
labeled hormones compete with labeled hormones compete with unlabeled hormones to binding sites, etcunlabeled hormones to binding sites, etc
DIAGNOSTIC TESTSDIAGNOSTIC TESTS
INDIRECT:INDIRECT:– Measures the substance the hormone Measures the substance the hormone
controls not the hormone itselfcontrols not the hormone itself– Less costlyLess costly– Easier to administerEasier to administer– EX: glucose measures insulin; calcium EX: glucose measures insulin; calcium
measures PTHmeasures PTH
DIAGNOSTIC TESTSDIAGNOSTIC TESTS
PROVACATIVE:PROVACATIVE:– Helps to determine endocrine gland’s reserve Helps to determine endocrine gland’s reserve
function with tests that show borderline resultsfunction with tests that show borderline results– Stimulate an under-active gland or suppress Stimulate an under-active gland or suppress
over-active glandover-active gland– StimulationStimulation confirms hypofunction; hormone confirms hypofunction; hormone
given to stimulate target glandgiven to stimulate target gland Stimulus that increases secretion- hypofunctionStimulus that increases secretion- hypofunction If does not increase despite stimulus- hypofunctionIf does not increase despite stimulus- hypofunction
– Suppression Suppression Hormone secretion continues despite suppression Hormone secretion continues despite suppression
confirms hyperfunctionconfirms hyperfunction
DIAGNOSTIC TESTSDIAGNOSTIC TESTS
RADIOGRAPHIC:RADIOGRAPHIC:– Routine x-raysRoutine x-rays
Evaluates dysfunction and effect on body Evaluates dysfunction and effect on body tissuetissue
– CAT scansCAT scansAssesses endocrine gland structureAssesses endocrine gland structure
– MRIMRIHelps to diagnose thyroid disordersHelps to diagnose thyroid disorders
DEFINITIONSDEFINITIONS
SYNTHESIZE = PRODUCESYNTHESIZE = PRODUCE INHIBIT = BLOCK= SUPPRESSINHIBIT = BLOCK= SUPPRESS ANTAGONIZE= goe against; oppositeANTAGONIZE= goe against; opposite SECRETESECRETE STIMULATESTIMULATE ANTAGONIST= substance that inhibitsANTAGONIST= substance that inhibits AGONIST= Support; help stimulate or AGONIST= Support; help stimulate or
produceproduce
GLANDULAR DYSFUNCTIONSGLANDULAR DYSFUNCTIONS
PITUITARY: gland is divided into 2 PITUITARY: gland is divided into 2 lobes, anterior and posterior. lobes, anterior and posterior. Dysfunctions of these hormones can Dysfunctions of these hormones can alter growth, metabolism, or sexual alter growth, metabolism, or sexual problemsproblems
ANTERIOR PITUITARYANTERIOR PITUITARY HYPOPITUITARYISM: caused by deficiency of one HYPOPITUITARYISM: caused by deficiency of one
or more of hormones. Decreased production of or more of hormones. Decreased production of all hormones is rare, but referred to as all hormones is rare, but referred to as panhypopituitarismpanhypopituitarism
More commonly, one or two deficiencies are More commonly, one or two deficiencies are presentpresent– ACTHACTH: adrenocorticotropic hormone*: adrenocorticotropic hormone*– TSH:TSH: thyroid stimulating hormone* thyroid stimulating hormone*– **Most life-threatening**Most life-threatening– Deficiencies of gonadotropins (LH,FSH) change sexual Deficiencies of gonadotropins (LH,FSH) change sexual
function in men and womenfunction in men and women– Testicular failure in men, ovarian failure in womenTesticular failure in men, ovarian failure in women– Lags in puberty, amenorrhea, and infertilityLags in puberty, amenorrhea, and infertility
ETIOLOGYETIOLOGY
TumorsTumors Postpartum hemorrhage: Sheehan’s Postpartum hemorrhage: Sheehan’s
syndrome, pituitary enlarges during syndrome, pituitary enlarges during pregnancy and if hypotension occurs pregnancy and if hypotension occurs may lead to ischemia and infarction may lead to ischemia and infarction (necrosis) of pituitary gland leading (necrosis) of pituitary gland leading to hypofunctionto hypofunction
GROWTH HORMONEGROWTH HORMONE GROWTH HORMONE: changes tissue growth GROWTH HORMONE: changes tissue growth
indirectlyindirectly GH stimulates liver to produce somatomedins, GH stimulates liver to produce somatomedins,
which enhances growth in cells and tissueswhich enhances growth in cells and tissues May lead to dwarfism (growth retardation), May lead to dwarfism (growth retardation),
hypoglycemia, and delayed wound healinghypoglycemia, and delayed wound healing May give somatrem (Protropin) to help with linear May give somatrem (Protropin) to help with linear
growthgrowth In adults, leads to decreased bone density,In adults, leads to decreased bone density,
(osteoporosis) pathologic fractures, decreased (osteoporosis) pathologic fractures, decreased muscle strength, and increased cholesterolmuscle strength, and increased cholesterol
GROWTH HORMONEGROWTH HORMONE
ASSESSMENT: ASSESSMENT: – Changes in secondary sex characteristics, Changes in secondary sex characteristics,
libidolibido– Visual changes; diplopiaVisual changes; diplopia– HeadacheHeadache– Weakness, fatigue, apathyWeakness, fatigue, apathy– Mental slowness, poor stress toleranceMental slowness, poor stress tolerance– Dry, sallow skinDry, sallow skin– InfectionInfection– Orthostatic hypotensionOrthostatic hypotension
GROWTH HORMONEGROWTH HORMONE
Diagnostic tests:Diagnostic tests:– TT3 3 & T& T4 4
– FSHFSH– TSHTSH– ACTHACTH– CT scan or x-ray: changes in structureCT scan or x-ray: changes in structure– Stimulation tests- insulin increases GH & Stimulation tests- insulin increases GH &
ACTHACTH
GROWTH HORMONEGROWTH HORMONE
INTERVENTIONS: INTERVENTIONS: – Replace deficient hormonesReplace deficient hormones– TestosteroneTestosterone– EstrogenEstrogen– Surgical removal of tumorSurgical removal of tumor
HYPERPITUITARYISMHYPERPITUITARYISM
HYPERPITUITARISM: oversecretion of HYPERPITUITARISM: oversecretion of hormones (same hormones as hypo)hormones (same hormones as hypo)
ETIOLOGYETIOLOGY
Tumors: compresses brain tissue; Tumors: compresses brain tissue; occur between 40-50 yearsoccur between 40-50 years
Congenital defectsCongenital defects HemorrhageHemorrhage InfarctionInfarction Inflammation from TBInflammation from TB SyphilisSyphilis Prolonged mechanical ventilationProlonged mechanical ventilation
GROWTH HORMONEGROWTH HORMONE GROWTH HORMONE: produce gigantism or GROWTH HORMONE: produce gigantism or
acromegalyacromegaly– Gigantism:Gigantism: excess hormone occurs before puberty excess hormone occurs before puberty
causing rapid proportional growth in bone length. Height causing rapid proportional growth in bone length. Height >6’6”>6’6”
– Most die early with infection or trauma.Most die early with infection or trauma.– Acromegaly:Acromegaly: occurs after puberty producing skeletal occurs after puberty producing skeletal
thickness, hypertrophy of skin, enlarged visceral organ thickness, hypertrophy of skin, enlarged visceral organ like liver and heart.like liver and heart.
Enlarged hands, feet, paranasal and frontal sinuses, Enlarged hands, feet, paranasal and frontal sinuses, deformities of spin and mandilble, enlarged tongue, speech deformities of spin and mandilble, enlarged tongue, speech difficulties, hoarseness, hypertension, oily skin, and joint difficulties, hoarseness, hypertension, oily skin, and joint painpain
Cardiomegaly leads to CHFCardiomegaly leads to CHF GH is an insulin antagonist leading to hyperglycemiaGH is an insulin antagonist leading to hyperglycemia Stimulate adrenal cortex- Cushing’s DiseaseStimulate adrenal cortex- Cushing’s Disease
GROWTH HORMONEGROWTH HORMONE
DIAGNOSTIC TESTS:DIAGNOSTIC TESTS:– SAME AS FOR HYPOSAME AS FOR HYPO– Suppression testsSuppression tests
GROWTH HORMONEGROWTH HORMONE
INTERVENTIONS:INTERVENTIONS:– Surgical removal of tumorSurgical removal of tumor– RadiationRadiation– DrugsDrugs
Bromocriptine (Parlodel)- dopamine agonistsBromocriptine (Parlodel)- dopamine agonists Cabergoline (Dostinex)- dopamine agonists Cabergoline (Dostinex)- dopamine agonists Octrotide- somatostatin analog that reduces GH w/I 2 Octrotide- somatostatin analog that reduces GH w/I 2
weeks(given IM and can cause gallbladder disease)weeks(given IM and can cause gallbladder disease)
– Combination therapyCombination therapy– Prognosis depends on age of onset, age Prognosis depends on age of onset, age
treatment is started, and tumor sizetreatment is started, and tumor size– No reversal of bone growth, only soft tissueNo reversal of bone growth, only soft tissue
SURGICAL PROCEDURE: SURGICAL PROCEDURE: HYPOPHYSECTOMYHYPOPHYSECTOMY
Procedure to remove all or part of Procedure to remove all or part of hypophysis; hypophysis;
Uses transphenoidal approachUses transphenoidal approach 70-90% successful70-90% successful Reduces risk of complicatons and deathReduces risk of complicatons and death No visible scar or loss of hairNo visible scar or loss of hair Incision made in inner aspect of upper lip Incision made in inner aspect of upper lip
and gingivaand gingiva Enter sella turcica through floor of Enter sella turcica through floor of
sphenoid sinussphenoid sinus
HYPOPHYSECTOMYHYPOPHYSECTOMY Teach mouth breathing, mouth care, ambulation, pain control, Teach mouth breathing, mouth care, ambulation, pain control,
activity, and hormone replacement prior to ORactivity, and hormone replacement prior to OR Nasal packing for 2-3 daysNasal packing for 2-3 days Dressing applied to upper lip: “mustache dressing”Dressing applied to upper lip: “mustache dressing” Avoid coughing, sneezing, straining at stool to prevent CSF leak Avoid coughing, sneezing, straining at stool to prevent CSF leak
(cerebrospinal fluid leak)(cerebrospinal fluid leak) HOB elevated 30HOB elevated 3000 to avoid pressure on sella turcica and reduce HA to avoid pressure on sella turcica and reduce HA Tooth brushing avoided to prevent disruption of suture lineTooth brushing avoided to prevent disruption of suture line Nasal drainage assessed for CSF (risk for meningitis) c/o HA, Nasal drainage assessed for CSF (risk for meningitis) c/o HA,
yellow halo on pillow, tests + for sugar; usually resolved w/I 72yellow halo on pillow, tests + for sugar; usually resolved w/I 7200; ; may need patchmay need patch
S/S of meningitis-HA, nuchal rigidity, temperature, photosensitivityS/S of meningitis-HA, nuchal rigidity, temperature, photosensitivity Antibiotics startedAntibiotics started Hormone replacement startedHormone replacement started May develop diabetes insipidus which is usually transientMay develop diabetes insipidus which is usually transient
POSTERIOR PITUITARYPOSTERIOR PITUITARY
HYPOFUNCTION: responsible for ADH HYPOFUNCTION: responsible for ADH and oxytocinand oxytocin
Deficiency of ADHDeficiency of ADH
POSTERIOR PITUITARYPOSTERIOR PITUITARY
ETIOLOGY:ETIOLOGY:– TumorsTumors– Trauma; head injuryTrauma; head injury– RadiationRadiation– DrugsDrugs– InfectionInfection– IschemiaIschemia
DIABETES INSIPIDUS DIDIABETES INSIPIDUS DI
Disorder of water metabolismDisorder of water metabolism ADH is produced by hypothalamus; stored ADH is produced by hypothalamus; stored
and released by post. Pituitaryand released by post. Pituitary Decreased ADH leads to distal renal Decreased ADH leads to distal renal
tubules not retaining watertubules not retaining water Large volumes of urine excreted (polyuriaLarge volumes of urine excreted (polyuria)) Massive dehydrationMassive dehydration Increased plasma osmolarity/osmolalityIncreased plasma osmolarity/osmolality Stimulates thirst response (if intact)Stimulates thirst response (if intact)
CLASSIFICATIONS OF DICLASSIFICATIONS OF DI NEPHROGENIC:NEPHROGENIC:
– Inherited disorder where kidneys do not respond to ADH; no Inherited disorder where kidneys do not respond to ADH; no deficiency in hormonedeficiency in hormone
PRIMARY:PRIMARY:– Defect in pituitary or hypothalamus; lack of ADH production or Defect in pituitary or hypothalamus; lack of ADH production or
secretionsecretion SECONDARY:SECONDARY:
– Tumors of pituitary or hypothalamus; trauma, infection, Tumors of pituitary or hypothalamus; trauma, infection, surgery, metastasis of oat cell cancer in lung or breastsurgery, metastasis of oat cell cancer in lung or breast
DRUGS:DRUGS:– Any drug that might interfere with kidney’s response to ADH; Any drug that might interfere with kidney’s response to ADH;
lithium carbonate (psych- manic/depressive)lithium carbonate (psych- manic/depressive) PSYCHOGENIC:PSYCHOGENIC:
– Client ingests large quantities of water, usually 5 liters or more Client ingests large quantities of water, usually 5 liters or more which in turn depresses ADH production/secretionwhich in turn depresses ADH production/secretion
DIDI
ASSESSMENTS:ASSESSMENTS:– Water loss (free water)Water loss (free water)– Plasma osmolality increasesPlasma osmolality increases– Serum sodium increasesSerum sodium increases– Urine osmolality decreasesUrine osmolality decreases– ThirstThirst– Frequent voiding (4 liters/24Frequent voiding (4 liters/2400); 200ml/hr with ); 200ml/hr with
specific gravity<1.005specific gravity<1.005– Abrupt onset (1-2 days after injury)Abrupt onset (1-2 days after injury)– Weight loss, fatigue, constipation, anorexiaWeight loss, fatigue, constipation, anorexia
DIDI DIAGNOSTIC TESTS:DIAGNOSTIC TESTS:
– Serum sodium- increaseSerum sodium- increase– Plasma osmolality- increasePlasma osmolality- increase– Specific gravity of urine- decreasedSpecific gravity of urine- decreased– Water deprivation test- withhold food and water at 6am. Water deprivation test- withhold food and water at 6am.
Measure urine volume, osmolality, specific gravity hourly Measure urine volume, osmolality, specific gravity hourly until osmolality is constant. Measure serum osmolality, until osmolality is constant. Measure serum osmolality, give Vasopressin, and take measurements again. Urine give Vasopressin, and take measurements again. Urine osmolality >serum before and after test.osmolality >serum before and after test.
– Vasopressin test – used less frequentlyVasopressin test – used less frequently– Hypertonic saline test- NS followed by 3% saline- sudden Hypertonic saline test- NS followed by 3% saline- sudden
decrease in urine output is sign of ADH releasedecrease in urine output is sign of ADH release
DIDI INTERVENTIONS:INTERVENTIONS:
– Maintain fluid and e-lyte balanceMaintain fluid and e-lyte balance– Identify and correct causeIdentify and correct cause– IV fluids (hypotonic)IV fluids (hypotonic)– Unrestricted access to fluidsUnrestricted access to fluids– Administer VasopressinAdminister Vasopressin
Aqueous for short-acting needsAqueous for short-acting needs Tannate in oil for long-acting needsTannate in oil for long-acting needs
– Diabenese- only used if partial reduction in ADH; Diabenese- only used if partial reduction in ADH; increases action of ADHincreases action of ADH
– Severe cases administer desmopressin acetate DDAVP- Severe cases administer desmopressin acetate DDAVP- synthetic form of ADH (metered dose inhaler) irritate synthetic form of ADH (metered dose inhaler) irritate nasal mucosanasal mucosa
– Daily weights are a must!!Daily weights are a must!!
POSTERIOR PITUITARYPOSTERIOR PITUITARY
HYPERFUNCTIONHYPERFUNCTION Oversecretion of ADH even with low Oversecretion of ADH even with low
osmolalities (Schwartz-Bartter osmolalities (Schwartz-Bartter Syndrome)Syndrome)
SYNDROME OF INAPPROPRIATE SYNDROME OF INAPPROPRIATE ADH SIADHADH SIADH
Water is retained but no edemaWater is retained but no edema Dilutional HyponatremiaDilutional Hyponatremia Sodium loss from kidneys further Sodium loss from kidneys further
leads to hyponatremia leads to hyponatremia Positive feedback- elevated ADH Positive feedback- elevated ADH
release persists even with increased release persists even with increased plasma volume and decreased plasma volume and decreased osmolalityosmolality
SIADHSIADH
ETIOLOGY:ETIOLOGY:– CancerCancer– Cerebrovascular accident- CVACerebrovascular accident- CVA– Tuberculosis -TBTuberculosis -TB
SIADHSIADH ASSESSMENTS:ASSESSMENTS:
– Changes in LOC: Changes in LOC: Malaise, nausea, HA, irritabilityMalaise, nausea, HA, irritability
– TachycardiaTachycardia– Increased B/PIncreased B/P– Water intoxicationWater intoxication– Fluid shifts especially in brain lead to LOC Fluid shifts especially in brain lead to LOC
changeschanges– No dependent edema initiallyNo dependent edema initially– Na+ < 130; dilutional hypocalcemia; normal Na+ < 130; dilutional hypocalcemia; normal
BUN, creatinineBUN, creatinine– Symptoms depend on rate of onsetSymptoms depend on rate of onset
SIADHSIADH
DIAGNOSTIC TESTS:DIAGNOSTIC TESTS:– Serum sodium- decreasedSerum sodium- decreased– Serum calcium- decreasedSerum calcium- decreased– BUN and creatinine- normalBUN and creatinine- normal– Plasma osmolality- decreasedPlasma osmolality- decreased– Urine osmolality- elevatedUrine osmolality- elevated
SIADHSIADH
INTERVENTIONS:INTERVENTIONS:– Restrict fluids to 500-600cc/24Restrict fluids to 500-600cc/2400
– I & OI & O– Daily weightsDaily weights– DiureticsDiuretics– Hypertonic saline (3%) use with cautionHypertonic saline (3%) use with caution– Drugs:Drugs:
Lithium carbonate- can cause toxicityLithium carbonate- can cause toxicityDeclomycin**- more commonly used Declomycin**- more commonly used