Endocrine System

Care of the Client with Problems Related to the Endocrine System Earl Francis R. Sumile, RN Instructor, College of Nursing University of Santo Tomas

Endocrine System • • • • • • •

Pituitary Thyroid Parathyroid Thymus Adrenal Pancreas Gonads

1. Pituitary Gland A. Anterior lobe – Adenohypophysis – Releases and synthesizes hormones B. Posterior lobe – Neurohyphosis – Does not produce but stores and releases

A. Anterior Pituitary Gonadotropic or Somatropic Hormone – Stimulates growth of body tissues or bones Thryrotropic or Thyroid Stimulating Hormone (TSH) – Stimulates thyroid gland and secretions c. Adreno-Cortico Tropic Hormone (ACTH) – Stimulates steroid production by adrenal cortex d. Melanocyte Stimulating Hormone (MSH) – Stimulates pigmentation

A. Anterior Pituitary e. Luteinizing Hormone (LH) -

In females, ovulation and luteinization of ovarian follicles

f. Follicle Stimulating Hormone (FSH) -

Growth of ovarian follicle in females Spermatogenesis in males

g. Interstitial Cell Stimulating Hormone (ICSH) -

In males, production of testosterone

h. Prolactin -

Stimulates mammary tissues and lactation

B. Posterior Pituitary a. Anti-Diuretic Hormone (ADH) or

Vasopressin -

Reabsorption of water Decreases urinary output

b. Oxytocin - Ejection of milk - Uterine contraction - Sperm transport

2. Thyroid Thryroxin T4 – Metabolism (catabolic phase)

Triiodothryronin T3 – Cellular metabolism

c. Thryrocalcitonin – Calcium balance

3. Parathyroid a. Parathormone – Regulates calcium and phosphate levels

4. Thymus a. Thymosin – Incubator of T-lymphocytes – Cornered mainly with: Growth Maturation Metabolic processes Reproduction of target cell or tissue

5. Adrenal A. Cortex a. Glucocorticoids – Gluconeogenesis – Regulates blood sugar by conserving glucose and cortisone b. Mineralocorticoids – Aldosterone, corticosterone – Regulates electrolyte balance by Na retention and K excretion c. Androgens and Estrogens – Secondary sex characteristics

5. Adrenal B. Medulla a. Epinephrine or Adrenaline – Increases blood pressure – Increases cardiac rate – Dilates bronchioles

6. Pancreas A. Islets of Langerhans a. Insulin Hypoglycemic agent Metabolism of carbohydrates, proteins and fats

b. Glucagon Hyperglycemic agent Mobilizes glycogen stores Increases blood glucose level

7. Gonads A. Ovaries a. Estrogen and Progesterone Stimulates development of secondary sex characteristics

B. Testes a. Testosterone For normal functioning of male reproductive organs Development male secondary sex characteristics

Nursing Assessment a. b. –

c. – – –

d. e. f. g.

Nursing history Growth and Development Developmental history

Sexual functioning Loss of libido Impotence Menstrual cycle or irregularities

Hair growth; Voice Changes in the skin Emotional state Nutritional state

Physical Assessment •

Inspection • • • • • •

Height Weight Body stature Muscle wasting Hair growth and distribution Skin pigmentation

2. Palpation- e.g. thyroid gland • • • • •

Size Shape Symmetry Tenderness Growth

Pituitary Gland Diagnostic Assessment 1. Hematologic Interrelated with adrenal and gonads

2. Radiologic Skull; CT; MRI; Pneumoencephalography

•

Water Deprivation Test- no water 4-18 hrs (+) diabetes insipidus- ↑in volume, no ↑ in urine osmolality; ↓specific gravity

Disorders of the Pituitary Gland Hyperpituitarism a. b.

Gigantism Acromegaly

Hypopituitarism a. Dwarfism b. Diabetes Insipidus

1. Hyperpituitarism oversecretion because of pituitary tumor

A.Gigantism • sustained hypersecretion of growth hormone in children • General overgrowth of long bones, skeleton and tissue • Marked increase in height and weight

1. Hyperpituitarism B . Acromegaly  sustained hypersecretion of growth hormone in adults after epiphyseal closure • Bone grows wider and thicker • Extremities are enlarged Soft tissues on hands or feet enlarged and coarse • Prognathism Lengthened lower jaw • Bridge of nose broader

Nursing Assessment a. •

Oily skin and excessive sweating Hypertrophy of sebacious gland

b. Thickening of vocal chords • Voice change c. Visual impairment • Pressure on visual pathway d. Headache, diplopia, blindness, lethargy e. Gonadotropic hormone increased • Sexual promiscuity in children f. Increased prolactin • Amenorrhea and galactorrhea

Management of Hyperpituitarism Management of choice

• Surgery (removal of tumor) transpheinoidal hypophysectomy

Nursing interventions post op:

– Proper oral hygiene; no brushing; encourage use of H2O2 1;1 gargle – No chewing on affected site – No rough/coarse food – No sneezing and blowing of nose for 2 weeks – No dentures for 10 days

2. Hypopituitarism • deficiency of pituitary hormones • Panhypopituitarism When both both anterior and posterior lobes fail to secrete hormones

Causes: – – – – –

Hypophysectomy Nonsecreting pituitarytumors Pituitary dwarfism Postpartum pituitary necrosis Functional disorders Starvation, anorexia nervosa, severe anemia, GI disorders

A. Dwarfism  Secondary to congenital lack of growth

hormone or space occupying tumors • Retardation of growth on 1st year, chubby • Lack muscular development, delayed puberty

• Nursing management • Injection of growth hormone

B. Diabetes Insipidus  Passage of excessive amounts of highly diluted

urine • Diagnostic Assessment • (+) water deprivation test

• Nursing Management • Surgery (removal of tumor)- transphenoidal hypophysectomy • Pitressine tannate- vasopressin tannate in oil • Salt and protein restricted diet

Adrenal Gland •

Diagnostic Assessment: 1. Adrenal cortex functions a. Hematologic level of steroids •

cortisol, aldosterone, and testosterone level

b. Urinary level- 24 hr urine collection •

17-ketosteroid test

2. Adrenal medulla function Vanillylmandelic acid VMA- 24 hrs. urine collection

Disorders of the Adrenal Cortex Addison’s Disease- chronic adreno-cortical insufficiency • Nursing assessment: 1. Aldosterone deficiency • Polyuria, dehydration, hypotension, decreased cardiac output 2. Glucocorticoid deficiency • Hypoglycemia, weakness, exhaustion, anorexia, weight loss,nausea, vomiting

Disorders of the Adrenal Cortex Nursing assessment: 1. Androgen deficiency • Decreased pubic hair • Increased melanin stimulating hormone, increased adenocorticotropic hormonecortisol deficiency-external tan or bronzed appearance

Addison’s Crisis Causes • surgery, pregnancy, injury, infection, salt loss, second degree profuse diaphoresis • Sudden profound asthenia • Severe abdominal, back and leg pain • Hyperpyrexia followed by hypothermia • Peripheral vascular collapse, coma • Renal shutdown

Nursing management: • • • • • •

Hydrocortisone (solu-cortef) IV Monitor vital signs Prevent infection Daily weight Electrolyte balance High carbohydrate and protein diet

Disorders of Adrenal Cortex Aldosteronism- aldosterone excess • •

Primary (Conn’s syndrome) Secondary •

Results from the presence of exogenous conditions that stumulates renin-angiotensinaldosterone system

Nursing Assessment Muscular weakness, paralysis, edema Intermittent paresthesia Increased cardiac output, increased K

a. b. c. •

d. e. f. g.

ECG changes

Diminished deep tendon reflexes Increased blood volume Decreased concentrating kidney ability Polyuria, polydipsia, nocturia

Nursing Management a. K-sparing diuretics b. K replacement c. Na restriction

Disorders of Adrenal Cortex Cushing’s syndrome overactivity of adrenal glands with hypersecretion of glucocorticoids

Etiology: Adrenal tumor, adrenal hyperplasia, ectopic adrenocorticotropic hormone-secreting tumor, intake of synthetic glucocorticoids- iatrogenic cushing’s syndrome

Nursing Assesment a. Persistent hyperglycemia- Leads to diabetes b. c. d. e.

mellitus Protein tissue wasting- Stunted growth in children Capillary fragility- Ecchymosis Osteoporosis- Pathogenic fractures; kyphosis; height loss Potassium depletion- Hypokalemia, arrythmias

Nursing Assesment Sodium and water retention- edema and hypertension b. Abnormal fat distribution- moon face • Buffalo hump- cervico-dorsal fat pad on neck truncal obesity with slender limbs Increased susceptibility to infection Increased production of androgens- mild virilism, acne, thinning of scalp and hair and hirsutism a.

Nursing management a. Surgery • hypophysectomy, adrenalectomy, total or bilateral b. Irradiation c. Pharmacotherapeutics • Chlorophenyl dichloroethane (DDD); aminoglutethimide (elipten); metyrapone (metapirone)-long term

Disorders of the Adrenal Medulla • Pheochromocytoma • Tumor which results in ypersecretion of adrenal medulla • Typically benign; curable if detected early • Precipitating factors: pregnancy and stress

Nursing Assessment and Management • Nursing Assessment • Hypertension- main symptom • Persistent, fluctuating, pounding headache • Sweating palpitations, nausea or vomiting • Hyperglycemia and glycosuria • Shock-like state Pupils dilate, cold extremities, diaphoresis

• Management or choice • Surgical excision

Thyroid Gland • Iodine regulates body metabolism (oxygen

consumption and heat production) • Regulate growth and development TSH- from anterior pituitary stimulates thyroid gland to release thyroxine, triiodothyromine, thyrocalcitonin Euthyroid- normal thyroid function and secretion

Diagnostic Assessment: •

Thyroid function • • • • • • •

Serum thryroxine Serum triiodothyronine Triiodothyronin (T3) resin uptake test Radioactive iodine (131I) uptake and excretion test Serum TSH Thyrotropin- releasing hormone Serum cholesterol- increase in patients with myxedemia or hypothyrodism

Diagnostic Assessment h. PBI (Protein Bound Iodine)- measures the amount of iodine binded in blood protein. •

Preparation: no food or drug containing iodine 24 hours before the test

i. BMR (Basal Metabolic Rate)- indirect measure of amount of oxygen consumed in the body under basal conditions during given time. •

Preparation: proper sleep or rest night before the preocedure • •

Fasting for 6-8 hours Done before getting out of bed

Disorders of the Thyroid Gland Goiter- enlargement of the Thyroid Gland Etiology a. lack of iodine •

•

(simple goiter), pregnancy, lactation, iodine deficient areas

Intake of too much goitrogenic foods • •

Nutritional goitrogens that inhibit thyroxine production Such as cabbage, soybeans, peanuts, spinach, peaches, radish, strawberries

c. Inflammation- thyroiditis d. Thyroid cancer

Nursing Management a. Prevention • Iodized salt, avoid goitrogenic foods

Lugol’s solution or Potassium Iodide Saturated Solution (KISS) •

Dose comes in drops; mixed with cold water and given with a straw

c. Thryroid hormone replacement • Watch for thyrotoxicosis • Tachycardia, increase appetite, diarrhea, sweating, tremor, palpitations, shortness of breath

Disorders of the Thyroid Gland Hyperthyroidism; Grave’s Disease (Basedow’s disease) • Excessive production of T3 or T4 or both • Toxic diffuse goiter or exophthalmic goiter

Incidence: females

Nursing Assessment Agitated, nervous, irritable Goiter (excessive thyroid hormone in blood) Heat intolerance Increased appetite Amenorrhea Exophthalmus •

Abnormal protrusion of eyes

Nursing Management Antithyroid therapy

a. • •

To suppress thyroid secretions Prophylthiouracil PTU; methimazole tapazole

Iodine- lugol’s solution or KISS

b. •

To decrease the vascularity and size of the thyroid

Radioactive Iodine Therapy

c. •

to middle aged and elderly clients

Nursing Management d. Surgery • When patient is euthyroid • Post-operative • Semifowler’s position when conscious • tracheostomy set at bedside • Ambulate 2nd post-operative day

Nursing Management Complications • Hemorrhage • Check dressings by sliding hand on the patient’s nape • Respiratory obstruction • Laryngeal edema- observe for sudden difficulty in breathing • Keep tracheostomy set at bedside

Nursing Management: complications • Accidental injury to the laryngeal nerve

• Watch for decreasing voice • Hypocalcemia or tetany • Accidental removal of parathyroid gland • (+) Chovstek’s sign • Spasms of the facial muscles when tapped • (+) Troussaeu’s sign Carpopedal spasms upon constriction of the extremities

Nursing Management: complications • Management on Hypocalcemia

• Increase Ca – 100% sol of calcium carbonate or gluconate or calcium lactate • Calcium supplement and Vit D

*Thyroid storm Overactivity of thryroid characterized by increased temperature, severe tachycardia, delirium, dehydration and irritability, hypotension Nursing management: • Cool darkened quiet room • Antipyretic oral or parenteral antithyroid drug followed by K iodine; corticosteroids, propanolol- to relieve heart arrythmias

Hypothyroidism •

Cretinism • Usually silent baby • Severe hypothyroid condition of infancy due to deficiency of thyroid hormone synthesis during fetal life or soon after birth

Hypothyroidism • Nursing assessment:

a.Physical and mental retardation b.Shunted stature c.Wide open mouth and lolling tongue d.Small eyes and half closed with swollen lids e.Stolid expressionless face f. Squat figure g.Muddy dry skin

Hypothyroidism Myxedema- deficiency in thyroid synthesis in adult • Asymptomatic to full blown • Nursing management: • Fatigue and apathetic • Obesity: puffy and edematous with course features • Dry and sparse hair, dry flaky skin • Severe intolerance to cold decreased metabolic rate • Fecal impaction, hypersensitive to narcotics, barbiturates, and anesthetics • MANAGEMENT: • Hormone therapy for life (synthroid, cytomel)

Pancreas- Islets of Langerhans • Controls endocrine functions • Insulin- from beta cells- fat or protein

metabolism- hypoglycemic agent • Glucagon- from alpha-cells- hyperglycemic agent

Diabetes Mellitus Chronic disorder of carbohydrate metabolism (imbalance between the supply and demand) Types: • Type I- insulin dependent (!DDM or juvenile diabetes) • Type II- non-insulin dependent (NIDDM or maturity onset)

Nursing Assessment Polyuria

• •

Water not reabsorbed by renal tunules because osmotic activity of glucose

Polydipsia

• •

Severe dehydration, causes thirst

Polyphagia

• •

Tissue breakdown and wasting causes starvation

Weight loss (IDDM)- no glucose available to cells, therefore body breaks down fat and protein stores for energy

Diagnostic Assessment Hematologic studies Fasting Blood Sugar (FBS)N=80-120 mgs% Post Prandial Blood Sugar (PPBS) Ability to dispose of glucose load in 2 hrs N= 150% Oral Glucose Tolerance Test (OGTT) Prep: NPO 10-12 hrs; baseline sugar in blood and urine; 100gms glucose diet is given; blood or urine is taken after 30 mins; 1 hr; 1 ½ hrs and 2 hrs after- N=150mgs/dl Glucosylated HGB Glucose bonds to hemoglobin – measures blood glucose levels120 days N= 3.5-8.5%

Diagnostic Assessment Urine test a. Benedict’s test •

use of benedict’s solution

b. Clinitest •

use of clinitest tablet

c. Testape•

use of tes-tape

d. Diastix•

use of urine strip

Nursing Management Activity (exercise) Diet Drugs A. Oral hypoglycemics

• • • • •

Triggers the islets of langerhans to produce insulin; sulfonylureas b. First generation- Orinase, Tolinase, Diabenese, Dymelor c. Second generation- Diabeta, Glucotrol, Micronase

Nursing Management Complication (oral hypoglycemic): HHNK- hyperglycemic, Hyperosmolar, NonKetotic Coma • Non-insulin dependent diabetics who have enough insulin but unable to use insulin to combat hyperglycemia

• Nursing Assessment • Same as DKA but no kussmaul breathing and acetone breath

Nursing Management B. Insulin- Lower blood sugar by transport of glucose to cells and inhibits conversion of glucogen to glucose Type

Insulin

Color

Peak

Rapid acting

Regular Semilente

Clear Cloudy

2-4 hrs 2-4 hrs

Intermediate acting

NPH Lente

Cloudy Cloudy

6-8 hrs 6-8 hrs

Long acting

Protamine/Zinc Ultralente

Cloudy Cloudy

18+ hrs 8-12 hrs

Premixed (NPH/Req)

Humulin 50/50 Humulin 70/30

Cloudy Cloudy

2-8 hrs 2-12 hrs

Nursing Management  Complications (insulin)

Tissue hyperthrophy or atrophy or lipodystrophy Diabetic Ketoacidosis • Fatty acids are broken down to ketone bodies because of absolute or relative deficiency in insulin

 Etiology • too little insulin dose • Omitting insulin dose • Increase need for insulin due to surgery, trauma, pregnancy, puberty, or febrile illness • Insulin resistance secondary to development of insulin antibodies or severe emotional stress

Nursing Management 

Nursing Assessment a. Polyuria, thirst, nausea or vomiting, dry mucus membrane, cracked lips b. Hot flushed skin, weight loss c. Abdominal pain, and rigidity (Na deficiency) d. Kussmaul respirations e. Acetone breath f. Weakness, paralysis, paresthesia g. Hypotension, oliguria, coma, stupor h. ABG’s, metabolic acidosis, with compensated respiratory alkalosis

Nursing Management Nursing management:

 • • • •

Insulin IVF-NS or1/2 NS K phosphate when urine is adequate Na HCO3, if pH < 7.0

Hypoglycemia (insulin reaction) Etiology: a. Overdose of insulin or sulfonylurea b. Omission of meals or eating less than prescribed food c. Overexertion without compensating with increase in carbohydrates d. Nutritional and fluid imbalance secondary to nausea and vomiting

Hypoglycemia Nursing assessment: • Headache, weakness, irritability, apprehension • Lack of muscular coordination • Diaphoretic • Behaves in bizarre, psychotic fashion • Palor, bradycardia, visual disturbances • Alterations in mental or level of consciousness • Confusion or hallucinations

Hypoglycemia  Nursing management

• Candy, glucose paste, sugar cubes, orange juice if awake • D50W IVP or glucagon • Epinephrine, steroids, diaoxide if with insulinemia

Long term complications • Degenerative vascular changes

• Atherosclerosis • Microangiopathy- major hallmark of DM destruction of small blood vessels (eyes and kidneys) • Ocular disorders • Blurred vision • Cataracts • Diabetic retinopathy • -major cause of blindness in diabetes 4.Retinal detachment

Long term complications Kidney disease • Current pyelonephritis • Nephropathy (kimmelsteil-wilson syndrome) 2. Neuropathy • Peripheral nerve degeneration 3. infections 1.