Endocrine Flashcards
Primary goal of the endocrine system
Maintain homeostasis
Hormone release
— response to altered cellular environment
— maintain level of another hormone or substance
Positive and negative feedback loops
What are endocrine disorders caused by
HYPER or HYPO secretion of any hormone produced or secreted by gland
Hypo = replace the hormone synthetically
Nursing goals
Control symptoms experienced by hypo or hyper situation
Examples of positive feedback loops
— birth
— clotting cascade
The body tries to create hormones = keeps adding until desired outcome (clots when getting a cut)
Negative feedback loop
Changing response to stimulus decreases synthesis and secretion of a hormone
— thermostat = temperature control
— once appropriate level is reached -> stops creating desired hormone since homeostasis is reached
— levels are sensed = added or decreased based on circulating blood levels
Thyroid = body senses low T3 + T4 -> TRH stimulates TSH to stimulate more T3 + T4
— once desired levels are reached -> stops making hormones
Posterior pituitary disorders
DI
SIADH
Anterior pituitary disorders
Gigantism
Dwarfism
Acromegaly
Adrenal disorders
Cushings and addisons disease
Endocrine lab values
CBC
BNP
Clotting cascade
— PT:
— INR:
Electrolytes:
— sodium: 135-145
— potassium: 3.5-5.2
— calcium: 8.4-10.5
— magnesium: 1.5-2.5
What are the anterior lobe hormones?
— Adrenocorticotropic hormone (ACTH)
— follicle stimulating hormone (FSH)
— growth hormone (GH)
— luteinizing hormone (LH)
— prolactin
— thyroid stimulating hormone (TSH)
Posterior lobe hormones
— antidiuretic hormone (ADH)
— oxytocin
What are the two types of pituitary tumors?
Secretory = secrete TOO much hormone
— ex: hyperthyroidism
— disrupts negative feedback loop
— creates too much T3 + T4
— over-secretion = too much hormone in the blood
Non-secretory = causes pressure
— extra pressure can cause gland to become squished
— anything in the body does not enjoy extra pressure
— only so much room
Posterior pituitary tumors
ADH deficiency excess
Anti-diuretic hormone = body holds onto extra flood
Anterior pituitary tumors
Hypopituitarism and hyperpituitarism
Hypopituitarism
Deficiency of one or more anterior pituitary hormones results in metabolism problems and sexual dysfunction
— growth hormones stimulate liver
— sex hormones
Hyperpituitarism
— hormone over-secretion
— neurological symptoms may occur
— compression of brain tissue -> increased ICP
— galactorrhea, amenorrhea, and infertility
Diabetes insipidus
↓ ADH
EXCESSIVE urination + thirst -> always thirsty
HYPERnatremia
— dehydration
— any fluid into the body -> peed out
SIADH
↑ ADH
Water is retained
HYPOnatremia
— CONFUSION; NEURO IMPAIRMENT
— fix sodium SLOWLY
Sodium Is Always Down!
Nursing interventions for DI and SIADH
— close monitor of I&O
— daily weight
— blood chemistries
— electrolytes
— monitor neurological status
Gigantism
TOO MUCH growth hormone
— rare
— height and girth are affected
— grow very large
— cause = pituitary gland tumor
— remove tumor will fix excessive growth
Manifestations of gigantism
— headache
— vision problems
— nausea
— excessive sweating
— weakness
— insomnia
— delayed puberty
— irregular menstrual period
Tumor = putting pressure on pituitary gland
Dwarfism
Too little growth hormone
— supplemental growth hormone can be given = handled well
Acromegaly
Pituitary adenmoa
— hyper secretions happen AFTER puberty
— gradual changes
Manifestations of acromegaly
— enlarged tongue, lips, nose, hands, feet, and facial bone growth
— skeletal changes are PERMANENT
— organ enlargement
Dx and medical tx of pituitary tumors
— visual acuity and visual field tests = visual acuity can be affected
— CT and MRI
— lab -> pituitary hormones
— also look at thyroid gland labs
— measurement and target organ hormones
Tx:
— surgery
— remove/destroy tumor
— replacement hormones are required after destruction
Medications:
— bromociptine
— octreotide
What is a total hypophysectomy? What are the complications?
Scope through the nose
— poke through back of the nasal cavity into the brain
— transphynoidal approach
Swelling = diabetes insipidus
Risk for CSF leakage
— LOOK FOR CLEAR FLUID FROM NOSE
Visual disturbances
Post-op meningitis
Pneumocephalus = air in intracranial cavity
SIADH
Pre-op teaching
— AVOID ACTIONS THAT INCREASE INTRACRANIAL PRESSURE
Do not:
— cough
— sneeze
— blow nose
— sucking through straw
— bending over or straining during urination/defecation
TEACHING:
— deep breathing exercises
— dressing and packing in nose
— nurse will check visual acuity often
— need for accurate I&O = early signs for DI or SIADH
— head of bed AT LEAST 30 DEGREES FOR 2 WEEKS = reduce increased intracranial pressure
Postoperative care
— neuro checks = visual acuity and visual fields
— accurate I&O
— incision/packing = keep DRY
Complications for this procedure
— DI
— SIADH
— meningitis -> CSF leakage (clear drainage)
— CSF on pillow case -> disperses in halo pattern
— make sure to get sample of clear fluid coming from nose to identify type of fluid
— monitor for visual disturbances
— continuous post nasal drip
— swallowing more frequently = CSF leaking to back of throat
Discharge instructions
Remember = hole has been poked through nasal cavity into the brain
— avoid increasing intracranial pressure
Report to surgeon:
— hunger
— thirst
— body swelling
— mood swings
— increased urine output (DI)
— weight lost
— continuous post nasal drip
— excessive swallowing = CSF leakage
— pain with bending neck = meningitis
— vision loss = damage to optic chia sim
Only use nasal medications/rinses as prescribed
Keep follow up appt 1 wk after d/c
Function of aldosterone
Regulates blood volume
Sodium reabsorption and potassium excretion into renal tubules
Water follows sodium
Gets rid of potassium and reabsorbs sodium
Function of cortisol
Stress hormone
— increased BG by inhibits insulin secretion promoting gluconeogenesis (metabolism is driven by glucose)
— increases breakdown of proteins and lipids = gluconeogenesis
— suppresses inflammatory and immune response
— increases sensitivity of vascular smooth muscle to norepinephrine and angiotensin II = vasoconstriction
— increases breakdown of bony matrix
— promotes bronchodilation (fight or flight response)
Addison’s disease
Hypofunction of adrenal gland
— decrease ACTH and acdrenocortical steroids from adrenal cortex
Cause:
— autoimmune
— stopping corticosteroids abruptly (2-4 wk)
— taper corticosteroids to avoid
CM of Addison’s disease
— hyperpigmentation
— fatigue
— weakness
— anorexia
— weight loss unexplained
— confusion/emotion liability
— going back and fourth between happy and sad
— hypoglycemia
— blood volume depletion
HYPERKALEMIA
— watch for cardiac arrhythmias
— put pt on tele
— tall peaked t waves -> vtach
HYPONATREMIA
Acute adrenal crisis
Sudden loss of cortisol and aldosterone
— LIFE THREATENING
— typically after surgery, trauma, severe infection
CM:
— vomiting
— abd pain -> shunting of blood from GI tract
— low glucose
— low sodium
— HIGH POTASSIUM
— severe hypotension -> lack of aldosterone
— hypovolemic shock -> dehydration; not enough circulating volume
Dx process
Early morning plasma cortisol provocation tests
— injection of ACTH admin blood draw 60 min later to measure cortisol
— performed to differentiate from secondary adrenal insufficiency
Secondary cause = distant; pituitary tumor affecting ACTH secretion
Primary = greater increase in plasma ACTH and lower than normal cortisol concentration
— fasting BG, electrolytes, BUN
— GLUCSE, SODIUM AND POTASSIUM
Medical interventions
— restore circulation blood volume and prevent shock
— replace hormones -> hydrocortisone
— REPLACE FLUIDS -> LR
— restore volume!!
— tx hyponatremia and hyperkalemia = dialysis may be needed
— tx hypoglycemia
— admin fluids and monitor I&O
— monitor VS
— vasopressin’s for HYPOTENSION
— determine cause
Nursing interventions
— monitor VS q 1-4 hr
— assess dysrhythmia or postural hypotension
— daily wt
— promote fluid balance
— monitor fluid deficit
— acute I&O
— monitor lab = BUN, creatinine, sodium, potassium
— give cortisol and aldosterone replacement therapy
— loop diuretics may be given but be careful with low circulating volume
Addisons= deficient of salt, sugar + steroid
Hyponatremia, hypoglycemia = not having cortisol and aldosterone
Cushing’s syndome
Adrenal gland: adrenocortical EXCESS
— pheochromocytoma tumor 85%
CM:
— muscle wasting
— weakness
— fragile skin
— MOON FACE
— BUFFALO HUMP
— acne
— enlarged trunk
— small arms and legs
— MOST OF THE BODY IS IN THE TRUNK
— virilization = male sex hormones; dark facial hair, balding on head, loss of libido,
— LOW VOICE IS PERMANENT
RETENTION OF SODIUM AND WATER = HTN AND HF
— HYPERglycemia
— excess fluid volume
— EXACT OPPOSITE OF ADDISONS
Dx of Cushing’s
— 3 tests: 2 must be abnormal for dx
— serum cortisol = blood level of cortisol
— urinary cortisol = 24 hr collection; proteins excreted vary for different people
— low dose dexamethasone suppression test
Medical management
Surgery:
— if cause of pituitary tumor or primary adrenal hypertrophy
— adrenal insufficiency 12-48 hr post op
— support with HYDROCORTISONE
— since we are removing source of steroid = nothing to produce steroid we must give supplment at normal levels
Drug therapy:
— surgery not an option = not stable enough
** mitotane used to suppress ACTH if tumor cannot be removed
Nursing interventions
— decrease risk for injury
— decrease risk for infection
— prep pt for surgery
— encourage rest and activity
— promote skin integrity
— improve body image
— improve coping
— monitor for potential complications
ADRENAL TUMOR: PRIMARY aldosteronism
Caused by functioning tumor excessive production of aldosterone
CM:
— profound decline in POTASSIUM and hydrogen ions -> ALKALOSIS with increased bicarbonate
— HTN IS UNIVERSAL SIGN
— muscle weakness
— cramping
— fatigue
— excessive urine volume
— polyuria
— losing lots of fluid in the urine
— excessive thirst
Medical management and nursing
Surgical removal of adrenal tumor
— tx HTN with spironolactone
— monitor potassium and creatinine for 4-6 wk while on drug therapy
— spironolactone -> hypokalemia
Nursing:
— post op care
— monitor surgical site for infections/bleeding
— assist with social services or rehab if needed
— make sure medications are received upon d/c
Function of the thyroid
Control cellular metabolic activity
— influences every major organ system
Function of parathyroid
Regulate calcium and phosphorus metabolism
— parathyroid glands are super small compared to the thyroid gland itself
— calcium and phos levels are always opposite
Thyroiditis
Inflammation, fibrosis, lymphotis infiltration
Symptoms: neck pain, swelling, dysphagia
Three types:
— acute = infection
— subacute = granulomatous
— chronic = hashimoto’s (most common)
Surgery only needed when drug therapy is not successful
Hyperthyroidism
Thyrotoxcois
Excessive output of thyroid hormones
Graves’ disease = most common
Excess secretion of T3 + T4
Other types:
— formation of nodues from iodine deficiency
— viral infection of thyroid gland
— excessive pituitary secretion of TSH (secondary hyperthyroidism)
CM of hyperthyroidism
— nervous all the time
— excessive sweating
— poor heat tolerance = hot flashes
— cannot sit still
— high HR 120-140 at rest
— flushed (red) skin
— tremors
— high appetite but still losing weight
— weakness
— amenorrhea
Exophthalmos = bulging eyes -> permanent change
— thyroid enlargement
— bruit over thyroid arteries
Lab and dx of hyperthyroidism
TSH will be low
T3 + T4 is high
Negative feedback loop = thyroid is producing more T3 + T4
Radioactive iodine update
— measure rate of iodine uptake by thyroid
— hyper = exhibit high uptake
— hypo = low iodine uptake
Fine-needle aspirate biopsy tissue sample to detect cancer
Thyroid scan
— radionuclide injected and test determines “hot” areas of increased activity and “cold” areas of decreased activity (cancer)
— entire body scan to assess for metastasis
Thyroid storm
EMERGENT
— worsening of normal hyperthyroid s/s
— fast forward x4
— extremely high HR at rest
— develop HF, circulatory collapse, HIGH FEVER
— RARE
Thyroid storm management
Fatal if not quickly recognized
— anti thyroid mediations
— plasmapheresis or dialysis to remove excessive T3 + T4 (methanazole)
— ablation or removal of gland
— cardiac monitor for dysrhythmias
— oxygen to tx dyspnea and possible HF
— beta blockers to slow sympathetic activity
— acetaminophen to decrease fever
— POTENTIAL SEIZURE ACTIVITY
Nursing interventions for thyroid storm
SPECIAL ATTENTION TO FEVER AND HR
— monitor VS
— provide calm and quiet environment
— maintain cool room and reduce stimulation
— heat intolerance
— provide eye care -> dry eyes
— elevate HOB at night
— increased risk for seizures
— corticosteroids to reduce inflammation
— hypermetabolic state -> INCREASE CALORIES
— encourage 6 meals per day
— need for anti thyroid medications
— follow up with HCP
— provide support groups
— tx photophobia with dark glasses
Medical management
Ablation/removal
— radioactive iodine therapy -> most common tx
— surgical removal of thyroid
— total thyroidectomy/ablation = will need lifelong thyroid hormone replacement
Radioactive iodine therapy
Ablative dose of I-131 admin
— causes acute release of thyroid hormone as it is destroyed
— observe for thyroid storm
Fever >101.3 and HR >130 AFFECTS ORGANS
— abd pain
— diarrhea
— edema
— chest pain
— dyspnea
— delirium
— psychosis
Management:
— cooling blanket
— hydrocortisone
— methimazole impedes formation of thyroid hormone
Precautions for hospitalized I-131 thyroid therapy patients
— wear gloves and shoe covers
— dosimetry badge = shows how much radiation exposed to
— minimize time spent w pt
— remain at least 3 ft away
— cluster care
— contaminated linen must be collected -> laundered separately
— pt must stay in room at all times
— pt must use disposable utensils
— no minors or pregnant visitors allowed
— radiation safety must clear the room before another patient gets admitted to the room
Nursing post-op thyroidectomy
Observe for:
— hemorrhage
— resp distress
— ABCs
— hypocalcemia and tetany (parathyroid)
— laryngeal nerve damage
— thyroid storm
Admin hormone replacement
— Levothyroxine
Hypothyroidism
Low levels of thyroid hormones
Autoimmune (hoshimoto’s), thyroid surgery, iodine deficiency, tumors, drugs
CM:
— fatigue
— c/o cold
— cold intolerance
— low HR
— weight gain
— poor appetite
— constipation
HIGH TSH and LOW T3 + T4
Slow motion = complete opposite as hyperthyroid (sped up)
Medical management = Levothyroxine
Compensatory mechanism -> enlarged thyroid
Goiter
— abnormal enlargement of thyroid
— hypothalamus signals release of TSH binds to thyroid cells and causes thyroid to enlarge in attempt to trigger release of T3 + T4
Nursing management of hypothyroidism
— modify activity
— risk for immobility problems
— monitor physical status
— VS and mental status (foggy feelings)
— keep room warm, NO HEATING PADS
— adequate nutrition and hydration
— enhance coping mechanism
— depressive episodes
— teach about medications and seeing provider for labs
Myxedema crisis
EMERGENT 60% MORTALITY RATE
— undiagnosed and untreated hypothyroidism
— tissue and organs failure due to decreased metabolism
CM:
— mucinous edema = eyes, hands, feet, all over the body
— hypothermic = low body temp
— lethargy
— stupor
— coma
— cardiovascular collapse -> shock -> death
— “super slow motion”
— depressed resp drive
— VERY SENSITIVE TO SEDATING DRUGS -> body is already in super slow motion
Nursing interventions for myxedema
Infective breathing pattern:
— observe and record rate and depth of resp
— auscultate lungs
— assess for resp distress
— assess client receiving sedation for resp adequacy
— resp status is adequate to meet oxygen demands
Decreased cardiac output:
— monitor circulatory status
— signs of inadequate tissue oxygenation
— assess for cold toes and peripheral pulses
— change in mental status
— fluid status and HR
— admin oxygen and mechanical ventilation as appropriate
Thyroid cancer
Surgery tx = thyroidectomy; removal of cancer tissue
— suppressive doses of thyroid hormone for 3 mo after surgery
— genetic component
Hyper parathyroidism
EXCESSIVE SECRETION OF PTH
— increased calcium in blood
— calcium in blood stream
— renal calculi = kidney stones
CM:
— skeletal pain
— HTN
— fatigue
— muscle weakness
— constipation
— dysrhythmias
— peptic ulcers and pancreatitis
Dx: elevated calcium, X-ray to look at bones, scans
Medical management:
— diuretics
— fluids
— mobility
— diet restriction -> calcium rich foods
— MEDS: phosphates, calcitonin
— surgery to remove parathyroid glands
Nursing pre-op to remove parathyroid glands
Calcium must be stabilized
— full CBC
Teaching:
— limit coughing
— deep breathing exercises
— neck support
— monitor airway
Post-op
Resp distress
— close to airway
Hypocalcemia crisis can occur
— tetany
— seizures
— trousseu’s sign -> occurs when BP cuff is on (wrist flops over)
Laryngeal nerve damage can occur
Hypoparathyroidism
Decrease PTH secretion
— INCREASE phosphate and DECREASE calcium
Give supplemental vitamin D and calcium
— quiet environment
— free of bright lights to decrease neurological stimuli
