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endocrine disorders
- too much or too little
- must understand normal hormone function
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pituitary gland
- base of hypothalamus (brain)
- "master gland" - regulates many body functions
- anterior and posterior
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anterior pituitary
- growth hormone (GH) - increases protein production and bone formation
- thyroid-stimulating hormone (TSH) - stimulates release of thyroid hormones from thyroid
- adrenocorticotropic hormone (ACTH) - stimulates release of hormones (glucocorticoids) from adrenal cortex
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posterior pituitary
antidiuretic hormone (ADH/vasopressin) - causes renal tubules to reabsorb water from urine and return it to blood (decreases urine production)
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thyroid gland
- anterior to trachea/inferior to larynx
- secretes T3/T4 (TH) - controls metabolism
- --initiated by TSH - negative feedback
- --requires iodine
- secretes calcitonin (tones it down)
- --decreases excess serum calcium
- --slows calcium releasing bone cells
- --reduces intestinal absorption of calcium
- --promotes excretion in kidneys
- --opposite of PTH
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parathyroid glands
- embedded on surface of thyroid
- parathyroid hormone (PTH) - increases serum calcium, decreases serum phosphate
- increases excretion of phosphate/decreases excretion of calcium in kidneys
- mobilized skeletal calcium stores
- increases calcium absorption in GI
- requires vitamin D
- opposite of calcitonin
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adrenal glands
- pyramids on top of kidneys
- adrenal medulla - epi/norepi
- adrenal cortex - steroids
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adrenal medulla
- short term stress response
- epinephrine (adrenalin)
- --increases blood glucose
- --stimulates ACTH release
- --increases cardiac contractility
- --increased HR
- --vasoconstriction in skin, mucous membranes, kidneys
- --vasodilates coronary and pulmonary arteries
- norepinephrine (noradrenalin) - vasodilates heart, brain, skeletal muscle
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adrenal cortex
- long term stress response
- mineralocorticoids (aldosterone)
- --conservation of sodium/water
- --maintains BP under stress
- --release controlled by renin
- --decreased BP > kidney > renin > AngI > AngII > aldosterone > Na, H2O reabsorbed
- glucocorticoids (cortisol/cortisone)
- --carbohydrate metabolism
- --mobilize fatty acids
- --excess depresses inflammatory response
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pancreas
- behind stomach, behind spleen and duodenum
- endocrine and exocrine gland
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hyperthyroidism
- excessive TH
- increased metabolism
- etiology
- --Graves' disease - autoimmune
- --pituitary tumor - increase TSH secretion
- --thyroiditis - inflammation of the thyroid (viral)
- --cancer
- --Synthroid
- --toxic multinodular goiter - thyroid tumor
- dx: elevated TSH, elevated T3/T4, increased radioactive iodine, thyroid Ab test (Graves')
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hyperthyroid manifestations
- caloric/nutritional deficiencies
- increased HR, SV, cardiac output, peripheral blood flow
- weight loss
- hypermotile bowels/DHR
- heat intolerance/sweating
- insomnia
- palpations
- smooth, warm skin
- fine hair/hair loss
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Graves' Disease
- autoimmune - Abs binds to TSH receptors in thyroid/causes hyperfunction
- more common in females 20-40
- goiter
- proptosis/exophthalmos - forward eye displacement
- fatigue
- hand tremors
- menstrual changes
- Afib/angina/CHF in older patients
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thyroid crisis
- extreme hyperthyroidism (RARE)
- medical emergency
- hyperthermia (102-106)
- tachycardia
- HTN
- dyspnea
- abd pain, DHR, vomiting
- tx: cooling (no aspirin), fluids, glucose, electrolytes
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hyperthyroidism meds
- potassium iodine/iodide
- --large doses of iodine suppress thyroid function
- --10-15 day therapy
- methimazole (Tapazole), propylthiouracil (PTU)
- --decrease TH production
- assess for iodine allergy (give iodide instead)
- administer at same time each day
- monitor for s/s of hypothyroidism
- tape eyes closed for sleep
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hyperthyroidism nursing dx
- risk for decreased cardiac output r/t increased HR, increased SV, increased metabolic demands, increased O2 requirements
- disturbed sensory perception: visual r/t proptosis/exophthalmos
- imbalanced nutrition: less than body requirements r/t hypermetabolic state
- disturbed body image r/t goiter, tremors, hair loss
- anxiety r/t insomnia, mood changes
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hypothyroidism
- insufficient TH
- decreased metabolism
- etiology
- --Hashimoto's thyroiditis - autoimmune - Abs attack thyroid
- --Cretinism - congenital/neonatal
- --thyroidectomy/radiation
- --antithyroid medications
- --iodine deficiency
- --amiodarone (Cordarone) - contains iodine
- --Myxedema - severe hypothyroidism
- --Cretinism - congenital (primary)
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hypothyroid manifestations
- goiter
- fluid retention/edema
- decreased HR
- decreased appetite
- elevated cholesterol/triglycerides
- weight gain
- constipation
- dry skin
- dyspnea
- pallor
- hoarseness
- muscle stiffness
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myxedema coma
- severe hypothyroidism
- medical emergency
- decreased HR, BP, BGL, body temp, LOC
- cardiovascular collapse
- coma
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hypothyroid meds
- levothyroxine (Synthroid) - give in AM, monitor TH levels
- desiccated thyroid
- liotrix
- give same time daily, 1 hr before or 2 hrs after meals
- monitor for s/s of hyperthyroidism
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goiter
- enlargement of thyroid gland
- visible on anterior neck
- caused by hypo and hyperthyroidism
- airway/swallowing
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hyperparathyroidism
- excess PTH
- increased serum calcium/decreased serum phosphate
- increased bone decalcification (PTH mobilizes skeletal muscles)
- increased calcium absorption in GI
- retention of calcium by kidneys
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hyperparathyroidism manifestations
- musculoskeletal:
- --hypercalcemia (Ca > 10.2)
- --osteoporosis
- --pathologic fractures
- --muscle weakness/atrophy (depressed neuromuscular excitability)
- renal:
- --renal calculi/failure
- --metabolic acidosis
- --polyuria
- constipation
- dysrhythmias
- HTN
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hyperparathyroidism tx
- fluids to dilute excess Ca
- increase activity (push Ca back into bones)
- biphosphonates (Zometa, Boniva, Fosamaz)
- calcitonin
- surgical removal of PT
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hypoparathyroidism
- insufficient PTH
- decreased calcium/increased phosphate
- s/s hypocalcemia (Ca < 8): numbness/tingling around mouth and fingertips, muscle spasms (bronchial/abdominal), hypotension, bradycardia, dysrhythmias
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tetany
- muscle spasms
- assess Chvostek - tap facial nerve in front of ear
- assess Trousseau - inflate BP cuff for 2-5 mins
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hypoparathyroid tx
- dietary Ca
- vitamin D (Calcitrol)
- Forteo - synthetic PTH
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Cushing's syndrome
- excess ACTH or glucocorticoid (cortisol) due to hyperfunction of adrenal cortex
- STEROIDS, SALT, SUGAR
- aka hypercortisolism
- etiology:
- --iatrogenic - long term steroid use
- --Cushing's disease - ACTH hypersecretion from pituitary
- --ectopic - ACTH secreting tumors
- --adrenal - excess cortisol secretion
- dx: cortisol level (increased) , ACTH level (increased), serum Na (increased), K (increased), glucose (increased), ACTH suppression test (ACTH should decrease)
- tx: meds to suppress cortisol/ACTH, surgery (adrenalectomy)
- --Mitotane (suppresses adrenal cortex
- --ketoconazole - inhibits cortisol synthesis
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Cushing's manifestations
- increased blood glucose
- increased Na and H20 - excess aldosterone secreted by adrenal in addition to cortisol
- --HTN
- decreased K
- buffalo hump, moon face, abdominal obesity, skinny arms (fat redistribution) - carb metabolism changes
- muscle weakness/wasting - protein metabolism changes
- immunosuppression
- facial hair
- bruising, thin skin, delayed wound healing - loss of collagen
- osteoporosis, fractures, renal calculi - calcium absorption changes
- emotional instability
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Cushing's nursing dx
- fluid volume excess r/t excess cortisol leading to increased sodium and water reabsorption
- electrolyte imbalance
- risk for infection
- risk for injury
- hyperglycemia
- impaired skin integrity
- impaired tissue integrity
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Addison's disease
- deficient cortisol (gluco) and aldosterone (mineral) from adrenal cortex
- aka chronic adrenal insufficiency, hypercortisolism
- etiology:
- --autoimmune
- --adrenal hemorrhage
- --tumors
- --abrupt steroid withdrawal
- dx: serum cortisol (decreased), Na (decreased), K (increased), BUN (increased), glucose (decreased), plasma ACTH, 24 hour urine, CT scan
- tx: hydrocortisone (replaces cortisol), fludrocortisone/Florinef (replaces aldosterone), increased Na in diet
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Addison's manifestations
- hyperpigmentation
- poor stress response
- decreased Na
- --dizziness
- --confusion
- --neuromuscular irritability
- decreased fluid volume
- --hypotension
- --syncope
- increased K
- --dysrhythmias
- hypoglycemia
- lethargy
- weakness
- anorexia
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Addisonian crisis
- medical emergency
- triggered by stress (trauma, surgery, acute illness, abrupt steroid W/D)
- high fever
- weakness
- severe abd pain
- severe vomiting, DHR
- hypotension and circulatory collapse
- shock
- coma
- tx: fluids, glucocorticoids
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Addison's nursing dx
- fluid volume deficit
- hypoglycemia
- electrolyte imbalance
- decreased tissue perfusion
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pheochromocytoma
- excess catecholamines (epi, norepi) from adrenal medulla
- stimulates sympathetic nervous system
- BP 200-300/150-175
- peripheral vasoconstriction
- tachycardia
- risk of kidney failure, stroke
- tx: adrenalectomy
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hyperpituitarism
- excess secretions from anterior pituitary
- benign adenomas most common cause
- excess GH, prolactin, ACTH
- causes gigantism, acromegaly
- tx: transsphenoid hypophysectomy
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gigantism
- excess growth hormone before puberty
- causes abnormal height with normal proportions (before epiphyseal plates close)
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acromegaly
- excess growth hormone after puberty (after epiphyseal plates close)
- causes enlarged hands, feet, forehead, maxilla
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transsphenoid hypophysectomy
- through sphenoid up nose to remove pituitary
- monitor nasal drainage for CSF
- monitor for s/s meningitis
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diabetes insipidus
- deficient ADH from posterior pituitary
- neurogenic - disruption of hypothalamus or pituitary (head trauma, surgery)
- nephrogenic - kidneys not sensitive to ADH (renal failure)
- s/s:
- --polyuria (up to 12L/day)
- --dilute urine - low specific gravity, low osmolality
- --concentrated blood - high serum osmolality
- --polydipsia
- --dehydration
- --dilutional hypernatremia (fluid volume deficit causes increased Na level)
- tx: DDAVP (IV or intranasal), hypotonic fluids
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SIADH
- increased ADH from posterior pituitary
- caused by ectopic ADH production (cancer), head injury, pituitary surgery
- s/s:
- --water retention
- --decreased urine output
- --concentrated urine - high specific gravity, high osmolality
- --dilute blood - low serum osmolality
- --hyponatremia - aldosterone suppressed
- --mushy brain - brain cells swell - AMS, HA
- tx: fluid restriction, demeclocycline (tetracycline - increases output), diuretics
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serum osmolality
amount of chemicals dissolved in blood
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