Endocrine System

Lecture at a glance .
Thyroid Gland Adrenal Gland Pancreas

THYROID GLAND Secretes 3 hormones a. Thyroid hormones (T3 and T4) - metabolic activity of tissues b. Calcitonin inhibits bone resorption (antagonistic to PTH), lowers serum calcium

Hyperthyroidism
1. 2.

3. 4.

3 Basic concepts: Increased metabolic rate ( inc. T3) Increased body heat (inc. T4) Hypocalcemia (inc. calcitonin) Graves disease - with ocular signs and diffuse goiter

Hyperthyroidism
Assessment: 1. Increased rate of body metabolism - weight loss despite ravenous appetite and inc. ingestion of food 2. Heat intolerance 3. Nervousness, fine tremors of the hand 4. Hyperkinesis and diaphoresis 5. Tachycardia and palpitations 6. Diarrhea

GOITER
Hypertrophy of the thyroid gland Types: Endemic nutritional iodine deficiency Sporadic A. Ingestion of goitrogenic foods cabbage, soybeans, peaches, strawberry, radish, spinach B. Ingestion of goitrogenic drugs e.g. lithium

Hyperthyroidism
Nursing Management: 1. Non-stimulating cool environment 2. Diet: increase calorie, and protein decrease fiber (if with diarrhea), NO STIMULANTS 3. Dark sunglasses when going outside the sun, use eye drops

Hyperthyroidism
Management: 1. Anti-thyroid drugs A. Propylthiouracyl (PTU) - inhibits synthesis of T3 and T4 SE: agranulocytosis (fever, sore throat) B. Lugols solution or SSKI - To decrease the size and vascularity of the gland C. Radioactive iodine to destroy thyroid cells 2. Beta blocker to control tachycardia, HPN 3. Surgery a. Subtotal thyroidectomy to relieve pressure symptoms and for cosmetic reason b. Total thyroidectomy

Thyroidectomy
Postop Care 1. Semi-fowlers 2. Ice collar on neck to prevent hemorrhage. Check back of neck for blood. 3. Assess for hypocalcemia (can cause laryngospasm): Trousseaus sign Chvosteks sign Keep tracheostomy set and calcium gluconate available 48 hrs post op. 4. Assess for laryngeal nerve damage. Ask the patient to speak every hour.

Q: Post thyroidectomy nursing care includes which measures? a. Have the client speak every 5 to 10 minutes if hoarseness is present b. Provide low calcium diet c. Check the dressing at the back of the neck for bleeding d. The patient should be flat on bed

Q: Which medication will the nurse have available for emergency treatment of tetany in a post thyroidectomy patient? a. Calcium gluconate b. Potassium chloride c. Magnesium sulfate d. Sodium bicarbonate

Thyroid storm
Uncontrolled and life threatening hyperthyroidism Causes: Unprepared thyroid surgery, stress, infection Assessment: elevated temp (initial sign), tachycardia, inc. BP, inc. RR, delirium, coma Management: 1. Maintain patent airway, administer oxygen 2. Lower body temp and heart rate a. Hypothermia blanket, acetaminophen b. Propanolol (inderal) 3. Administer oral PTU, iodine to inhibit release of thyroid hormones

Q: When caring for a client in a thyroid crisis, the nurse would question an order for: a. IV fluids b. Propanolol (Inderal) c. Propylthiouracyl d. Hyperthermia blanket

Hypothyroidism
Deficiency of thyroid hormones Myxedema (adult), cretinism in children Causes: autoimmune, surgery, antithyroid drugs 3 Basic concepts: 1. Decreased metabolic rate (dec T3) 2. Decreased body heat (dec T4) 4. Hypercalcemia (dec calcitonin)

Hypothyroidism
Assessment: 1. Slowed rate of body metabolism - Lethargic - Intolerance to cold - Weight gain - Cold, dry, rough skin - Constipation
2. Personality changes - forgetfulness, loss of memory

Hypothyroidism
Management: 1. Diet. Low calorie high fiber 2. Provide warm environment during cold weather 3. Thyroid hormone replacement e.g. Levothyroxine (Synthroid) Health Teaching: 1. Take in am to prevent insomia 2. SE: Inc. metabolism, hyperactivity, cardiac stimulation

Q: A client is prescribed levothyroxine (Synthroid) daily. The most important instruction to give the client for administration of this drug is: a. Taper the dose and discontinue if mental and emotional status stabilize b. Take it at bedtime to reduce side effects c. Call the doctor if palpitations or nervousness occur d. Decrease intake of juices and fruits with high potassium and calcium contents

ADRENAL GLANDS
Paired organ on the apex of each kidney CORTEX produces steroid hormones 1. Glucocorticoids (cortisol) 2. Mineralocorticoids (aldosterone) 3. Sex hormones (testosterone/estrogen) MEDULLA secretes cathecolamines

ADRENAL CORTEX
1. ALDOSTERONE - For electrolyte regulation Causes Sodium and water retention Potassium excretion Inc. BP 2. Cortisol Increases blood sugar Anti-inflammatory Enable individual to cope with stress 3. Sex hormones Responsible for secondary sex characteristics Menstruation and spermatogenesis

Cushings Disease
Adrenocortical hyperfunction resulting to excess adrenal cortex hormones Females > males; between 30-60 y.o. Causes: 1. Tumor in Adrenal cortex 2. Tumor in the pituitary causing increased ACTH

Cushings Disease
S/Sx: 1. Personality changes 1. Central type obesity weight gain in the face (moon face), neck, shoulders and abdomen, buffalo hump 2. Increased susceptibility to infection 3. Edema, hypertension 4. If female: amenorrhea, atrophy of the breast, excessive growth of hair in face (hirsutism), enlargement of clitoris, voice changes If male: libido, impotence, gynecomastia

Cushings Disease
Nursing Interventions: 1. Provide diet low in sodium, high in potassium
2. Provide adequate rest and prevent infection. 3. Observe for hypertension and edema. Monitor I/O and daily weights

Addisons disease
Decreased secretion of adrenal cortex hormones Assessment: 1. Fatigue, Decreased response to stress 2. Bronze pigmentation of the skin (eternal tan) 3. Hypoglycemia 4. Hyponatremia, hyperkalemia 5. Addisonian Crisis: hypotension, severe weakness; due to abrupt withdrawal of meds

Addisons disease
Nursing interventions: 1. Replace adrenal hormones(lifelong): Glucocorticoid (cortisone, hydrocortisone) Mineralocorticoid (florinef) 2. Provide rest period 3. Prevent exposure to infection 4. Diet: high sodium, low potassium

Q: The nurse performing an assessment of a client who has been receiving long term steroid therapy would expect to find: a. Jaundice b. Flank pain c. Bulging eyes d. Central obesity

Adrenal Medulla
CATHECOLAMINES (Epinephrine, Norepinephrine, Dopamine) Produced by pheochromocytes Secreted in response to stress EPINEPHRINE is the major cathecolamine of the adrenal medulla NOREPINEPHRINE AND DOPAMINE are major cathecolamine neurotransmitter

Pheochromocytoma
Benign tumor of the adrenal medulla Secretes excess epinephrine and norepinephrine Assessment: 1. Hypertention Diagnostics: Vanillyl Mandelic Acid (VMA) test - uses 24 hour urine specimen Drugs: 1. Antihypertensive drugs Management: 1. Bed rest, semi fowlers to provide othostatic dec. in BP 2. Monitor VS especially BP

Pancreas
1. Insulin - Beta cells of the islets of Langerhans - Dec. serum glucose (glycogenesis)
2. Glucagon - Alpha cells of the islets of Langerhans - Inc. serum glucose (glycogenolysis)

Diabetes mellitus
Cause: Unknown Predisposing factors: Heredity, obesity, pregnancy Diagnostics: 1. FBS 80 110 mg/dL; >126 mg/dL DM 2. Oral Glucose Tolerance Test (OGTT) - 2 hr value more than 200 mg/dL DM 3. Glycosylated hemoglobin - Reflects serum glucose for the past 3 months > 7% DM

Q: A client is scheduled for a routine glycosylated hemoglobin test. What is important for the nurse to tell the client before this test? a. Drink only water after midnight and come for blood extraction early AM b. Eat normal breakfast and come back after 2 hours c. Expect to be at the clinic for several hours because of multiple blood extraction d. Come to the clinic anytime for blood extraction

Diabetes mellitus
1. Type I Insulin dependent DM - Juvenile onset - Absolute insulin deficiency, - Thin, with diabetic ketoacidosis (DKA) - Manage by diet, exercise and insulin 2. Type II Non insulin dependent DM - Maturity onset DM - With insulin resistance (low insulin) - Obese, with hyperosmolar hyperglycemia nonketotic coma (HHNC) - Manage by diet, exercise, oral hypoglycemic agents and insulin

Diabetes mellitus
Assessment: All types: polyuria, polydipsia, polyphagia, blurred vision, with glucosuria Type I weight loss Type II obese
Complications of uncontrolled DM: Macroangiopathy: CVA, MI Microangiopathy:RF, retinopathy Peripheral neuropathy (diabetic foot)

Diabetes mellitus
Nursing interventions: 1. Regular physical activity 2. Diet 50% complex CHO,30% fats, 20% CHON 3. Administer insulin or oral hypoglycemic drugs as ordered 4. Observe for signs of hyperglycemia/hypoglycemia

Comparison of DKA and Hypoglycemia

A. Hyperglycemia (DKA) Polyuria, polydipsia, polyphagia, warm flushed skin, tachycardia, Kussmauls breathing, acetone breath, altered LOC Management: Administer insulin B. Hypoglycemia (insulin shock) Diaphoresis (1st sign), restlessness, shallow respiration, cold clammy skin, tachycardia, altered LOC Management: Simple sugars (candy, honey, orange juice)

Q: What is a characteristic symptom of hypoglycemia that should alert the nurse to an early insulin reaction? a. Diaphoresis b. Drowsiness c. Severe thirst d. Coma

Insulin
1. Rapid acting clear insulin Regular, Humulin R (SQ, IV) Onset: 30 min-1 hr Peak: 2-4 hrs Duration 6-8 hrs 2. Intermediate acting cloudy NPH, Humulin N, Lente (SQ) Onset: 1-2 hrs Peak 6-8 hrs Duration: 18-24 hrs 3. Long acting cloudy Ultralente (SQ) Onset 3-4 hrs Peak 16-20 hrs Duration: 30-36 hrs 1. Usually given 20-30 min before meals

2. May be given alone or in combination

1. Hypoglycemia in mid or late afternoon

Q: A client is receiving NPH insulin at 6:00 am daily. At 2 pm the nurse finds the client apparently asleep. How would the nurse know if the client is having a hypoglycemic reaction? a. Feel the client and bed for dampness b. Observe for Kussmauls respiration c. Smell the clients breath for acetone odor d. Check the clients skin for warmth

Insulin tx: 1. Administer at the same time each day. 2. Administer insulin at RT. Cold insulin causes lipodystrophy. 3. Abdomen is the primary site for SQ. Rotate injection sites, at least 1 inch apart 4. If mixing insulin: draw up clear insulin before cloudy Oral hypoglycemic agents 1. Avoid alcohol ingestion 2. Avoid in pregnancy

Foot Care
1. Inspect feet daily, 2. Wash feet with mild soap. Dry thoroughly between the toes 3. Apply moisturizing cream to prevent drying and cracking 4. Wear properly fitted shoes. Break in new pair of shoes 1-2 hrs until comfortable 5. Use cotton socks. Do not go barefooted 6. Trim toe nails straight across.