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The endocrine system

- Consists of a group of glands that produce hormones
- Works with nervous system to control and coordinate all other body systems
- Effects body systems by chemical stimuli
- Tissues other than endocrine glands also secrete hormones. Ie Brain, Digestive organs, kidney


- Travel through the blood to specific receptor sites.
- Exert their effects on target tissue
- the specificity of hormone-target cell interaction is determined by receptors in a "lock-and-key" type of mechanism.
- Regulation of hormone levels in the blood depend on a highly specialized mechanism called feedback

Hormone classification

- Steroid hormones: hydrocortisone
- Peptide/protein hormones: insulin
- Amine hormones: epinephrine
- Fatty acid derivatives: retinoids

Feedback mechanisms

- change in homeostatic environment
- signal sent to CNS
- Signal sent from CNS
- produce effect
- Body returns to homeostasis

Positive feedback

- Not common
- Increases the target organ action beyond normal.

Positive feedback
Classic example

- action of oxytocin on uterine muscles during birth
- Baby pushes on cervix sends signal to hypothalamus
- Hypothalamus manufactures oxytoxin
- Oxytocin is transported to posterior pituitary and released
- Oxytocin stimulates uterine contraction
- the loop stops when the baby leaves birth canal

Negative feedback

- Most common control mechanism
- like a thermostat
- lack of homeostasis of a hormone in the blood or body turns on the production of said hormone at the hypothalamus and pituitary.
- when homeostasis is returned, the loop is shut off.

Basic structure of a feedback loop

- An environmental stimulus occurs
- This stimulates the control center (aka brain-hypothalamus)
- Hypothalamic hormones stimulate the pituitary
- Pituitary hormones stimulate the target area
- The target area produces a change
- the change acts negatively or positively on the cycle.


- The "master gland" of the neuroendocrine system
- Constantly monitors the body's homeostasis
- analyzes input from the periphery and the CNS
- coordinates response through the autonomic, endocrine, and nervous systems

Hypothalamic hormones

- Release inhibiting hormones (turn pituitary off)
- Releasing hormones (turn pituitary on)

Release inhibiting hormones

- somatostatin
- Prolactin release inhibiting hormone

Releasing hormones

- Thyrotropin releasing hormone
- Growth Hormone Releasing hormone

Connection to pituitary

- Neuronal connection to the posterior pituitary
- Endocrine connection to the anterior pituitary

Hypothalamus and the anterior pituitary

- The hypothalamus secretes releasing factors to cause the anterior pituitary to release stimulating hormones
- These hormones act with specific endocrine glands to cause the release of hormones or stimulate cells directly
- This stimulation shuts down the production of releasing factors
- Leads to decreased stimulating factors and decreased hormone release.

The Hypothalamic-pituitary axis (HPA)

- Most feedback loops run through this axis.
- HPA mediates growth, metabolism, stress response and reproduction.
- is secondarily in charge of almost everything else.

Posterior Pituitary hormones

- manufactures in hypothalamus, but released from the posterior pituitary.
- Oxytocin


- Target is smooth muscles of the uterus and breast.
- Functions in labor and delivery, and milk ejection


- Target: kidneys
- Function: water reabsorption

Anterior Pituitary hormones

- Thyroid Stimulating hormones (TSH)
- Growth Hormone (GH)
- Adrenocortico-tropin Hormone (ACTH)
- Prolactin (PRL)
- Follicle stimulating Hormone (FSH)
- Luteinizing Hormone (LH)

Thyroid Stimulating hormones (TSH)

- Target: Thyroid gland
- Function: Thyroid hormone synthesis and release

Growth Hormone (GH)

- Target: many tissues
- Function: growth

Adrenocortico-tropin Hormone (ACTH)

- Target: Adrenal cortex
- Function: Cortisol release (androgens)

Prolactin (PRL)

- Target: Breast
- Function: Milk production

Follicle stimulating Hormone (FSH)

- Target: Gonads
- Function: Egg/Sperm production

Luteinizing Hormone (LH)

- Target: Gonads
- Function: Sex hormones


- Uncommon disease that occurs in adults exposed to continuously high levels of Growth Hormone
- Begins insidiously around 40-45


- A primary GH secreting pituitary adenoma is the most common cause.
- Leads to unwanted growth of bones and other soft tissue.


- occurs if high levels of growth hormone present before epiphyseal plates close

Clinical Manifestations

- Enlargement of hands and feet
- Distortion of facial features, lower jaw and forehead protrude
- Enlargement of soft tissue around eyes, nose, mouth and tongue.
- Skin becomes thick, leathery, oily
- may have peripheral neuropathy

Syndrome of Inappropriate ADH (SIADH)

- high levels of ADH without normal physiologic stimuli for release.
- Released despite normal or low plasma osmolarity
- Failure of negative feedback system

Syndrome of Inappropriate ADH (SIADH)

- Malignancy is the most common cause, especially small cell lung cancer.
- can also be cause by infections, head injury, COPD, and certain drugs

Syndrome of Inappropriate ADH (SIADH)
Clinical manifestations

- Water retention
- decreased plasma osmolality
- Increased glomerular filtration rate
- decreased urinary output
- increased body weight
- Vomiting Abdominal cramps, muscle twitching
- Cerebral edema
- dilutional hyponatremia

Syndrome of Inappropriate ADH (SIADH)
Collaborative Care

- Correct the problem
- Goal is to restore normal fluid volume and osmolality
- fluid restriction in Mild cases
- Drugs that block ADH action on collecting tubules in more severe cases
- Administration of hypertonic saline solution in cases of severe hyponatremia

Anterior pituitary hypofunction
Sheehan's syndrome

- infart/necrosis of pituitary following postpartum shock or hemorrhage
- Causes partial to complete loss of thyroid, adrenocortical, and gonadal function
- Marked ACTH and TSH deficiency
- symptoms appear hours to years post partum

Adrenal gland

- The gland located atop of the kidneys
- Cortex is the outer part
- Inner part is the medulla

Adrenal cortex

- secretes cortisol, androgens, and aldosterone (electrolytes)

Adrenal medulla

- Sympathetic nervous system control
- Secrete Epinephrine and Nor-epinephrine (fight or flight)

Adrenal cortex steroid hormones

- Glucocorticoids
- Mineralcorticoids
- androgens


- Regulate metabolism and increase blood glucose
- Critical to physiologic stress response


- Regulate sodium and potassium balance


- Contributes to growth and development in both genders.
- Contributes to sexual activity in adult women

Cushing syndrome
Etiology and pathophysiology

- Caused by excess of corticosteroids, particularly glucocorticoids.
- Most common cause is iatrogenic administration of exogenous corticosteroids.
- 85% of endogenous cases due to ACTH secreting pituitary tumor
- Other causes include Adrenal tumors and ectopic (abnormal) ACTH production in tumors outside the H-P-Adrenal axis (usually in the lungs or pancreas)

Cushing syndrome
Etiology and pathophysiology
Male vs female

- Cushing disease (ACTH secreting pituitary tumor) and adrenal tumors are more common in women aged 20 - 40
- Ectopic ACTH production is more common in men

Cushing syndrome
Clinical manifestations
Part 1

- related to excess corticosteroids
- weight gain most common feature
- hyperglycemia
- protein wasting
- Loss of collagen
- wound healing delayed

Cushing syndrome
Clinical manifestations
Part 2

- mood disturbances
- insomnia
- irrationality
- psychosis
- Purplish red striae on abdomen, breast or buttocks

Cushing syndrome
CM: Weight Gain

- Trunk (centripetal obesity)
- Face ("moon face")
- Cervical area (buffalo hump)
- Transient weight gain from sodium and water retention.

Cushing syndrome
CM: Hyperglycemia

- Glucose intolerance associated with cortisol induced insulin resistance.
- Increased gluconeogenesis by liver

Cushing syndrome
CM: Protein wasting

- Catabolic effects of cortisol
- leads to weakness, especially in extremities
- Protein loss in bones leads to osteoporosis, bone and back pain.

Cushing syndrome
CM: Mineralocorticoid excess

- may cause hypertension secondary to fluid retention

Cushing syndrome
CM: Adrenal Androgen excess

May cause
- pronounced acne
- Virilization in women
- Feminization in men

Cushing syndrome
CM: Adrenal carcinomas

- menstrual disorders and hirsutism in women
- Gynecomastia and impotence in men.

Cushing syndrome
Diagnostic studies
Part 1

- 24 hour urine for free cortisol.
- levels of cortisol above 80-120 mcg/day in adults indicate Cushing syndrome
- Low dose dexamethasone suppression test used for borderline results of 24-hour urine cortisol
- False positives can occur with depression and with certain drugs

Cushing syndrome
Diagnostic studies
Part 2

- Plasma cortisol levels may be elevated with loss of diurnal variation.
- CT and MRI of pituitary and adrenal glands
- Hypokalemia and alkalosis are seen in ectopic ACTH syndrome and adrenal carcinoma.
- plasma ACTH may be low, normal or elevated depending on problem

Cushing syndrome: DS
Associated findings that are not diagnostic of Cushing's

- Leukocytosis
- Lymphopenia
- Eosinopenia
- Hyperglycemia
- glycosuria
- hypercalciuria
- osteoporosis

Cushing Syndrome
Callaborative care
Part 1

- Primary goal is to normalize hormone secretion.
- Drug therapy indicated when surgery is contraindicated or as adjunct to surgery
- Goal of drug therapy is inhibition of adrenal function.

Cushing Syndrome
Callaborative care
Part 2

- Treatment depends on cause.
- Pituitary Adenoma treated with surgical removal of tumor and/or radiation.
- Adrenal tumors or hyperplasia is treated with adrenalectomy.
- Ectopic ACTH-secreting tumors is managed by treating primary neoplasm.

Cushing Syndrome
Callaborative care
If Cushing's develops during use of corticosteroids

- Gradually discontinue therapy
- Decrease dose
- Convert to an alternate-day regimen
- Gradual tapering avoids potentially life-threatening adrenal insufficiency

Cushing Syndrome
Nursing assessment
Patient medical history

- pituitary tumor
- adrenal, pancreatic or pulmonary neoplasms
- GI bleeding
- frequent infections

Cushing Syndrome
Nursing assessment
Part 1

- Use of corticosteroids
- Weight gain
- Anorexia
- Polyuria
- prolonged wound healing
- weakness, fatigue

Cushing Syndrome
Nursing assessment
Part 2

- Easy bruising
- Insomnia
- headache, back, joint, bone, and rib pain
- amenorrhea
- Impotence
- Mood distubances, anxiety, psychosis, poor concentration

Cushing Syndrome
Nursing assessment
Part 3

- Truncal obesity
- Buffalo hump
- Moon face
- Hirsutism of body and face
- Thinning of head hair

Cushing Syndrome
Nursing assessment
Part 4

- Thin, Friagle skin
- Acne
- Petechiae
- Purpura
- Hyperpigmentation
- Purplish Red striae on breasts, buttocks, and abdomen

Cushing Syndrome
Nursing assessment
Part 5

- Edema of lower extremities
- Hypertension
- Muscle wasting
- Thin extremities
- Awkward gait

Cushing Syndrome
Nursing Diagnoses

- Risk for infection
- Imbalanced nutrition
- Disturbed body image
- Impaired skin integrity

Cushing Syndrome
Nursing planning

Patient goals include
- Experience relief of symptoms
- have no serious complications
- Maintain positive self-image
- Actively participate in therapeutic plan

Cushing syndrome
Nursing Implementation

- Health promotion
- identify patients at risk for cushing syndrome
- Long-Term exogenous cortisol therapy is major risk factor
- teach patients about medication use and to monitor side effects.

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