2255 Endocrine

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What 2 hormones are produced by the hypothalmus and stored in the posterior pituitary

ADH, Oxytocin

What are the 2 hypothalamic hormones we are concentrating on

Thyropin-Releasing Hormone (TRH), Corticotropin-Releasing Hormone (CRH)

A gland responds to a low hormone level by releasing additional hormones, as the hormone level returns to normal the hormone release is inhibited this is considered what type of system

Negative feedback system (Simple)

The interaction of the hypothalamus, the anterior pituitary, and the thyroid, adrenal cortex, and gonads are all part of what type of system

Complex Negative Feedback System

List the 3 types of intrinsic rhythmicity

Rhythms originate in the brain structures, Circadian Rhythms (Diurnal) hormone levels fluctuate during a 24hr period, Ultradian Rhythms : longer than 24hrs

What hormones are produced by the anterior pituitary

GH, TSH, ACTH, Prolactin, FSH and LH

List the stimuli that will release the ADH (Anti-diruetic hormone) from the posterior pituitary

Increased serum osmolality, Decreased blood volume, Hypotension, Pain, N&V, Certain drugs (Lithium=hyponatremia)

This gland is located in the anterior portion of the neck in front of the trachea

Thyroid Gland

List the 2 thyroid hormones

Thyroxine (T4), Triiodothyrnine (T3), Calcitonin

What does Thyroxine (T4) and Triiodothyronine (T3) affect

Metabolism

What is Thyroxine (T4) and Triiodothyronine (T3) stimulated by

TSH from the anterior pituitary

What stimulates calcitonin to be produced by the thyroid

High calcium levels (may be malignancy)

What does the parathormone (PTH) from the parathroid glands regulate and what does it act on to regulate it.

Regulates calcium in the blood, acts on the Bone, Kidney and GI tract

What should the nurse be aware of with thyroid surgery and what must be checked before discharge

Respiratory distress due to inflammation, check calcium levels before discharge

What do the adrenal glands consist of

Inner Medulla and outer Cortex

What hormones does the adrenal medulla secrete

Epinephrine, Norepinephrine, and Dopamine

What are the functions of epinephrine

Fight or Flight, Induce release of free fatty acids, Increase BMR, Elevate blood glucose levels

What hormones does the adrenal cortex secrete

Glucocorticoids (Cortisol), Mineralocorticoids (Aldosterone), Androgens

With the pancreas where does endocrine activity occur

Islets of Langerhans

What 3 type of cells do the Islets of Langerhans have

Alpha, Beta, Delta

What does the Alpha, Beta, Delta cells produce of the pancreas

Alpha-Glucagon, Beta-Insulin, Delta-Gastrin, Somatostatin

What are the major endocrine alterations with aging

Decreased ovarian function (40-60yrs), Decreased ADH secretion (dehydration), Decreased thyroid hormone levels (might need replacement), Impaired glucose tolerance (might need oral hyperglycemic), Altered calcium homeostasis (osteoporosis)

This gland secretes hormones that maintain metabolic stability, carbohydrates, protein and fat metabolism

Thyroid Gland

What 3 hormones does the Thyroid Gland produce

Thyroxine (T4), Triiodothyrnine (T3), Calcitonin

These 2 thyroid glands primary functions is to control cellular metabolic activity and is important in brain development and normal growth

Thyroxine (T4), Triiodothyrnine (T3)

This thyroid hormone is secreted in response to high serum calcium

Calcitonin (Thyrocalcitonin)

___ is a condition of severely stunted physical and mental growth due to untreated congenital deficiency of thyroid hormone

Cretinism

Name 3 unique appearances that an infant will have with cretinism

Dull look, puffy face, thick tongue that sticks out

What is essential for thyroid hormone synthesis

Iodine

Where does the thyroid get iodine

(Diet) From the blood absorbed by the GI tract and concentrates it within the cells

What influences Thyroid stimulating hormone release

Thyroid releasing hormone by hypothalamus

List 3 diagnostic tests for thyroid disorders

TSH Assay, Radioactive Iodine Uptake, Thyroid Scan

What is the single best screening test for thyroid disorders and at what interval must it be done

TSH Assay (Every 6 months)

What hormone is used to confirm an abnormal TSH (T3 or T4)

Free (Unbound) Thyroxine (T4)

What hormone is the Active form of the thyroid hormone and a good indicator of hyperthyroidism

T3

What is thyroid enlargement called (caused by increased TSH)

Goiter

What is the nurses main concern with goiter

Airway

What is the management of goiter and what teachings could be done with the patient

Iodine meds (Lugol's or SSKI, Thyroid hormones), Teach patient need for diet higher in iodine and use of iodized salt

A patient will have slowed body metabolism, decreased heat production and decreased oxygen consumption with this disorder

Hypothyroidism

In primary hypothyroidism TH levels are ___ and TSH levels are ___

TH-low, TSH-high

What is the cause of secondary hypothyrodism. TH and TSH levels with be both ___

Malfunction of pituitary or hypothalamus. Both TH and TSH levels will be low

Due to low TH secretion there will be a ___ in metabolic rate, an ___ in serum cholesterol and triglycerides and stimulatory hormone secretion is increased (TSH) as compensation which results in ___

decrease in metabolic rate, an increase in serum cholesterol and triglycerides and stimulatory hormone secretion is increased (TSH) as compensation which results in goiter

Describe the integumentary, Pulmonary, Cardiovascular, Hematologic, Gastrointestinal, Neurologic, Musculoskeletal and Reproductive systems with hypothyroidism

Integument (Dry coarse hair, cool dry scaly skin), Pulmonary (Dypsnea), Cardio (Bradycardia, hypotension, activity intolerance, dysrhythmias

What is the collaborative management for hypothyroidism

Correct thyroid deficiency (synthroid, Levothyroid, Assess labs), Minimize cardiac dysfunction (monitor for bradycardia, low urine output, hypotension, arrhythmias)

What is the term for extreme hypothyroid

Myxedema

What are the manifestations of Myxedema

Cellular metabolite build up of mucous and water, Non-pitting edema (eyes, hands, feet, between shoulders), Hypercholerterolemia, hyperlipidemia, and proteinemia may occur, tongue thickens voice becomes husky.

What is Myxedema coma precipitated by

Stressor (sugery, infections)

What happens to the heart with myxedema and what are other complications that may occur with myxedema coma

becomes flabby, chamber size increases results in decreased cardiac output and perfusion to the brain, (hypoventilation, hypothermia, hypotension, hypothermia, hypotension, hypoglycemia may occur)

What is the management of the myxedema coma

Maintain patent airway, replace fluids, monitor BP, Levothyroxine, glucose, steroids IV as ordered, cover patient with blankets (hypothermia), monitor mental status changes.

This is inflammation of the thyroid gland and an autoimmune disorder where thyroid tissue is DESTROYED causing decreased hormone levels and increased TSH levels and affects women more than men 30-50 years of age

Hashimoto's Disease

What are the manifestations Hashimoto's disease

Dysphagia, Thyroid enlargement

What is the management of Hashimoto's disease

Thyroid hormone replacement or surgery if affecting airway

What is the nursing management for a patient receiving Synthroid

Monitor labs, I&O, Weights, VS

What is the mechanism of action of Synthroid

Increases metabolic rate, Controls protein synthesis, Increases cardiac output, body temperature, and renal blood flow

What is the most common form of Hyperthyroidism

Grave's Disease

Hyperthyroidism will have ___ levels free T3&T4 and ___ levels of TSH

High levels of T3&T4 and low levels of TSH

What are the etiologies of hyperthyroidism

Grave's Disease, Thyroid carcinoma, Ingestion of thyroid hormone, Benign Adenomas, Subacute and Chronic Thyroiditis

This is an autoimmune disorder mediated by antibodies that activate TSH receptors. Excessive stimulation of Adrenergic nervous system or excess circulating TH

Grave's Disease

What are the 3 major characteristics of Grave's Disease

Hyperthyroidism, Thyroid Gland Enlargement, Exophthalmos

Describe the pathophysiology of hyperthyroidism

Excessive stimulation of SNS or excess circulating thyroid hormone leads to Hypermetabolism, Negative nitrogen balance, weight loss, cardiac system is stimulated. Results in altered secretion and metabolism of other hormones from Hypothalamic, Pitituitary, Gonadal

What are the clinical manifestations of Hyperthyroidism in the Integumentary, Pulmonary, Cardiovascular, Gastrointestinal, Neurologic, Musculoskeletal, Reproductive

Integument (Diaphoresis, warm moist skin, thinning of scalp hair), Pulmonary (SOB), Cardio (Palpitations, Tachycardia, chest pain), Gastro (weight loss, increased appetite, diarrhea), Neuro (Tremors, insomnia, irritability, paranoia), Muscle (weakness), Reproductive (amenorrhea, decreased menstrual flow, increased libido, impotence)

What do the lab values show for Grave's Disease (TH, Serum cholesterol)

TH levels increased, Serum Cholesterol decreased (Antibodies to TSH measured for Grave's)

What are the complications / interventions for Grave's Disease Exophalmus

May not regress with therapy, Treated with diuretics, steroids, eyedrops, radiation, or surgery, Have patient wear dard glasses, Elevate HOB at night, Restrict salt intake

What type of heart complications and rhythm are know for Grave's Disease

Heart disease, Tachycardia, Atrial Fib.

This complication of Grave's disease has an episode of acute thyroid overactivity and the patient will have a high fever, Tachycardia, and dehydration

Thyroid Storm

What is the therapies for hyperthyroidism

Antithyroid drug to decrease TH (Iodide, PTU, Tapazole), Radioactive Iodine Therapy (1-2 months to be effective), Beta blockers for HR, Potassium Iodide (Blockade of thyroid hormone release

What type of diet, environment and activity considerations should be made for hyperthyroidism

High calorie, High Protein diet (4000-5000 Cal), Daily Weight, Environment cool, Promote rest periods and VS

What is the pre-op preperation for a Total or Sub-total Thyroidectomy

Patient must be euthyroid (no activity of thyroid hormone), may take 2-3 months, Patient should be optimal weight

What should be monitored after a thyroidectomy

ABC's, dressing for bleeding (look under head), Respiratory obstruction, Laryngeal Edema, Vocal cord Injury (O2 suction, Trache set at bedside monitor for hoarseness, voice weakness) Monitor for hypocalcemia/Tetany

This presents as a hard, irregular painless nodule in an enlarged thyroid gland

Thyroid cancer

How is thyroid cancer confirmed

Biopsy

Can you use radioiodine uptake scan if you suspect thyroid cancer

no

What electrolytes does the parathyroid gland maintain

Calcium and Phosphate balance

What 3 body systems does PTH work on to reasorb calcium

Bone, Kidney, Intestine

What does chronic levels of PTH lead too

Bone damage, Hypercalcemia, Kidney Damage, PUD, Changes in mental function

List the pathophysiology in primary hyperparathyroidism

Calcium transported into the blood from the intestine, kidneys and bone

List the pathophysiology in secondary hyperparathyroidism

GFR decreases, Phosphate levels Increase, Calcium levels decrease, PTH secretion stimulated to decrease phosphate levels

What are the clinical manifestations of hyperparathyroidism for Musculoskeletal, Renal, Gastrointestinal, Neurologic

Muscle (Joint and bone pain, fatigue, weakness, osteoporosis, pathologic fractures), Renal (Hypercalciuria, Kidney stones, UTI, Polyuria), Gastro (N&V, Constipation, PUD, Pancreatitis), Neuro (Emotional instability, Memory Impairment, Psychosis, Confusion, Delirium)

What is the normal serum calcium level

8-11mg/dl

What is the normal serum phosporus level

2.5-4.5 mg/dl

What will hyperparathyroidism show in the levels of serum calcium, and phosporus

Increased Calcium, Decreased Phosporus

What will hyperparathyroidism show in the levels of serum alkaline phosphatase if there are bone disorders

Increased levels

What will the PTH Radioimmunoassay test show with hyperparathyroidism

High concentrations

Collaborative management of hyperparathyroidism. How will calcium levels be lowered

Hydration (NS) and Diuretics

What is the drug therapy for hyperparathyroidism

Phosphates (inhibit bone resorption), Calcitonin (increases Ca excreation), Mithracin (binds calcium), Gallium Nitrate (Ganite)

What should be encouraged with hyperparathyroidism

Mobility

What are 2 risks with hyperparathyroidism

Risk for injury related to demineralization of bones and Risk for altered urinary elimination (Stones)

What is the management with nutrition and fluids with hyperparathyroidism

Increase fluid intake, Acidify urine, Improve patients appetite, minimize constipation.

What should be monitored after a parathyroidectomy

Similar to thyroidectomy ABC's, dressing for bleeding (look under head), Respiratory obstruction, Laryngeal Edema, Vocal cord Injury (O2 suction, Trache set at bedside monitor for hoarseness, voice weakness) Monitor for hypocalcemia/Tetany

What are the etiologies of hypoparathyroidism

Accidental removal of gland during thyroidectomy, inadequate blood supply to glands

What will lab's values show with phophate and calcium with hypoparathyroidism

Increase phosphate, decreased calcium

Describe the pathophysiology of hypoparathyroidism

PTH deficiency, Decreased absorption in intestines, muscular irritability develops

What are the clinical manifestations of hypoparathyroidism for neuromuscular and cardiovascular

Neuromuscular irritability (positive Trousseau's and Chvostek's sign, Numbness and tingling of extremities, Cramps both GI and muscle, Hyperactive DTR's, Tetany) Cardio (arrhythmias)

What will tests with bone, brain and eye show with hypoparathyroidism

Increased bone density, Calcification in Brain, Calcification of ocular lens in eyes

What is the collaborative management of hypoparathyroidism (drugs to raise calcium)

Calcium gluconate, Oral calcium, Phosphate binders (Amphogel, Gelusil), PTH, Vitamin D, High Calcium low phosphate diet, (Cheese and milk have high phosphorus), Monitor for seizures and tetany

What hormones are released by the Adrenal cortex

Glucocorticoids, ACTH, Mineralcorticoids, Androgens

What regulates glucocorticoids

ACTH

What is the action of glucocorticoids

Promotes gluconeogenesis (maintains blood glucose levels), Inhibits inflammatory response to tissue injury, Suppresses allergic reactions

What is the action of ACTH (Adrenocorticotropic Hormone)

Regulates MSH (melanocyte stimulating hormone) and skin pigmentation

What is the action of mineralcorticoids

primary hormone is aldosterone, promotes sodium and water retention

What is the action of androgens

Increase in males=decrease in libido, impotence, Increase in females=acne, hirsutism, Decrease in females=amenorrhea, loss of body hair

What is the name of the disease for Adrenal insufficiency

Addison's Disease

Abrupt stopping of this can lead to Addison's Disease

Steroids

What are the manifestations of Addison's Disease (Musculoskeletal, Cardiovascular, Integumentary, Neurological, Gastrointestional)

Muscle (Weakness, fatigue, joint/muscle pain), Cardio (Anemia, Hypotension, Hyponatremia, Hyperkalemia), Integument (Vitiligo no uniform pigmentation, Hyperpigmentation), Neuro (mental confusion, mild depression), Gastro (Hypoglycemia, anorexia, weight loss, N&V)

What are the diagnostic findings of Addison's Disease (Cortisol, ACTH, Blood Glucose, Sodium, Potassium,

Decrease Cortisol, Increase ACTH, Decrease Blood glucose, Decreased sodium (sometimes), Increase serum potassium

This is an acute, Life threatening emergency caused by insufficient adrenocortical hormones

Addisonian Crisis

What is the Addisonian Crisis precipitated by

Stressor

What is the manifestation of Addisonian Crisis

Dehydration, Hypotension, Hyponatremia, Hypoglycemia

What is the treatment for the Addisonian Crisis

IV 0.9NS to restore volume, Replace steroids with hydrocortizone, Correct Lyte and blood sugar imbalances, monitor VS

With patient teaching with steroids

2/3 in morning, 1/3 in afternoon, Dietary modification during diaphoresis, Adjust doses for minor illnesses and stress, Teach to monitor BP, KEEP EMERGENCY STEROID INJECTION KIT AVAILABLE, Wear ID bracelet, Monitor for osteoporosis

What is the name of the mineralcorticoid and when should it be taken

Florinef (take in PM)

What drug is taken for hypotension with Addisonian Crisis

Midodrine hydrochloride is a vasopressor/antihypotensive agent

This disease is a rare and results from adrenal overactivity, pituitary tumors, non-endocrine tumors, or adrenal cancer

Cushing's Disease

What is Cushing's syndrome caused by

Long-term administration of steroids for treatment of illness

What are the clinical manifestations of adrenal hyperfunction (Cardiovascular, Integumentary, Musculoskeletal, General)

Cardio (HTN, Edema), Integument (Thin fragile skin, purplish red striae, bruises, poor wound healing, decreased s/s inflammation), Muscle (wasting, osteoporosis), General (Truncal obesity, Buffalo Hump, Moon Faces, Hirsutism, Acne)

What are the diagnostic findings of Cushing's (Sodium, Potassium, Blood glucose, Urinary and blood cortisol, WBC)

Na increased, K decreased, Blood glucose increased, urinary and blood cortisol increased, WBC increased (Leukocytosis maybe)

What is the management in adrenal hyperfunction (Drug therapy to inhibit corticosteroid synthesis), (Interferes with ACTH production)

Mitotane (Lysodren), Aminoglutethimide (Cytadren), Trilostane (Modrastane) INTERFERES - (Bromocriptine, Somatostatin)

What is the surgical management if increased pituitary secretion of ACTH

Transphenoidal Hypophysectimy or Hypophysectomy

What is the surgical management if hypercortisolism from adrenal adenomas or cancer

Partial or complete adrenalectomy or Laproscopic adrenalectomy

What is the pre-op care for an adrenalectomy or hypophysectomy

Correct Electrolytes, Monitor Blood Glucose (Treat hyperglycemia), Increase calorie and protein intake, Minimise risks for falls, Administration of glucocorticoids pre, intra, and post

Where is the incision for the transphenoidal approach

Above upper lip through sphenoid sinus

What is the post-op management for transphenoidal hypophysectomy

Monitor for DI, Monitor nasal drainage (Presence of glucose-csf), Light yellow color at edge of clear drainage = halo sign = csf, Complaint of headache may indicate leakage of csf

What should the patient be taught after transphenoidal hypophysectomy

No brushing teeth for 2-3 weeks, Avoid coughing, straining upon defecation post-op, Teach about replacement steroids

What needs to be monitored after an adrenalectomy in critical care and what should be prevented

Prevent shock and infection monitor VS, I&O, LABS, Electrolytes, prevent skin breakdown, pathologic fractures, GI bleeding

What is the primary cause of hyperaldosteronism

Conn's Syndrome from adrenal lesion

What is the secondary cause of hyperaldosteronism

Diuretic, Laxative abuse, Renal disease

What electrolyte imbalances does hyperaldosteronism lead to

Hypernatremia, Hypokalemia

What is the medical management of hyperaldosteronism

Decreased Na diet, Spironolactone, Increase Potassium in diet, of potassium supplements

This is a catecholamine producing tumor that arises mainly in the adrenal medulla

Pheochromocytoma

What is the peak incidence of pheochromocytoma

20-50

What cells of the SNS in the adrenal medulla form the benign tumor

Chromaffin cells

What is the mechanism of action of epinephrine

Constricts superficial blood vessels, Dilates brain, coronary vessels, muscles, Raises BP and Pulse dramatically, Increases CO, Increases RR, Stiumlates CNS, Dilates pupils, Increases alertness

What are the clinical manifestations of pheochromocytoma

Headache (worst ever had), Diaphoresis, Palpitations, Hypertension (persistent, fluctuating, paroxysmal), Symptoms of DM (Glucosuria increased BS), Anxiety emotional instibility, N&V

What are the 5 H's of sympathetic nervous system overactivity

Hypertension, Headache, Hyperhidrosis, Hypermetabolism, Hyperglycemia

What is the prep for a urinary VMA (24hr urine) for pheochromocytoma

No meds 2-3 days prior to test, No chocolate, tea, vanilla, fruits 2 days prior to test

What is the pro-op management (7-10 days) for pheochromocytoma

rest, relief from stress, dark room, increase calories, vitamins, no caffeine, monitor VS

What is the pharmacologic therapy pre-op for pheochromocytoma

Administer prescribed sedatives, Alpha blocking agents (Nipride, Regitine, Dibenzyline (long lasting), Inderal (if not responsive to alpha blockers)

What should be assessed for after an adrenalectomy

hypoglycemia, Lytes (K, Na) monitor for shock

What is the most common hormone secretion tumor with hyperpituitarism

Prolactin

What does prolactin inhibit and result in

Inhibits secretion of gonadal steroids, results in galactorrhea, amenorrhea, infertility

What drug reduces serum prolactin

Bromocriptine (Parlodel)

This hypersecretion is prior to puberty resulting in accelerated linear growth and result is excessive but proportionate height

Gigantism

This hypersecretion is after puberty causing growth of extremities caused from GH producing cells of the pituitary

Acromegaly

What are the clinical findings for acromegaly

Enlarged feet and hands, Protrusion of lower jaw, Joint enlargement and pain, Excessive sweeting (hands, feet, face), Coarse facial hair, Hyperglycemia, Airway narrowing-sleep apnea, Organomegaly

What is the drug therapy for hyperpituitarism

Octreotide (Sandostatin) - acts on anterior pituitary to inhibit GH for acromegaly, Bromocriptine (Parlodel) - decreases prolactin levels by inhibiting release used in hyperprolactinemia

What is the post-op management for transphenoidal hypophysectomy

No bending at waist or tying shoes, minimize constipation, avoid toothbrushing for 2 weeks

What drug might be needed to maintain fluid balance after a transphenoidal hypophysectomy

Vasopressin

This deficiency causes limited growth and dwarfism

Hypopituitarism

List some non-specific symptoms of hypopituitarism

weakness, fatigue, headache, sexual dysfunction, fasting hypoglycemia

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