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Adrenal Cortex secretes
- mineralcorticoids (Aldosterone)
- glucocorticoids (cortisol)
- Androgens
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Adrenal Medulla secretes
- epinephrine
- norepinephrine
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Pancreas secretes
- glucagon
- insulin
- Somatostatin
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Thyroid secretes
- thyroxine T4
- Triodothyronine T3
- thyrocalcitonin
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Parathyroid secretes
parathromone
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Anterior pituitary gland secretes
- adrenocorticotropic hormone (ACTH)
- melanocyte
- TSH
- Gonadotropic hormone (LH and FSH)
- Prolactin
- Growth Hormone
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Posterior pituitary gland secretes
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Testes secretes
Androgens (Testosterone)
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The adrenal cortex influences F&E balance through the secretion of.....how?
aldosterone
it increases sodium retention and potassium excretion by the kidneyes
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How does the adrenal cortex raise blood glucose levels?
by releasing glucocorticoids (cortisol)
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How does the anterior lobe of the pituitary gland stimulate thyroid and adrenocortical secretion?
by secreting TSH and ACTH
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What does the posterior pituitary gland do?
promotes water retention by secreting ADH, thus decreasing urine output
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Where does the synthesis of the 2 posterior pituitary hormones (ADH, Oxytocin) occur?
hypothalamus
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Clinical manifestations of hyperthyroidism
- tremors
- tachy
- exophthalmos (bulging eyes)
- diarrhea
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Clinical manifestations of hypothyroidism
- weight gain
- dry brittle hair
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Clinical manifestations of Cushings Disease
- weight gain
- Hirutism (excessive body hair)
- buffalo hump
- moon face
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Clinical manifestations of Addison's disease
- fatigue
- weight loss
- skin hyperpigmentation
- orthostatic hypotension
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What does the endocrine system do?
- consists of glands and hormones
- hormones regulate metabolic processes and energy production
- balance F&E
- provide stress response
it is a communication system that links all of the other body systems
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What part of the brain makes and secretes inhibiting hormones?
hypothalamus
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Positive feedback loop vs. Negative feedback loop
positive stimulates the release of hormones when levels are low.
negative stops the release of hormones when levels are high
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How is endocrine dysfunction treated?
- replace missing hormones
- or
- suppress the hormone when levels are too high
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What does prolactin do?
stimulates mammary tissue growth and lactation
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What does thyrocalcitonin do?
regulates calcium and phosphorous levels
stops calcium reabsorption from bone and prevents bones from being broken down and the release of calcium in to the blood
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What does cortisol do?
- promotes carb, protein and fat metabolism
- increases tissue response to other hormones
- part of the stress response
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What does aldosterone do?
increases sodium retention and K excretion
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How does aldosterone have a direct impact on CO?
by increasing sodium retention, fluid volume is increased, which increases blood pressure....increasing CO
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LH and FSH do what?
affect growth, maturity and functioning of primary and secondary sex organs
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What does ADH and Vasopressin do?
Na and water reabsorption-promotes reabsorption of water by the distal tubules and collecting ducts of the kidney, thus decreasing urine output
vasoconstriction
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What stimulates the ejection of milk from the mammary glands and stimulates uterine contractions?
oxytocin
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What do T3 and T4 do?
regulates metabolic activity of all cells and processes of cell growth and tissue differentiations
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Where is T3 converted to T4?
in the liver and peripheral tissues
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What does parathormone do?
regulates calcium and phosphorous blood levels
promotes bone breakdown and increases intestinal absorption of calcium and the excretion of phosphorous in the kidneys
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What does thyrocalcitonin do?
regulates calcium and phosphorous blood levels
decreases serum calcium by preventing calcium reabsorption from the bone
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Which hormone increases and decreases calcium levels
thryocalcitonin decreases and parathormone increases
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What do epi and norepi do?
- stress response....
- elevate bp
- convert glycogen to glucose
- increase hr
- increase cardiac contractility
- dilate bronchioles
- prolongs effects of sympathetic nervous system
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What does insulin do?
promotes metabolism of cholesterol, proteins and fat, thus decreasing blood glucose levels
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What does glucagon do?
mobilizes glycogen stores causing an increase in blood glucose levels
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Somatostatin
decreases secretion of insulin, glucagon, growth hormone and several GI hormones
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What is the sign of low serum cortisol?
during stress the person will still have low bp
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How do you check a hormone problem?
figure out if the problem is with the gland? Or is it the problem in the axis...so you must look above the gland for the problem.
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How do you figure out where the problem is if a person has low cortisol....specifics.
primary problem-this is a result of the gland not kicking out cortisol (gland isn't functional)
- secondary problem-draw cortisol levels and give the patient synthetic cortisol.
- wait an hr
- draw cortisol levels again
- if cortisol increased, then the problem is somewhere in the axis
- but if the give synthetic cortisol and no change (cortisol level stays low) then the gland is the problem
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What's the problem with hyper-pituitaryism? What's usually the problem?
no negative feedback causing secretion of hormone in excess
benign tumor on the pituitary gland
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2 problems result of excess growth hormone
gigantism and acromegaly
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Gigantism
from too much GH prior to the closure of the growth plates
causes rapid proportional growth in the length of all bones
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Acromegaly
occurs after the growth plates have closed
- results in lg features
- cardiomegaly w/ LV hypertrophy
- CHF
- HTN
- increased glucose
- visual problems
- hoarseness
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Who recognizes acromegaly a lot of the time?
the dentist....changes in x ray. Will ask to see an old/wedding picture of the client for comparison
or you notice a change in shoe size....these changes are subtle
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How do you dx acromegaly?
- Hx and physical
- MRI of brain (tumor causes)
- Test looking at growth hormone response to glucose
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Describe how growth hormones response to glucose can dx acromegaly
GH is inhibited by glucose.
- give GH x2 along with 75-100g of glucose
- GH level should decrease, but if you have acromegaly it wont decrease
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What is the goal of care for a person with acromegaly?
to return GH levels back to normal....done with meds, surgery, radiation
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Surgery to correct acromegaly
Hypophysectomy
- surgery to snip out the tumor on the pituitary gland
- can get to the sinuses and then pituitary gland thru the nose or upper lip
will decrease hormone levels, reverse soft tissue body changes
skeletal changes will stay and may still have visual problems
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Post op care for the person having hypophysectomy surgery
- Neuro checks....brain surgery
- Monitor fluid balance....watching for output greater than input (dumping urine)
- Teach don't cough, sneeze, blow nose
- Teach don't brush teeth....floss till incision heals
- Monitor nasal drip for s/s of CSF leak
- Monitor BM to prevent constipation....strain = increased ICP
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Transphenyodal Hypophysectomy
through the nose surgery
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Importance of hormone replacement after hypophysectomy
hormone replacement is important and all anterior pituitary hormones need to be monitored
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Why can a person after hypophysectomy surgery dump urine?
Because they can have transient diabetes insipudus....this means they are not secreting enough ADH so they diurese....dump urine
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3 meds to treat Acromegaly/Gigantism
and why are they used?
- Sandostatin
- Dostinex
- Somavert
usually as a bridge for treatment while prepping for surgery
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How does Sandostatin work?
decreases GH levels
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How does Dostinex work?
blocks the secretion of GH
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How does Somavert work?
blocks the uptake of GH
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What is the patient with acromegaly/gigantism most concerned with?
body image
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What's the problem with Cushings Disease?
high levels of glucocorticoids and mineralcorticoids
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What's the result of hypopituitaryism?
- growth retardation from low levels of GH
- metabolic abnormalities from low ACTH and TSH
- sexual immaturity from low FSH and LH
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What is panhypopituitarianism?
partial or total failure of production of all the anterior pituitary hormones
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Which 2 hormones are the most fatal to be deficient in?
ACTH and TSH
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What causes hypopituitaryism?
- tumor
- surgical hypophysectomy
- radiation
- trauma
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Clinical manifestations of hypopituitaryism
- headache
- visual changes
- seizures
- weakness
- decreased energy
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Deficiencies of gonadotropins with hypopituirarism causes....
infertility in men and women
delayed onset of puberty in males
ovarian failure, amenorrhea and loss of secondary sex characteristics in females
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How do you dx hypopituitarism?
- Hx and physical
- MRI, CT
- Labs to measure hormones....all!!
- GH
- ACTH
- Cortisol
- T3, T4
- Testosterone/progesterone/Estrogen
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Collaborative care for the treatment of hypopituitarism
lifelong hormone replacement
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Contraindication meds for persons with hypopituitarism?
males....cant take testosterone if have had prostate cancer
females....cant take estrogen if have had breast cancer, phlebitis or problems with pulmonary embolism
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What is the desired effects of giving a person with hypopituitarism testosterone?
Testosterone-return of secondary sex characteristics, libido, deep voice and no problems with sterility
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What will happen if a person with hypopituitarism gets estrogen/progesterone prior to puberty?
their epiphyses will close
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Estrogen therapy causes....
DVT and HTN
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What do you teach a person who is on estrogen therapy?
cant take if you have hx of clots, breast cancer or htn.
Teach: watch blood pressure and drink plenty of fluids
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What can cause disorders of ADH?
- TBI
- anything that affects the hypothalamus, pituitary gland or post transhypophosectomy surgery
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What causes Diabetes Insipidus?
deficiency in ADH....without ADH you will have massive diuresis
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Clinical manifestations of Diabetes Insipidus
- Excessive thirst from dehydration
- Increase in frequency of urine
- dilute urine
- hypernatremia
- hypotension....that can lead to hypovolemic shock
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Diabetes Insipidus will have the following labs:
Specific gravity-
Serum Osmolality-
Urine output-
Na levels
- Specific Gravity <1.005
- Serum Osmolality 300+
- Urine output of >250 cc/hr for 2 hrs
- Na levels >145
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How do you treat Diabetes Insipidus?
- It is self limiting
- replace F&E with hypotonic saline solution (.45% saline or D5) cc for cc
- medications
- low sodium diet
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Test to dx Diabetes Insipidus
- withhold water and test urine, plasma osmo, urine spec. gravity and BP
- give ADH and then remeasure urine osmo
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2 meds to treat Diabetes Insipidus
DDAVP and Diabinaase
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How does DDAVP work for Diabetes Insipidus?
given PO, IV or nasal spray
know it is working quickly....will see decreased UO to normal levels, increase in specific gravity and serum osmolality with be normal
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When do you take Diabinaase for Diabetes Insipidus and how does it work?
when you haven't lost all of your ADH
makes kidneys more responsive to ADH that is still there
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2 specific ways to get Diabetes Insipidus
24-48 hrs after brain injury to the pituitary or hypothalamus this can occur
Post transhypophysectomy from GH increase.
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What do I need to teach a person who just had hypophysectomy?
Once discharged from the hospital watch out for s/s of Diabetes Insipidus
typically occurs 24-48 hours after surgery
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SIADH-what is it and who is at risk to get it?
Syndrome of Inappropriate Antidiuretic Hormone secretion
too much ADH....causing hyponatremia
old people and people with small cell lung cancer
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Patho of SIADH
Too much ADH causes water retention resulting in dilutional hyponatremia and expansion of the extracellular fluid volume. Increase in plasma volume causes and increase in glomerular filtration rate and inhibits the release of renin and aldosterone
Concentrated urine with normal kidney function
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Labs for a person with SIADH
- Serum Na <134
- Serum Osmolal <280
- Urine specific Gravity >1.005
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What is the main problem with SIADH
risk of seizures
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S/S of SIADH
- Hyponatremia
- decreased LOC
- headache
- lethargy
- seizures
- coma
- confusion
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How do you treat SIADH?
- Fluid restriction
- Admin. hypertonic solutions-D5NS, D5LR
- Seizure precautions
- frequent turning
- oral hygiene
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VS you will see in a person with SIADH
increased BP, but low sodium
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When you give a hypertonic IV solution to a person with SIADH what do I need to do?
- monitor them q 1hr for neurologic dysfunction
- serial electrolyte checks q4-6 hrs
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When a person has a serum Na of >125 why can I give Lasix?
because the Lasix will make you lose the water but keep the sodium....causing an increase in sodium levels
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When a person has a serum Na of >125 why would I give Lithium or Declomycin?
cuz they block the effect of ADH on the renal tubules making urine dilute....increasing sodium levels
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What is thyrotoxicosis
s/s that appear when excess TH stimulates the body....the feedback loop has failed
patient ends up hypermetabolic w/ increased nervous system activity
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What is thyroid hormones effect on the body?
- increases SV and HR
- which increases BP and then CO
- increases blood glucose levels
- increases protein degredation and fat metabolism
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How do you get hyperthyroidism?
- over function of the gland
- thyroid adenoma-tumor
- Pituitary adenoma...causes increase in TSH
- over treatment of myxedema (hypothyroidism)
- thyroid carcinoma
- graves disease
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Example of primary and secondary hyperthyroidism
- Thyroid Adenoma-primary
- Pituitary Adenoma-secondary
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What causes Graves Disease?
Auto Immune Disease
TSH antibodies bind to receptors keeping them activated causing TH to continue to be produced....= hyperthyroidism
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How do you get a goiter?
over active thyroid gland causes it to hypertrophy
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S/S of hyperthyroidism/Graves Disease
- Exopthalmos-protruding eyes
- Heat Intolerance
- Increase HR and BP
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What does thyrocalcitonin do?
it's job is to decrease calcium levels by preventing bone resorption
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What's a thyroid storm?
a potentially fatal acute episode of thyroid overactivity...
death from impact on heart...CHF to shock
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What can cause a thyroid storm?
- goiter being vigorously palpated
- undiagnosed or under treated hyperthyroid
- infection, stress, surgery when you have hyperthryoidism
- thyroid ablation
- med OD
- Inadequate prep of clients for thyroid surgery
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S/S of thyroid storm
- fever 105
- tachy
- systolic htn
- agitation
- anxiety
- confusion
- psychosis
- seizures
- HEAT INTOLERANCE
- ABD pain
- N/V
- BM...diarrhea
- Increase BG and BP
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What's the medication to give first if a person is having a thyroid storm? Why?
Inderall
blocks the effects on the heart
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Two anti thyroid meds and how do they work
PTU...impairs synthesis of TH, and allows the thyroid to store more TH
Methimazole....blocks the action of TH in the body
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Describe Iodine therapy for hyperthyroidism
- It is used to reduce the vascularity of the gland before surgery....called SSKI
- It also inhibits the release of thyroid hormones into circulation, by increasing the glands ability to store more TH
- Give PTU with it so the thyroid can store more hormone
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What medication shouldn't a person with hyperthryroidism take? Why?
Aspirin/Salicylites
causes the release of more TH
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Pre op for a person having a thyroidectomy
- check thyroid levels
- VS
- control cardiac problems
- prepare for possible airway complications post op
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Post op care for a person after a thyroidectomy
- Assess for respiratory compromise...neck surgery
- Monitor VS closely
- Assess for tetany
- Teach about needs to do lab follow up and daily thyroid hormone replacement for life
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Why am I watching for tetany in a person post thyroidectomy?
cuz will probably take out parathyroid too...which regulates calcium. So watch for hypocalcemia
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Cretinism
congenital hypothryoidism
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Mixedema
soft tissue edema...puffy face
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S/S of hypothyroidism
- fatigue
- hemodynamic compromise issues
- brady
- hypotension
- constipation
- cold intolerance
- weight gain
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What causes mixedema coma and give examples
extreme stressor plus hypothyroidism
- acute illness
- abrupt withdrawl of thyroid meds
- anesthesia
- sedatives
- narcotics
- surgery
- hypothermia
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Dx of hypothyroidism
- H&P....had hyperthyroidism...thyroidectomy
- Labs....
- TSH
- Free T4
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Treatment for hypothyroidism
- Synthroid/Levothyroxine
- prevent cardiac and arterial damage
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First time a person takes synthroid what do I monitor?
cardiovascular status...especially in older patients
- chest pain
- arrhythmias
- increased BP
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What is the most important nursing dx for hypothyroidism/myxedema?
Knowledge deficit of life long thyroid replacement, and avoid sedatives
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Nursing management for a person with mixedema coma
- *Maintain a patent airway
- replace fluids
- IV Levothyroxine
- Admin glucose IV
- Admin corticosteroids
- Monitor temp and gradually warm them
- VS
- Watch for LOC change
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Least aggressive thyroid cancer and how is it treated?
Papillary adenoma
surgery...excellent prognosis
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Most aggressive thyroid cancer and how is it treated?
Anaplastic carcinoma
highly malignant, treat palliatively using surgery, radiation, chemo. prognosis is grave.
Temporary trach
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Which thyroid cancer will the patient have a temporary trach?
Anaplastic Carcinoma...
Post op watch for airway issues and tetany from hypocalcemia
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What do you teach a patient who is on levothyroxine?
it causes increased myocardial O2 requirements....report chest pain and arrhythmias
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Any medication that replaces TH watch for these problems
- diarrhea
- cramps
- tachy
- heat intolerance
- weight loss
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