Endocrine Flashcards by Erika Maecel Erese

The endocrine system involves the release of chemical transmitter substances known as __ .

• These substances regulate and integrate body functions by acting on local or distant target sites.

• Hormones are generally produced by the endocrine glands but may also be produced by specialized tissues such as those found in the __, __, __

• Chemicals such as neurotransmitters (e.g., __) released by the nervous system can also function as hormones when needed.

hormones

gastrointestinal (GI) system, the kidney, and white blood cells.

epinephrine

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Glands of the Endocrine System

• The endocrine system is composed of the (7)

• Most hormones secreted from endocrine glands are released directly into the __.

• However, __ glands, such as ,__ glands, secrete their products through ducts onto epithelial surfaces or into the GI tract.

pituitary gland, thyroid gland, parathyroid glands, adrenal glands, pancreatic islets, ovaries, and testes.

bloodstream

exocrine

sweat

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Function and Regulation of Hormones

• Hormones help regulate organ function in concert with the __

• The __ action by the nervous system is balanced by hormonal action.

• The endocrine glands are composed of secretory cells arranged in minute clusters known as __.

• A ___ provides a vehicle for the hormones produced by the endocrine glands to enter the bloodstream rapidly.

• In the healthy physiologic state, hormone concentration in the bloodstream is maintained at a relatively __ level.

• To prevent accumulation, these hormones must be __ continuously by a __ so that when the hormone concentration increases, further production of that hormone is inhibited.

nervous system

rapid
slower

acini

rich blood supply

constant

inactivated
negative feedback system

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Hormones are classified into four categories according to their structure:

amines and amino acids
peptides, polypeptides, proteins, and glycoproteins
steroids
fatty acid derivatives

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amines and amino acids (e.g., __,__, __);
peptides, polypeptides, proteins, and glycoproteins (e.g., __,__,__)
steroids (e.g., __; which are hormones produced by the __ or their synthetic equivalents)
fatty acid derivatives (e.g., __,__)

epinephrine, norepinephrine, and thyroid hormones

thyrotropin-releasing hormone [TRH],
follicle-stimulating hormone [FSH], and growth hormone [GH]);

corticosteroids,
adrenal cortex

eicosanoid, retinoids

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Some hormones act locally in the area where they are released; this is called ___
(e.g., the effect of __).

paracrine action
sex hormones on the ovaries

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Others may act on the actual cells from which they were released; this is called
(e.g., the effect of __).

autocrine action

insulin from pancreatic beta cells on those cells

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Hormones can alter the function of the target tissue by interacting with __ located either on the cell membrane or in the interior of the cell (e.g. __ or __ for peptide and protein hormones).

___, because of their smaller size and higher lipid solubility, penetrate cell membranes and interact with intracellular receptors.

chemical receptors
cyclic AMP or the “second messenger”

Steroid hormones

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• Releasing and inhibiting hormones
• Controls the release of pituitary hormones

HYPOTHALAMUS

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Hypothalamus hormones (4)

Corticotropin-releasing hormone (CRH)
Thyrotropin-releasing hormone (TRH)
Growth hormone–releasing hormone (GHRH)
Gonadotropin–releasing hormone (GnRH)

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Anterior pituitary hormone

Give 5

Somatostatin

Adrenocorticotropic hormone (ACTH)

Follicle-stimulating hormone (FSH)

Luteinizing hormone (LH)

Prolactin

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• Inhibits growth hormone and thyroid-stimulating hormone

Somatostatin

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• Stimulates synthesis and secretion of adrenal cortical hormones

Adrenocorticotropic hormone (ACTH)

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• Female: stimulates growth of ovarian follicle, ovulation
• Male: stimulates sperm production

Follicle-stimulating hormone (FSH)

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• Female: stimulates development of corpus luteum, release of oocyte, production of estrogen and progesterone
• Male: stimulates secretion of testosterone, development of
interstitial tissue of testes

Luteinizing hormone (LH)

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• Prepares female breast for breast-feeding

Prolactin

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Posterior pituitary hormone

Adh

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• Increases water reabsorption by kidney

Antidiuretic hormone (ADH)

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ADRENAL CORTEX hormones 2

Mineralocorticosteroids, mainly aldosterone

Glucocorticoids, mainly cortisol

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__
• Increase sodium absorption
• potassium loss by kidney

__
• Affect metabolism of all nutrients;
• regulates blood glucose levels,
• affects growth,
• has anti-inflammatory action, and
• decreases effects of stress.

Mineralocorticosteroids, mainly aldosterone

Glucocorticoids, mainly cortisol

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THYROID (__)

Thyroid hormones: 2

FOLLICULAR CELLS

triiodothyronine (T3), and thyroxine (T4)

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• Increase the metabolic rate;
• increase protein and bone turnover;
• increase responsiveness to catecholamines;
• necessary for fetal and infant growth and development

Thyroid hormones: triiodothyronine (T3), and thyroxine (T4)

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Lowers blood calcium and phosphate levels

Calcitonin

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THYROID C CELLS hormone

Calcitonin

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• Regulates serum calcium

Parathormone (PTH, parathyroid hormone)

PANCREATIC ISLET CELLS Give 3

Insulin Glucagon Somatostatin

• Lowers blood glucose by facilitating glucose transport across cell membranes of muscle, liver, and adipose tissue

Insulin

• Increases blood glucose concentration by stimulation of glycogenolysis and glyconeogenesis

Glucagon

• Delays intestinal absorption of glucose

Somatostatin

KIDNEY hormone

Renin

Activates renin–angiotensin–aldosterone system

Renin

OVARIES hormones TESTES hormones

Estrogen Progesterone Androgens, mainly testosterone

• Affects development of female sex organs and secondary sex characteristics

Estrogen

• Influences menstrual cycle; stimulates growth of uterine wall; maintains pregnancy

Progesterone

• Affect development of male sex organs and secondary sex characteristics; aid in sperm production

Androgens, mainly testosterone

Assessment 1. Health History - Patients should be asked if they have experienced changes in Give 5

in energy level, tolerance to heat or cold, weight, thirst, frequency of urination, fat and fluid distribution, secondary sexual characteristics such as loss or growth of hair, menstrual cycle, memory, concentration, sleep patterns, and mood, as well as vision changes, joint pain, and sexual dysfunction.

- It is important to document Give 3

(1) the severity of these changes, (2) the length of time the patient has experienced these changes, (3) the way in which these changes have affected the patient’s ability to carry out activities of daily living, (4) the effect of the changes on the patient’s selfperception, and (5) family history

2. Physical Assessment Give 2

- should include vital signs; head-to-toe inspection; and palpation of skin, hair, and thyroid. Findings should be compared with previous findings, if available. - Physical, psychological, and behavioral changes should be noted. - The patient may also exhibit changes in mood and behavior such as nervousness, lethargy, and fatigue.

Diagnostic Evaluation Give 2

1. Blood Tests 2. Urine Tests

- determine the levels of circulating hormones, the presence of autoantibodies, and the effect of a specific hormone on other substances. - The __ of a specific hormone may provide information to determine the presence of hypofunction or hyperfunction.

1. Blood Tests serum levels

- used to measure the amount of hormones or the end products of hormones excreted by the kidneys. - __ or, in some disorders, ___ are collected to measure hormones or their metabolites.

2. Urine Tests One-time specimens 24-hour urine specimens

Additional Diagnostic Studies Give 4

1. Stimulation tests 2. Suppression tests 3. Imaging studies 4. Genetic screening

- used to confirm hypofunction of an endocrine organ. - The tests determine how an endocrine gland responds to the administration of stimulating hormones that are normally produced or released by the hypothalamus or pituitary gland.

1. Stimulation tests

- used to detect hyperfunction of an endocrine organ. - They determine if the organ is not responding to the negative feedback mechanisms.

2. Suppression tests

- include radioactive scanning, MRI, CT, ultrasonography, PET and dual-energy x-ray absorptiometry (DEXA).

3. Imaging studies

- DNA testing can be used for the identification of specific genes associated with endocrine disorders

4. Genetic screening

, is commonly referred to as the master gland because of the influence it has on secretion of hormones by other endocrine glands.

The pituitary gland, or hypophysis

It is located on the __ of the brain and is divided into anterior and posterior lobes It is controlled by the __, which is an adjacent area of the brain that is connected to the pituitary by the pituitary stalk.

inferior aspect hypothalamus

Anterior Pituitary • The major hormones of the anterior pituitary gland are: 6 • The secretion of these major hormones is controlled by releasing factors secreted by the __. • These releasing factors reach the anterior pituitary by way of the bloodstream in a special circulation called the __ • Other hormones include __ & __ • The hormones released by the anterior pituitary enter the general circulation and are transported to their target organs. • The main function of __, __ ,__ ,__ is the release of hormones from other endocrine glands. • __ acts on the breast to stimulate milk production. • __ , the most abundant anterior pituitary hormone, regulates growth in children and energy and metabolism in adults. • __ increases protein synthesis in many tissues, increases the breakdown of fatty acids in adipose tissue, and increases blood glucose levels. • Secretion of GH is increased by (3)

FSH, luteinizing hormone (LH), prolactin (PRL), adrenocorticotropic hormone (ACTH), thyroid-stimulating hormone (TSH), and GH (also referred to as somatotropin). hypothalamus pituitary portal blood system. melanocyte-stimulating hormone and beta-lipotropin. TSH, ACTH, FSH, and LH PRL GH GH deep sleep, stress, exercise, fasting, malnutrition, hypoglycemia, trauma, hypovolemic shock, and sepsis, and is decreased in the presence of obesity, depression, and hypothyroidism.

Posterior Pituitary • The important hormones secreted by the posterior lobe of the pituitary gland are ___, also referred to as __, and ___.

Vasopressin antidiuretic hormone (ADH) Oxytocin

__ controls the excretion of water by the kidney; its secretion is stimulated by an increase in the osmolality of the blood or by a decrease in blood pressure.

Vasopressin

__ secretion is stimulated during pregnancy and at childbirth. It facilitates milk ejection during lactation and increases the force of uterine contractions during labor and delivery.

Oxytocin

Pathophysiology – pituitary gland • Abnormalities of pituitary function are caused by __ or __ of any of the hormones produced or released by the gland. • Abnormalities of the anterior and posterior portions of the gland may occur independently. • Hypofunction of the pituitary gland (__) can result from disease of the pituitary gland itself or disease of the hypothalamus. • it can result from __ to the head and neck area. • The total destruction of the pituitary gland by trauma, tumor, or vascular lesion removes all stimuli that are normally received by the __,__,__ • The result is (3) • Coma and death occur if the __

over-secretion or under-secretion (hypopituitarism) radiation therapy thyroid, the gonads, and the adrenal glands. extreme weight loss, emaciation, atrophy of all endocrine glands and organs, hair loss, impotence, amenorrhea, hypometabolism, and hypoglycemia. missing hormones are not replaced.

Pathophysiology - Anterior Pituitary • Oversecretion (hypersecretion) of the anterior pituitary gland • __ - group of symptoms produced by an oversecretion of ACTH. • __ - a disorder caused by an excess of GH in __, results in enlargement of peripheral body parts and soft tissue, __ the fusion of the epiphyseal plates has occurred, without an increase in _. • Oversecretion of GH in __, __ the fusion of epiphyseal growth plates result in ___ (7 or even 8 ft tall). • Insufficient secretion of GH during childhood can result in generalized limited growth and ___. • __ may result from destruction of the anterior lobe of the pituitary gland.

Cushing syndrome Acromegaly adults after height children Before pituitary gigantism pituitary dwarfism Hypopituitarism

Pathophysiology - Posterior Pituitary • The most common disorder related to posterior lobe dysfunction is __ (abnormally large volumes of dilute urine are excreted as a result of deficient production of __).

diabetes insipidus (DI) vasopressin

• Almost all pituitary tumors are __. • The tumors may be __ or __ and __ or __

benign primary or secondary functional or nonfunctional.

• Three principal types of pituitary tumors represent an overgrowth of

(1) Eosinophilic cells, (2) Basophilic cells, or (3) Chromophobic cells.

• Functional tumors secrete __, whereas nonfunctional tumors secrete _

pituitary hormones None

__ tumors that develop early in life result in __ • If the disorder begins during adult life __ • Many suffer from __ & __ because the tumors exert pressure on the optic nerves. • Decalcification of the skeleton, muscular weakness, and endocrine disturbances, similar to those occurring in patients with ___.

Eosinophilic gigantism acromegaly severe headaches and visual disturbances hyperthyroidism

Basophilic tumors give rise to __

Cushing syndrome

___ tumors represent 90% of pituitary tumors.

Chromophobic

more than 7 ft tall and large in all proportions, yet so weak and lethargic excessive skeletal growth in feet, hands, molar eminences, the nose, and the chin.

gigantism acromegaly

hyperadrenalism, masculinization and amenorrhea in females, truncal obesity, hypertension, osteoporosis, and polycythemia.

Cushing syndrome

___ tumors give rise to cushing syndrome

Basophilic

• __ tumors usually produce no hormones but destroy the rest of the pituitary gland, causing __. • Patients are often: give 4

Chromophobic hypopituitarism obese and somnolent and exhibit fine, scanty hair; dry, soft skin; a pasty complexion; and small bones. • They also experience headaches, loss of libido, and visual defects progressing to blindness. • Other signs and symptoms include polyuria, polyphagia, a lowering of the basal metabolic rate and a subnormal body temperature.

Assessment and Diagnostic Findings Diagnostic evaluation requires a careful history and physical examination, including assessment of visual acuity and visual fields. • __ & __ are used to diagnose the presence and extent of pituitary tumors. • Serum levels of pituitary hormones may be obtained along with measurements of hormones of target organs (e.g., __, __) to assist in diagnosis.

CT and MRI scans thyroid, adrenal

Medical Management __ - surgical removal of the pituitary gland. __ - external-beam radiation therapy precisely to the pituitary tumor with minimal effect on normal tissue. • Replacement therapy with __ & __ is necessary.

Hypophysectomy Stereotactic radiation therapy corticosteroids and thyroid hormone

• Other treatments include conventional radiation therapy, bromocriptine (__, a dopamine antagonist), and octreotide (__ , a synthetic analog of GH). • Octreotide and lanreotide (__, a somatostatin analog) may also be used preoperatively to improve the patient’s clinical condition and to shrink the tumor.

Parlodel Sandostatin Somatuline Depot

• a deficiency of ADH (vasopressin). • It may occur secondary to head trauma, brain tumor, or surgical ablation or irradiation of the pituitary gland. • It may also occur with infections of the central nervous system (give 2) or with ___. • Another cause of DI is failure of the __ to respond to ADH.

Diabetes Insipidus meningitis, encephalitis, tuberculosis Tumors renal tubules

Clinical Manifestations of di

• An enormous daily output (greater than 250 mL per hour) of very dilute urine with a specific gravity of 1.001 to 1.005. • The urine contains no abnormal substances such as glucose or albumin. • Excessive thirst - 2 to 20 L of fluid daily and craves cold water.

Assessment and Diagnostic Findings 1. __ - carried out by withholding fluids for 8 to 12 hours or until 3% to 5% of the body weight is lost. • The patient is ___ frequently during the test. • ___ are performed at the beginning and end of the test. • The inability to increase the specific __& __ of the urine is characteristic of DI • The patient continues to excrete large volumes of urine with __ specific gravity and experiences weight loss. • The test is terminated if __, __,__ develops 2. Other diagnostic procedures include: 4

Fluid deprivation test weighed Plasma and urine osmolality studies gravity and osmolality low tachycardia, excessive weight loss, or hypotension develops. a. plasma levels of ADH b. plasma and urine osmolality c. trial of desmopressin (synthetic vasopressin) therapy d. intravenous (IV) infusion of hypertonic saline solution.

Medical Management 1. Pharmacologic Therapy a. __ - a synthetic vasopressin without the vascular effects of natural ADH. - given ___; the patient sprays the solution into the nose through a flexible calibrated plastic tube. - ___ administrations daily. - Vasopressin causes ___; thus, it must be used cautiously in patients with ___. b. (Diabinese) and __ - used in __ forms of the disease because they potentiate the action of __. - is possible. c. Thiazide diuretics, mild salt depletion, and prostaglandin inhibitors - used to treat the ___ of DI.

Desmopressin (DDAVP) intranasally One or two vasoconstriction coronary artery disease Chlorpropamide and thiazide diuretics mild vasopressin Hyperglycemia nephrogenic form

• excessive ADH secretion from the pituitary gland. • Patients cannot excrete a dilute urine, retain fluids, and develop a sodium deficiency known as __ • SIADH is often of nonendocrine origin (__). • Can be caused by disorders of the __, such as head injury, brain surgery or tumor, and infection.

Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH) dilutional hyponatremia bronchogenic carcinoma central nervous system

Medical Management • Interventions include eliminating the underlying cause, if possible, and ___ • Diuretic agents such as ___ may be used along with fluid restriction if severe ___ is present.

restricting fluid intake. furosemide hyponatremia

The __ —the largest endocrine gland—is a butterfly-shaped organ located in the lower neck, anterior to the trachea. • It consists of __ lateral lobes connected by an __. • The gland is about 5 cm long and 3 cm wide and weighs about 30 g. • The blood flow to the thyroid is very __, approximately five times the blood flow to the __. • The thyroid gland produces three hormones:

thyroid gland two isthmus high liver thyroxine (T4), triiodothyronine (T3), and calcitonin.

• Thyroid hormone is comprised of __ & __. Both are amino acids that contain __ bound to the amino acid structure. • These hormones are synthesized and stored bound to __ in the cells of the __.

T4 and T3 iodine molecules proteins thyroid gland

Synthesis of Thyroid Hormone • __ is essential to the thyroid gland for synthesis of its hormones. • The major use of iodine in the body is by the __, and the major derangement in iodine deficiency is __. • __ is ingested in the diet and absorbed into the blood in the GI tract. • __ are converted to __, which react with __ (an amino acid) to form the ___

Iodine thyroid alteration of thyroid function Iodide Iodide ions iodine molecules tyrosine thyroid hormones.

Regulation of Thyroid Hormone • The secretion of T3 and T4 is controlled by __ (also called ___) from the ___ pituitary gland. • TSH controls the rate of thyroid hormone release through a • The term __ refers to thyroid hormone production that is normal. • __, secreted by the __, exerts a modulating influence on the release of TSH from the pituitary

TSH thyrotropin anterior negative feedback mechanism euthyroid TRH hypothalamus

Function of Thyroid Hormone • The main function of thyroid hormone is to control __ • __, a relatively weak hormone, maintains body metabolism in a steady state. • __ is about five times as potent and has a more rapid metabolic action. These hormones accelerate __ by increasing the level of specific enzymes that contribute to __ consumption and altering the __ of tissues to other hormone • The thyroid hormones influence __ and are important in __ development. • Thyroid hormone is also necessary for __

cellular metabolic activity T4 T3 metabolic processes oxygen responsiveness cell replication brain normal growth.

is secreted in response to high plasma levels of calcium, and it reduces the plasma level of calcium by increasing its deposition in bone.

Calcitonin, or thyrocalcitonin,

Inadequate secretion of thyroid hormone during fetal and neonatal development results in intellectual disability and stunted physical growth (___) because of general depression of metabolic activity. • In adults, hypothyroidism manifests as (3) • Oversecretion of thyroid hormones (__) is manifested by a greatly increased metabolic rate (usually associated with an enlarged thyroid gland known as a __).

congenital hypothyroidism lethargy, slow mentation, weight gain, constipation, cold intolerance, and generalized slowing of body functions. Hyperthyroidism goiter

Thyroid Diagnostic Evaluation: give 8

1. Serum Thyroid-Stimulating Hormone - 2. Serum Free T4 - 3. Serum T3 and T4 - 4. T3 Resin Uptake Test - 5. Thyroid Antibodies - 6. Radioactive Iodine Uptake - 7. Fine-Needle Aspiration Biopsy - 8. Thyroid Scan, Radioscan, or Scintiscan - 9. Serum Thyroglobulin -

- Measurement of the serum TSH concentration is the primary screening test of thyroid function.

1. Serum Thyroid-Stimulating Hormone

- a direct measurement of free (unbound) thyroxine, the only metabolically active fraction of T4. The range of free T4 in serum is normally 0.9 to 1.7 ng/dL (11.5 to 21.8 pmol/L).

2. Serum Free T4

- includes protein-bound and free hormone levels that occur in response to TSH secretion. Normal range for T4 is 5.4 to 11.5 μg/dL (57 to 148 nmol/L). The normal range for serum T3 is 80 to 200 ng/dL (1.2 to 3.1 nmol/L)

3. Serum T3 and T4

- an indirect measure of unsaturated TBG. Its purpose is to determine the amount of thyroid hormone bound to TBG and the number of available binding sites. The normal T3 uptake value is 25% to 35%.

4. T3 Resin Uptake Test

- immunoassay techniques for antithyroid antibodies. Positive in chronic autoimmune thyroid disease (90%), Hashimoto thyroiditis (100%), Graves disease (80%).

5. Thyroid Antibodies

- measures the rate of iodine uptake by the thyroid gland. The patient is given a tracer dose of iodine 123 (123I) or another radionuclide. Patients with hyperthyroidism exhibit a high uptake of the 123I and vice versa.

6. Radioactive Iodine Uptake

- The use of a small-gauge needle to sample the thyroid tissue for biopsy is a safe and accurate method of detecting malignancy.

7. Fine-Needle Aspiration Biopsy

- helpful in determining the location, size, shape, and anatomic function of the thyroid gland, particularly when thyroid tissue is substernal or large.

8. Thyroid Scan, Radioscan, or Scintiscan

Thyroglobulin (Tg) can be measured reliably in the serum by radioimmunoassay. Clinically, it is used to detect persistence or recurrence of thyroid carcinoma

Serum Thyroglobulin

Nursing Implications • When __ are scheduled, it is necessary to determine if the patient is allergic to iodine (__) and whether the patient has taken medications or agents that contain iodine. • Obvious sources of iodine-containing medications include __ and those used to treat thyroid disorders such as __. • Less obvious sources of iodine are __; __ preparations; food supplements that may contain _ and _ (frequently found in health food stores); and __ (Cordarone), an antiarrhythmic agent. • Other medications that may affect test results are _,_ , amphetamines, chemotherapeutic agents, _, _, and diuretics.

thyroid tests (shellfish) contrast agents radioactive iodine topical antiseptics multivitamin Kelp and seaweed amiodarone estrogens salicylates antibiotics corticosteroids

•__ results from suboptimal levels of thyroid hormone. • The most common cause in adults is autoimmune thyroiditis (__), in which the immune system attacks the thyroid gland • Hypothyroidism also occurs in patients with previous hyperthyroidism that has been treated with __ or __ medications or __.

Hypothyroidism Hashimoto disease radioiodine, antithyroid thyroidectomy

• Causes of Hypothyroidism: Give 5

1. Autoimmune disease (Hashimoto thyroiditis, post-Graves disease) 2. Atrophy of thyroid gland with aging 3. Therapy for hyperthyroidism a. Radioactive iodine (131I) b. Thyroidectomy 4. Medications a. Lithium b. Iodine compounds c. Antithyroid medications 5. Radiation to head and neck in treatment for head and neck cancers, lymphoma 6. Infiltrative diseases of the thyroid (amyloidosis, scleroderma, lymphoma) 7. Iodine deficiency and iodine excess

Clinical Manifestations of hypothyroidism give 5

Extreme fatigue • Hair loss, brittle nails, and dry skin • Numbness and tingling of the fingers • The voice may become husky, presence of hoarseness. • Menstrual disturbances such as menorrhagia or amenorrhea, loss of libido. • Severe hypothyroidism results in a subnormal body temperature and pulse rate. • Weight even without an increase in food intake. • Face becomes expressionless and masklike. • Cold intolerance • Mental processes become dulled, and the patient appears apathetic. • Speech is slow, the tongue enlarges, the hands and feet increase in size, and deafness may occur. • The patient frequently reports constipation. • Advanced hypothyroidism may produce personality and cognitive changes characteristic of dementia. • Inadequate ventilation and sleep apnea can occur with severe hypothyroidism. • Severe hypothyroidism is associated with an elevated serum cholesterol level, atherosclerosis, coronary artery disease, and poor left ventricular function. • Myxedema - swelling of the face and swelling and thickening of skin anywhere on your body. • Myxedema coma – a decompensated state of severe hypothyroidism in which the patient is hypothermic and unconscious.

• ___ - swelling of the face and swelling and thickening of skin anywhere on your body.

Myxedema

– a decompensated state of severe hypothyroidism in which the patient is hypothermic and unconscious.

• Myxedema coma

Medical Management hypothyroidism 1. Pharmacologic Therapy (4) 2. Supportive Therapy (3)

a. Synthetic levothyroxine (Synthroid or Levothroid) b. High-dose glucocorticoids (hydrocortisone) c. Prevention of Cardiac Dysfunction d. Prevention of Medication Interactions - Assisted ventilation to combat hypoventilation. - Oxygen saturation levels should be monitored using pulse oximetry. - Fluids are given cautiously because of the danger of water intoxication.

- commonly prescribed for treating hypothyroidism and suppressing nontoxic goiters. - every 8 to 12 hours for 24 hours followed by lowdose therapy is recommended until coexisting adrenal insufficiency is ruled out.

Synthetic levothyroxine (Synthroid or Levothroid) High-dose glucocorticoids (hydrocortisone)

Serum levels of __,__,__ should be obtained before and after administration of ACTH and before administration of glucocorticoid and thyroid hormone therapies. c. Prevention of Cardiac Dysfunction – if angina or dysrhythmias occur, __ administration must be discontinued immediately.

T4, TSH, and cortisol thyroid hormone

There is a decrease in thyroid hormone absorption when patients are taking __ containing antacids. - Thyroid hormones may also decrease the pharmacologic effects of __ - Doses of __ agents need to be decreased when beginning thyroid replacement because of the increased risk of bleeding. - __ & __ agents may induce profound somnolence, lasting far longer than anticipated and leading to __ (stupor like condition).

magnesium digitalis glycosides. anticoagulant Hypnotic and sedative narcosis

• A form of thyrotoxicosis resulting from an excessive synthesis and secretion of endogenous or exogenous thyroid hormones by the thyroid. • The most common causes are __, toxic multinodular __, and toxic __. • Other causes include thyroiditis and excessive ingestion of thyroid hormone.

Hyperthyroidism Graves disease goiter adenoma

Hyperthyroidism Clinical Manifestations give 5

• The presenting symptom is often nervousness. • These patients are often emotionally hyperexcitable, irritable, and apprehensive; they cannot sit quietly; they suffer from palpitations; and their pulse is abnormally rapid at rest as well as on exertion. • They tolerate heat poorly and perspire unusually freely. • The skin is flushed continuously, with a characteristic salmon color in Caucasians, and is likely to be warm, soft, and moist. • A fine tremor of the hands may be observed. • Patients may exhibit as exophthalmos (abnormal protrusion of one or both eyeballs), which produces a startled facial expression. • Other manifestations include an increased appetite and dietary intake, weight loss, fatigability and weakness, amenorrhea, and changes in bowel function. • Cardiac effects may include sinus tachycardia or dysrhythmias, increased pulse pressure, and palpitations. • Myocardial hypertrophy and heart failure may occur if the hyperthyroidism is severe and untreated. • It is also likely to result in premature osteoporosis, particularly in women

Assessment and Diagnostic Findings • The thyroid gland is __ • It is soft and may __; a __ often can be palpated, and a __ is heard over the thyroid arteries. • In advanced cases, the diagnosis is made on the basis of the symptoms, a decrease in __, increased __, and an increase in __.

enlarged pulsate thrill bruit serum TSH free T4 radioactive iodine uptake

Medical Management Treatment of hyperthyroidism is directed toward reducing thyroid __ to relieve symptoms and preventing complications. 1. Pharmacologic Therapy (2) c. Surgical Management (1)

hyperactivity Radioactive Iodine Therapy Antithyroid medications Thyroidectomy

- used to treat toxic adenomas, toxic multinodular goiter, and most varieties of thyrotoxicosis. - __ - given 4 to 6 weeks prior to administration of radioactive iodine. - contraindicated during pregnancy because it crosses the __. - thyroid cells exposed to the __ are destroyed, resulting in reduction of the hyperthyroid state and inevitably hypothyroidism. - ___ is started 4 to 18 weeks after the antithyroid medications have been stopped based on the results of thyroid function tests. - Once a normal thyroid state has been established, TSH should be measured every __ - Patients should be informed that they can contaminate their household and other persons through saliva, urine, or radiation emitting from their body. - The patient is observed for signs of __

Radioactive Iodine Therapy Methimazole placenta radioactive iodine Thyroid hormone replacement 6 to 12 months for life. thyroid storm.

__ - inhibit one or more stages in thyroid hormone synthesis or hormone release. - take the medication in the __ on an empty stomach __ minutes before eating to avoid decrease in absorption. - it may take several ___ until symptom relief occurs. Toxic complications of antithyroid medications are relatively __. - With any sign of infection, especially __ and __ or the occurrence of __, the patient is advised to __ the medication. - __ is recommended during the first trimester of pregnancy rather than __ due to the teratogenic effects - it should be discontinued __ trimester and the patient should be switched to MMI for the __ of the pregnancy and when __. - Discontinuation of antithyroid medications before therapy is complete usually results in relapse within ___.

Antithyroid Medications morning 30 mins weeks uncommon pharyngitis fever mouth ulcers stop PTU MMI after the first trimester remainder breast feeding 6 months

Surgical Management of hyperthyroidism – - reserved for special circumstances (__ who are __ to antithyroid medications, in patients with _, or in patients who are unable to take antithyroid agents. - ___, an antithyroid medication is given until signs of hyperthyroidism have disappeared. - Medications that may prolong clotting (e.g., __) are stopped several __ before surgery. - Patients receiving iodine medication must be monitored for evidence of iodine toxicity (_), which requires immediate withdrawal of the medication. - Symptoms of iodinism include: (2)

Thyroidectomy (total, subtotal pregnant women allergic Large goiter Before surgery aspirin weeks (iodinism) swelling of the buccal mucosa, excessive salivation, cold symptoms, and skin eruptions.

NURSING DIAGNOSES (2)

• Imbalanced nutrition: less than body requirements related to exaggerated metabolic rate, excessive appetite, and increased GI activity. • Ineffective coping related to irritability, hyperexcitability, apprehension, and emotional instability • Situational low self-esteem related to changes in appearance, excessive appetite, and weight loss • Risk for imbalanced body temperature

Nursing Interventions hyperthyroidism • IMPROVING NUTRITIONAL STATUS - To reduce diarrhea, highly seasoned foods and stimulants such as __ are discouraged. - foods high in __ & __ are encouraged. __ and dietary intake are recorded to monitor nutritional status. • ENHANCING COPING MEASURES - Stressful experiences should be minimized and a quiet, uncluttered environment should be maintained. - It is important to balance periods of activity with __. • IMPROVING SELF-ESTEEM • MAINTAINING NORMAL BODY TEMPERATURE - the environment should be maintained at a cool, comfortable temperature, and the bedding and clothing should be changed as needed. - Cool baths and cool or cold fluids may also provide relief. • MONITORING AND MANAGING POTENTIAL COMPLICATIONS (3)

coffee, tea, cola, and alcohol High calorie, high protein Weight rest - Thyrotoxicosis or thyroid storm - Hypothyroidism

Nursing Interventions for hyperthyroidism

• IMPROVING NUTRITIONAL STATUS • ENHANCING COPING MEASURES • IMPROVING SELF-ESTEEM • MAINTAINING NORMAL BODY TEMPERATURE • MONITORING AND MANAGING POTENTIAL COMPLICATIONS

2 types of Thyroid Tumors

• Endemic (Iodine-Deficient) Goiter • Nodular Goiter

• __ is a compensatory hypertrophy of the thyroid gland, caused by stimulation by the pituitary gland. • occurs when iodine intake is __ • __ has also been found to also have antithyroid actions. • usually causes no symptoms, except for the swelling in the __, which may result in tracheal compression when excessive swelling is present. • recedes after the __ is corrected. • Supplementary iodine, such as ___, is prescribed to suppress the pituitary’s thyroid-stimulating activity. • The introduction of __ has been the single most effective means of preventing goiter in at-risk populations.

Endemic (Iodine-Deficient) Goiter deficient Lithium neck iodine imbalance SSKI iodized salt

__ Some thyroid glands are __ because of areas of hyperplasia (overgrowth). No symptoms may arise as a result of this condition, but can cause __ pressure symptoms. Some nodules become __, and some are associated with a __ state. Therefore, the patient with many thyroid nodules may eventually require __.

Nodular Goiter nodular local malignant hyperthyroid surgery

THE PARATHYROID GLANDS Anatomic and Physiologic Overview • The parathyroid glands (normally __) are situated in the __ and embedded in the posterior aspect of the thyroid gland. • Parathormone (parathyroid hormone) - regulates __ metabolism. • Increased secretion of parathormone results in increased calcium absorption from the __,__,__ • Some actions of parathormone are increased by the presence of __. • The serum level of ionized calcium regulates the output of parathormone. • Increased serum calcium results in decreased __, creating a __

four neck calcium and phosphorus kidney, intestine, and bones. vitamin D parathormone secretion negative feedback system.

• caused by overproduction of parathormone by the parathyroid glands. • characterized by bone __ and the development of __ (kidney stones) containing __. • Primary hyperparathyroidism occurs two to four times more often in __ than in __ and is most common in people between __ & __ years of age. • __ occurs in patients who have chronic kidney failure and so-called __ as a result of phosphorus retention, increased stimulation of the parathyroid glands, and increased parathormone secretion.

Hyperparathyroidism (Increase Parathormone) decalcification renal calculi calcium women than in men 60 and 70 Secondary hyperparathyroidism renal rickets

CLINICAL MANIFESTATIONS hyperparathyroidism Give 4

• The patient may have no symptoms or may experience signs and symptoms resulting from involvement of several body systems • Apathy, fatigue, muscle weakness, nausea, vomiting, constipation, hypertension, and cardiac dysrhythmias may occur. • Psychological effects may vary from irritability and neurosis to psychoses. • Formation of stones in one or both kidneys (nephrolithiasis). • The patient may develop skeletal pain and tenderness, especially of the back and joints; pain on weight bearing; pathologic fractures; deformities; and shortening of body stature. • The incidence of peptic ulcer and pancreatitis is increased with hyperparathyroidism.

• Formation of stones in one or both kidneys .

(nephrolithiasis)

ASSESSMENT AND DIAGNOSTIC FINDINGS hyperparathyroidism • diagnosed by persistent elevation of levels and an elevated concentration of __. • __ for parathormone are sensitive and differentiate primary hyperparathyroidism from other causes. • Bone changes may be detected on __ in advanced disease. • The __ is used to distinguish between primary hyperparathyroidism and malignancy as a cause of hypercalcemia. • __,__,__,__ have been used to evaluate the function of the parathyroids and to localize parathyroid cysts, adenomas, or hyperplasia.

serum calcium parathormone Radioimmunoassays x-ray or bone scans double-antibody parathyroid hormone test Ultrasound, MRI, thallium scan, and fine-needle biopsy

Medical Management hyperparathyroidism

1. Surgical Management b. Hydration Therapy c. Mobility d. Diet and Medications

Medical Management hyperparathyroidism 1. Surgical Management – __ - surgical removal of abnormal parathyroid tissue - recommended for asymptomatic patients who meet one or more of the following criteria: a) younger than __ years b) any patient unable or unlikely to participate in follow up care c) serum calcium level more than _ mg/dL (0.25 mmol/L) above normal reference range d) GFR __ < mL/min e) urinary calcium level greater than 400 mg/day (10 mmol/day f) bone density at hip, lumbar spine, or distal radius with T score < -2.5 or previous fracture fragility at any site g) nephrolethiasis or nephrocalcinosis b. Hydration Therapy - daily fluid intake of ___ ml or more is encouraged to help prevent calculus formation. The patient is instructed to report other manifestations of renal calculi, such as abdominal pain and hematuria. - __ are avoided. - Because of the risk of hypercalcemic crisis, the patient is instructed to avoid __ and to seek immediate health care if conditions that commonly produce dehydration (e.g., vomiting, diarrhea) occur. c. Mobility - The patient with limited mobility is encouraged to __. - __ increases calcium excretion and the risk of renal calculi. d. Diet and Medications - patient is advised to avoid a diet with restricted or excess __. - If the patient has a coexisting peptic ulcer, prescribed __ and protein feedings are necessary. - Because __ is common, efforts are made to improve the appetite. - __, stool softeners, and physical activity, along with increased fluid intake, help offset constipation, which is common postoperatively.

parathyroidectomy 50 1 60 2,000 mL Thiazide diuretics dehydration walk Bed rest calcium antacids anorexia Prune juice

What is the complication of hyperparathyroidism

Hypercalcemic crisis

Complications: hyperparathyroidism • __ can occur with extreme elevation of serum calcium levels. • Serum calcium levels greater than __mg/dL (3.25 mmol/L) result in neurologic, cardiovascular, and kidney symptoms that can be life threatening. • Rapid rehydration with large volumes of IV isotonic saline fluids to maintain urine output of _ to _ per hour is combined with administration of calcitonin. • __ promotes renal excretion of excess calcium and reduces bone resorption. • The saline infusion should be stopped and a loop diuretic may be needed if the patient develops __. • __ are added to promote a sustained decrease in serum calcium levels by promoting calcium deposition in bone and reducing the GI absorption of calcium. • _,_,_ may be used in emergency situations to decrease serum calcium levels quickly. • A combination of _&_ is given in emergencies to reduce the serum calcium level by increasing calcium deposition in bone.

Hypercalcemic Crisis 13 mg/dl 100 to 150 mL Calcitonin edema Bisphosphonates Cytotoxic agents, calcitonin, and dialysis calcitonin and corticosteroids

• __ inadequate secretion of parathormone • caused by abnormal parathyroid development, destruction of the parathyroid glands (__ or __), and vitamin D deficiency. • The most common cause is the near-total removal of the __. • Deficiency of parathormone results in increased blood __ and decreased ___ levels. • there is __ of dietary calcium and ___ of calcium from bone and through the renal tubules. • Decreased renal excretion of phosphate causes __, and low serum calcium levels result in __.

Hypoparathyroidism surgical removal or autoimmune response thyroid gland phosphate (hyperphosphatemia) blood calcium (hypocalcemia) decreased intestinal absorption decreased resorption hypophosphaturia hypocalciuria

Clinical Manifestations • Hypocalcemia causes irritability of the neuromuscular system and contributes to the chief symptom of hypoparathyroidism— __. • it is general muscle __, with tremor and spasmodic or uncoordinated contractions occurring with or without efforts to make voluntary movements. • Symptoms of latent tetany are numbness, tingling, and cramps in the extremities, and the patient complains of stiffness in the hands and feet. • In __, the signs include bronchospasm, laryngeal spasm, carpopedal spasm (flexion of the elbows and wrists and extension of the carpophalangeal joints and dorsiflexion of the feet), dysphagia, photophobia, cardiac dysrhythmias, and seizures. • Other symptoms include anxiety, irritability, depression, and even delirium. __ changes and __ also may occur.

tetany hypertonia overt tetany ECG hypotension

Assessment and Diagnostic Finding in hypothyroidism (5)

• Chvostek sign • Trousseau sign • Tetany • Serum phosphate levels are increased x-rays of bone show increased density. • Calcification is detected on x-rays paraspinal basal ganglia of the brain

- positive when a sharp tapping over the facial nerve just in front of the parotid gland and anterior to the ear causes spasm or twitching of the mouth, nose, and eye.

Chvostek sign

- positive when carpopedal spasm is induced by occluding the blood flow to the arm for 3 minutes with a blood pressure cuff

• Trousseau sign

develops at very low serum calcium levels.

Tetany

• The diagnosis of hypoparathyroidism often is difficult because of the vague symptoms, such as • Serum __ levels are increased, and x-rays of bone show increased __. • __ is detected on x-rays of the subcutaneous or paraspinal basal ganglia of the brain

aches and pains. Serum phosphate levels density Calcification

Medical Management hypoparathyroidism • The goal of therapy is to increase the serum calcium level to __ to __ mg/dL (2.2 to 2.5 mmol/L) and to eliminate the symptoms of hypoparathyroidism and hypocalcemia. • Treatment may include combinations of __,__,__,_, (ergocalciferol) or vitamin D3 (calcitriol). • A __ may be given to help decrease urinary calcium excretion. • ___ has been approved for the treatment of osteoporosis but not for hypoparathyroidism at this time. • When hypocalcemia and tetany occur after a thyroidectomy, the immediate treatment is administration of ___. Sedative agents such as pentobarbital may be given. • Because of neuromuscular irritability, the patient with hypocalcemia and tetany requires an environment that is free of noise, drafts, bright lights, or sudden movement. • ___ may become necessary, along with bronchodilating medications, if the patient develops respiratory distress. • A diet high in __ and low in __ is prescribed. • Although milk, milk products, and egg yolk are high in calcium, they are ___ because they also contain high levels of phosphorus. • Spinach also is avoided because it contains __, which would form insoluble calcium substances. • Oral tablets of calcium salts, such as __, may be used to supplement the diet.

9 to 10 calcitriol, calcium, magnesium, and vitamin D2 or d3 thiazide diuretic Recombinant parathyroid hormone IV calcium gluconate calcium phosphorus Tracheostomy or mechanical ventilation restricted oxalate calcium gluconate

Nursing Management hypoparathyroidism • Care of postoperative patients who have undergone thyroidectomy, parathyroidectomy, or radical neck dissection is directed toward detecting early signs of __ and anticipating signs of tetany, seizures, and respiratory difficulties. • __ should be available for emergency IV administration. If the patient requiring administration of calcium gluconate has a cardiac disorder, is subject to dysrhythmias, or is receiving digitalis, the calcium gluconate is given slowly and cautiously. • _&_ increase systolic contraction and also potentiate each other; this can produce potentially __. Consequently, the cardiac patient requires continuous cardiac monitoring and careful assessment.

hypocalcemia Calcium gluconate Calcium and digitalis fatal dysrhythmias

Each person has __ adrenal glands, one attached to the upper portion of each __. Each adrenal gland is two endocrine glands with separate, independent functions. • The adrenal __ at the center of the gland secretes __, and the outer portion of the gland, the adrenal __, secretes __. • The secretion of hormones from the adrenal cortex is regulated by the __ • Increased levels of the adrenal hormone inhibits the production or secretion of __ and __.

two kidney medulla catecholamines cortex steroid hormones hypothalamic–pituitary– adrenal axis. CRH and ACTH

• __ functions as part of the autonomic nervous system. • Stimulation of preganglionic sympathetic nerve fibers causes release of the __ hormones: _&_ • About 90% of the secretion of the human adrenal medulla is __ (also called __). • regulate metabolic pathways to promote __ of stored fuels to meet caloric needs from endogenous sources. • The major effects of epinephrine release are to prepare to meet a challenge (__). • Secretion of __ causes decreased blood flow to tissues that are not needed in emergency situations and increased blood flow to tissues that are important for effective ___. • Catecholamines also induce the release of __, increase the __, and elevate the .

Adrenal Medulla catecholamine epinephrine and norepinephrine. epinephrine adrenaline Catecholamines Catabolism fight-or-flight response epinephrine fight or flight free fatty acids basal metabolic rate blood glucose level

______ • ____ make it possible for the body to adapt to stress of all kinds. • The three types of steroid hormones produced by the adrenal cortex are ___; ___; ___ • Without the adrenal cortex, severe __ would cause peripheral circulatory failure, circulatory shock, and prostration. • Survival in the absence of a functioning adrenal cortex is possible only with __, __, and __ replacement and appropriate replacement with exogenous adrenocortical hormones.

Adrenal Cortex glucocorticoids: (cortisol) mineralocorticoid (aldosterone) sex hormones (androgens) (male sex hormones) adrenocortical secretions stress nutritional Electrolyte fluid

• Increased cortisol secretion results in elevated blood glucose levels.

Glucocorticoids

secreted from the adrenal cortex in response to the release of __ from the anterior lobe of the pituitary gland. • __ are the classification of drugs that include glucocorticoids. • ___ are given to inhibit the inflammatory response to tissue injury and to suppress allergic manifestations. • Corticosteroids side effects include the development of diabetes, osteoporosis, peptic ulcer, increased protein breakdown resulting in muscle wasting and poor wound healing, and redistribution of body fat. • When large doses of exogenous glucocorticoids are given, the release of ACTH and endogenous glucocorticoids are inhibited. This can cause the adrenal cortex to __. • If exogenous glucocorticoid administration is discontinued suddenly, ___ results because of the inability of the atrophied cortex to respond adequately.

ACTH Corticosteroids Corticosteroids atrophy adrenal insufficiency

______ • exert their major effects on electrolyte metabolism. • act principally on the renal tubular and GI epithelium to cause increased ___ ion absorption in exchange for excretion of ___ or hydrogen ions. • primarily secreted in response to the presence of __ in the bloodstream. • ___ is a substance that elevates the blood pressure by constricting arterioles. • Its concentration is increased when renin is released from the kidney in response to decreased perfusion pressure. • The release of aldosterone is also increased by ___. • ___ is the main hormone for the long-term regulation of sodium balance.

Mineralocorticoids sodium potassium angiotensin II Angiotensin II hyperkalemia Aldosterone

___ • exert effects similar to those of male sex hormones. • may also secrete small amounts of some estrogens, or female sex hormones. • __ controls the secretion of adrenal androgens. • when secreted in excess, they produce masculinization in women, feminization in men, or premature sexual development in children (____).

Adrenal Sex Hormones (Androgens) ACTH adrenogenital syndrome

______ • a tumor that is usually benign and originates from the chromaffin cells of the adrenal medulla. • This tumor is the cause of __ in 0.1% of patients with hypertension and is usually fatal if undetected and untreated. may occur at any age, but its peak incidence is between __ of age and affects men and women ___. • family members of affected people, the patient’s family members should be alerted and screened for this tumor.

Pheochromocytoma high blood pressure 40 and 50 years equally

Clinical Manifestations • The typical triad of symptoms is __,__,__ in the patient with hypertension. • ___ and other cardiovascular disturbances are common. The hypertension may be intermittent or persistent. • Other symptoms may include tremor, headache, flushing, and anxiety. • ___ - insulin may be required to maintain normal blood glucose levels. • During attacks, the patient is extremely anxious, tremulous, and weak. • The patient may experience headache, vertigo, blurring of vision, tinnitus, air hunger, and dyspnea. • Other symptoms include polyuria, nausea, vomiting, diarrhea, abdominal pain, and a feeling of impending doom. • ___ occurs in 70% of patients with untreated pheochromocytoma.

headache, diaphoresis, and palpitations Hypertension Hyperglycemia Postural hypotension

Assessment and Diagnostic Findings • Pheochromocytoma is suspected if signs of sympathetic nervous system __ occur in association with marked __ of blood pressure. • “five Hs”: _,_,_,_,_ • Measurements of urine and plasma levels of ___ and ___, a catecholamine metabolite, are the most direct and conclusive tests. • The total plasma catecholamine (epinephrine and norepinephrine) concentration is measured with the patient __ • Normal plasma values of epinephrine are __ pg/mL (590 pmol/L); normal values of norepinephrine are generally less than 100 to 550 pg/mL (590 to 3,240 pmol/L). • Values of epinephrine greater than _ pg/mL (2,180 pmol/L) or norepinephrine values greater than 2,000 pg/mL (11,800 pmol/L) are considered diagnostic of pheochromocytoma. . • A __ may be performed if the results of plasma and urine tests of catecholamines are inconclusive. • __, such as CT, MRI, and ultrasonography, may also be carried out to localize the pheochromocytoma and to determine whether more than one tumor is present. • __ is a centrally acting antiadrenergic medication that suppresses the release of neurogenically mediated catecholamines.

overactivity elevation hypertension, headache, hyperhidrosis (excessive sweating), hypermetabolism, and hyperglycemia. catecholamines metanephrine (MN) supine and at rest for 30 minutes. 100 400 clonidine suppression test Imaging studies Clonidine

Medical Management pheochromocytoma During an episode or attack of hypertension, tachycardia, anxiety, and the other symptoms of pheochromocytoma, ___ is prescribed to promote an orthostatic decrease in blood pressure. 1. Pharmacologic Therapy - goals are to control hypertension before and during surgery and volume expansion. - Preoperatively, the patient may begin treatment with a low dose of an __ 10 to 14 days or longer prior to surgery. - ___ are sometimes used as an alternative or supplement to preoperative alpha- and betablockers. - Additional preoperative medications include _

bed rest with the head of the bed elevated alpha-adrenergic blocker Calcium channel blockers catecholamine synthesis inhibitors

2. Surgical Management - __ - removal of one or both adrenal glands. - Surgery may be performed using a __ approach or an __ operation. - __ may be necessary if tumors are present in both adrenal glands. - A __ can be given intraoperatively exclusively or in combination with the alpha- and beta-blockers to control blood pressure. - In response to hypertensive crisis, _ can be given. - __ is used to control cardiac arrhythmias - __ is required if bilateral adrenalectomy has been necessary. - __ and __ may occur in the postoperative period because of the sudden withdrawal of excessive amounts of catecholamines.

Adrenalectomy laparoscopic open Bilateral adrenalectomy sodium nitroprusside, phentolamine, or nicardipine Lidocaine or esmolol calcium channel blocker Corticosteroid replacement Hypotension and hypoglycemia

Nursing Management pheochromocytoma Give 2

monitored until stable with special attention given to ECG changes, arterial pressures, fluid and electrolyte balance, and blood glucose levels. Iv access

Decrease ACTH disease

Addison Disease

occurs when the adrenal glands are damaged and cannot produce sufficient amounts of cortical hormones.

primary adrenal insufficiency (PAI),

Primary adrenal insufficiency • __ or __ of the adrenal glands is responsible for 80% to 90% of all cases. • Other causes include __ of both adrenal glands and __ of the adrenal glands. • __ & __ are the most common infections that destroy adrenal gland tissue. • Inadequate secretion of __ from the pituitary gland is a secondary cause of adrenocortical insufficiency. • Therapeutic use of __ is the most common cause of adrenocortical insufficiency. • Symptoms of adrenocortical insufficiency may result from the sudden cessation of __, which suppresses the body’s normal response to stress and interferes with __ feedback mechanisms, adrenal insufficiency should be considered in any patient who has been treated with corticosteroids.

Autoimmune or idiopathic atrophy surgical removal infection Tuberculosis and histoplasmosis ACTH corticosteroids exogenous adrenocortical hormonal therapy normal

Addison's disease CLINICAL MANIFESTATIONS Give 5

• muscle weakness; anorexia; GI symptoms; fatigue; emaciation; dark pigmentation of the mucous membranes and the skin, especially of the knuckles, knees, and elbows; hypotension; and low blood glucose, low serum sodium, and high serum potassium levels. • Depression, emotional lability, apathy, and confusion are present in 20% to 40% of patients. • In severe cases, the disturbance of sodium and potassium metabolism may be marked by depletion of sodium and water and severe, chronic dehydration. • With disease progression, addisonian crisis (i.e., hypotension, cyanosis, fever, nausea, vomiting, and signs of shock) develops.

Addison's disease ASSESSMENT AND DIAGNOSTIC FINDINGS Give 2

• The diagnosis is confirmed by laboratory test results. • Combined measurements of early morning serum cortisol and plasma ACTH. • Patients with primary insufficiency have a greatly increased plasma ACTH level and a serum cortisol concentration lower than the normal range. • Other laboratory findings include hypoglycemia and hyponatremia, hyperkalemia, and leukocytosis.

Addison's disease Medical Management • Immediate treatment is directed toward combating circulatory shock: restoring ___, administering fluids and __, monitoring __, and placing the patient in a ___ position with the legs elevated. • __ is administered by IV, followed by 5% dextrose in normal saline. • __ may be required if hypotension persists. • __ may be given if infection has precipitated adrenal crisis in a patient with chronic adrenal insufficiency. • If the adrenal gland does not regain function, the patient needs __ replacement of _&_ to prevent recurrence of adrenal insufficiency.

blood circulation corticosteroids vital signs recumbent Hydrocortisone Vasopressors Antibiotics lifelong corticosteroids and mineralocorticoids

Addison's disease Nursing Management (4)

• Assessing the Patient • Monitoring and Managing Addisonian Crisis • Restoring Fluid Balance • Improving Activity Tolerance

• results from excessive adrenocortical activity. • Commonly caused by the use of __ medications. • infrequently the result of excessive corticosteroid production secondary to __ of the adrenal cortex. • may be caused by a __ of the pituitary gland. • The signs and symptoms of Cushing syndrome are primarily a result of over secretion of _&_

Cushing syndrome corticosteroid hyperplasia tumor glucocorticoids and androgens.

Cushing syndrome CLINICAL MANIFESTATIONS • arrest of growth, obesity, and musculoskeletal changes occur along with glucose intolerance. • a fatty “__” in the neck and supraclavicular areas, a heavy trunk, and relatively thin extremities. • The skin is thin, fragile, and easily traumatized; ecchymoses (bruises) and striae develop. • The patient complains of weakness and lassitude. • Sleep is disturbed because of altered diurnal secretion of cortisol. • Excessive protein catabolism occurs, producing muscle wasting and osteoporosis. • Kyphosis, backache, and compression fractures of the vertebrae may result. • Retention of sodium and water occurs as a result of increased mineralocorticoid activity, producing hypertension and heart failure. • The patient develops a “__” appearance and may experience increased oiliness of the skin and acne. • Hyperglycemia or overt diabetes may develop. • The patient may also report weight gain, slow healing of minor cuts, and bruises. In females of all ages, virilization may occur as a result of excess androgens (hirsutism, breasts atrophy, menses cease, the clitoris enlarges, and the voice deepens. • Libido is lost in men and women. • Distress and depression are common. • If Cushing syndrome is a consequence of pituitary tumor, __ may occur because of pressure of the growing tumor on the optic chiasm.

buffalo hump moon-faced visual disturbances

Assessment and Diagnostic Findings • The three tests used to diagnose Cushing syndrome are: • __ of the three tests need to be unequivocally abnormal to diagnose Cushing syndrome. 1. __ levels - usually __ in the early morning (6 to 8 am) and __ in the evening (4 to 6 pm). This variation is lost in patients with Cushing syndrome. 2. test - requires a 24-hour urine collection. - If the results of the urinary cortisol test are three times the upper limit of the normal range, Cushing is suspected. 3. - used to diagnose pituitary and adrenal causes of Cushing syndrome. - __ is given orally late in the evening or at bedtime, and a plasma cortisol level is obtained at 8 am the next morning. - Suppression of __ to less than 5 mg/dL indicates that the hypothalamic–pituitary–adrenal axis is functioning properly.

serum cortisol, urinary cortisol, and low-dose dexamethasone suppression test. Two Serum cortisol higher lower Urinary cortisol Dexamethasone Overnight dexamethasone suppression test cortisol

Cushing syndrome Medical Management • If caused by pituitary tumors, treatment is directed at the __. • Surgical removal of the tumor by ___ is the treatment of choice. • ___ is the treatment of choice in patients with unilateral primary adrenal hypertrophy. • Medical management is recommended for bilateral adrenal dysplasia. • Temporary replacement therapy with __ may be necessary for several months. • __ may be used to reduce hyperadrenalism if the syndrome is caused by ectopic ACTH secretion by a tumor that cannot be eradicated. • If Cushing syndrome is a result of the administration of corticosteroids, an attempt is made to __ the medication to the __ dosage needed.

pituitary gland transsphenoidal hypophysectomy Adrenalectomy hydrocortisone Adrenal enzyme inhibitors reduce or taper minimum

• Excessive production of aldosterone. • occurs in some patients with __ of the adrenal gland.

Primary Aldosteronism (Increase Aldosterone) functioning tumors

Primary Aldosteronism (Increase Aldosterone) Clinical Manifestations • __ is the most prominent and almost universal sign. • Patients with uncomplicated, complicated, and treatment resistant hypertension and hypertension with ___ should be considered at risk for this disorder. • If hypokalemia is present, it may be responsible for the variable muscle ____ • Polyuria, polydipsia and arterial hypertension. • ___ may decrease the ionized serum calcium level and predispose the patient to tetany and paresthesias (assess _&_ signs). • ___ may occur, because hypokalemia interferes with insulin secretion from the pancreas.

Hypertension hypokalemia weakness or paralysis, cramping, and fatigue. Hypokalemic alkalosis Chvostek and Trousseau Glucose intolerance

Aldosteronism ASSESSMENT AND DIAGNOSTIC FINDINGS • A blood test to measure the ratio of __ to ___ can be performed even while the patient is taking an antihypertensive. • This should be followed by __ and subtype evaluation tests. MEDICAL MANAGEMENT • The recommended treatment of unilateral primary aldosteronism is total surgical removal of the adrenal tumor through ___. • If the adrenalectomy is bilateral, __ will be lifelong. • A normal serum glucose level is maintained with insulin, appropriate IV fluids, and dietary modifications. • __ is recommended over open surgery to reduce complications and hospital length of stay. • Hypokalemia should be treated with ___ preoperatively. • Medical treatment rather than surgery is recommended for patients with ___ involvement due to poor blood pressure control and other risks.

PAC PRA aldosterone suppression confirmatory tests laparoscopic adrenalectomy Laparoscopic surgery replacement of corticosteroids bilateral adrenal spironolactone

Primary Aldosteronism PHARMACOLOGIC THERAPY • Pharmacologic management is required for patients with __ or __ who do not undergo surgery. • __ is recommended as the first-line drug to control hypertension. • __ a newer, more expensive drug is recommended as a second-line drug if the patient cannot tolerate side effects of spironolactone. • Serum __ and __ should be monitored frequently during the first 4 to 6 weeks of taking spironolactone. • The half-life of __ may be increased when taken with spironolactone, and its dosage may need to be adjusted.

bilateral adrenal hyperplasia or unilateral aldosterone hypersecretion Spironolactone Eplerenone potassium creatinine digoxin

Primary Aldosteronism Nursing Management Give 2

• Frequent assessment of vital signs to detect early signs and symptoms of adrenal insufficiency and crisis or hemorrhage. • Explaining all treatments and procedures, providing comfort measures, and providing rest periods can reduce the patient’s stress and anxiety level.

Corticosteroid Therapy • Corticosteroids are used extensively for ___ and in suppressing inflammation and autoimmune reactions, controlling allergic reactions, and reducing the rejection process in __. • Their anti-inflammatory and antiallergy actions make corticosteroids effective in treating rheumatic or connective tissue diseases, such as __ • They are also frequently used in the treatment of __, multiple sclerosis, and __ . Side Effects • The dose required for anti-inflammatory and antiallergy effects produces _, pituitary and adrenal gland __, and changes in the function of the central nervous system. • Dosages of these medications are frequently altered to allow high concentrations when necessary and then tapered in an attempt to avoid undesirable effects. • Suppression of the __ may persist up to __ after a course of corticosteroids.

adrenal insufficiency transplantation rheumatoid arthritis and SLE. asthma Other autoimmune disorders metabolic effects suppression adrenal cortex 1 year

Therapeutic Uses of Corticosteroids Give 3

• Treatment of Acute Conditions - Examples include emergency treatment for bronchial obstruction in status asthmaticus and for septic shock from septicemia caused by gram-negative bacteria. • Ophthalmologic Treatment - Outer eye infections can be treated by topical application of corticosteroid eye drops. Dermatologic Disorders - Topical administration of corticosteroids in the form of creams, ointments, lotions, and aerosols is especially effective in many dermatologic disorders.

Corticosteroids Dosage • In keeping with the natural secretion of __, the best time of day for the total corticosteroid dose is in the ____ • If symptoms of the disorder being treated are suppressed, __ is helpful in reducing pituitary–adrenal suppression in patients requiring prolonged therapy. • Corticosteroid dosages are __ to allow normal adrenal function to return and to prevent steroid-induced adrenal insufficiency.

cortisol early morning alternate-day therapy reduced gradually (tapered)

Increase ACTH disease

Cushing Syndrome