Nurse Review Medical-Surgical Nursing Endocrine System 2007 The ENDOCRINE SYSTEM Review of the Anatomy and Physiology

of the endocrine glands Review of the Common Laboratory procedures Review of the Common endocrine disorders Review of Diabetes Mellitus The ANATOMY of the Endocrine System The endocrine system is composed of ductless glands that release their hormones directly into the bloodstream The ANATOMY of the Endocrine System The Hypothalamus controls most of the endocrinal activity of the pituitary gland The ANATOMY of the Endocrine System The pituitary gland controls most of the activities of the other endocrine glands The ANATOMY of the Endocrine System The ANATOMY of the Endocrine System Hypothalamus Pituitary Gland Endocrine gland Increased Hormones The ANATOMY of the Endocrine System The Hypothalamus This part of the DIENCEPHALON is located below the thalamus and is connected to the pituitary gland by a stalk The PHYSIOLOGY of the Endocrine System: Hypothalamus Secretes RELEASING HORMONES for the pituitary gland Releasing hormones= hypothalamus

The PHYSIOLOGY of the Endocrine System: Hypothalamus Secretes OXYTOCIN that is stored in the Posterior pituitary gland The PHYSIOLOGY of the Endocrine System: Hypothalamus Secretes Anti-Diuretic Hormone or VASOPRESSIN that is stored also in the posterior pituitary gland CBQ The ANATOMY of the Endocrine System The Pituitary Gland Is a gland located below the hypothalamus at the base of the brain The ANATOMY of the Endocrine System The Pituitary Gland The optic chiasm passes over this structure The ANATOMY of the Endocrine System The Pituitary Gland Is divided into two parts- the anterior or adenohypophysis and the posterior or the neurohypophysis The PHYSIOLOGY of the Anterior Pituitary Secretes the following hormones: 1. Growth hormone 2. Prolactin The PHYSIOLOGY of the Anterior Pituitary Secretes the following hormones: 3. Gonadotrophins- LH and FSH 4. Stimulating hormones and trophic hormones ACTH TSH MSH The PHYSIOLOGY of the Posterior Pituitary Stores and releases 1. OXYTOCIN 2. ADH/Vasopressin The ANATOMY of the Endocrine System The THYROID gland

Located in the anterior neck lateral to the trachea The ANATOMY of the Endocrine System The THYROID gland Contains two lobes connected by the isthmus Microscopically composed of thyroid follicles where the hormones are produced and stored The PHYSIOLOGY of the Endocrine System: Thyroid Produces the thyroid hormones by the thyroid follicles: 1. Tri-iodothyronine or T3 2. Tetra-iodothyronine or thyroxine or T4 The PHYSIOLOGY of the Endocrine System: Thyroid The Parafollicular cells secrete CALCITONIN The ANATOMY of the Endocrine System The PARAthyroid glands Located at the back of the thyroid glands Four in number The PHYSIOLOGY of the Endocrine System: Parathyroid gland Secretes PARATHYROID hormone (PTH) that controls calcium and phosphorus levels PTH is stimulated by a DECREASED Calcium level Parathyroid gland and thyroid gland The ANATOMY of the Endocrine System The Adrenal Glands Located above the kidneys Composed of two parts- the outer Adrenal Cortex and the inner Adrenal medulla The PHYSIOLOGY of the Endocrine System: Adrenal Cortex Secretes three types of STEROID hormones 1. Glucocorticoids- like Cortisol, cortisone and corticosterone

The PHYSIOLOGY of the Endocrine System: Adrenal Cortex Secretes three types of STEROID hormones 2. Mineralocorticoids- like Aldosterone 3. Sex hormones- like estrogen and testosterone Adrenal CORTEX The PHYSIOLOGY of the Adrenal Medulla Essentially a part of the SYMPATHETIC autonomic system Secretes Adrenergic Hormones: 1. Epinephrine 2. Nor-epinephrine The ANATOMY of the Endocrine System The Pancreas This retroperitoneal organ has both endocrine and exocrine functions The ANATOMY of the Endocrine System The Pancreas The endocrine function resides in the ISLETS of Langerhans The islets have three types of cells- alpha, beta and delta cells The PHYSIOLOGY of the Endocrine System: The Pancreas The ALPHA cells secrete GLUCAGON The BETA cells secrete INSULIN The DELTA cells secrete SOMATOSTATIN The ANATOMY of the Endocrine System The GONADS- Ovaries These two almond-shaped glands are found in the pelvic cavity attached to the uterus by the ovarian ligament The ANATOMY of the Endocrine System The GONADS- Testes These two oval-shaped glands are found in the scrotum The PHYSIOLOGY of the Endocrine System: Gonads

The Ovaries contains Granulosa and Theca cells which secrete ESTROGEN and Progesterone The PHYSIOLOGY of the Endocrine System: Gonads The testes contains Leydig cells that secrete Testosterone Board exam Question COMMON LABORATORY PROCEDURES Hormone Levels Assay These are blood examinations for the levels of individual hormones COMMON LABORATORY PROCEDURES Hormone Levels Assay Measurements can also be done after stimulation and suppression of the secretions- Stimulation and Suppression tests COMMON LABORATORY PROCEDURES Hormone Levels of T3/T4 Usually done to diagnose hypothyroidism or hyperthyroidism COMMON LABORATORY PROCEDURES Hormone Levels of T3/T4 If T3 and T4 elevated HYPERthyroidism COMMON LABORATORY PROCEDURES Hormone Levels of T3/T4 If T3 and T4 HYPOthyoidism COMMON LABORATORY PROCEDURES Radio-Active iodine uptake (RAI) This is a thyroid function test to measure the absorption of the injected iodine isotope by the thyroid tissue COMMON LABORATORY PROCEDURES Radio-Active iodine uptake (RAI) Increased uptake may indicate HYPERfunctioning gland Decreased uptake my indicate HYPOfunctioning gland

COMMON LABORATORY PROCEDURES Thyroid Scan Performed to identify nodules or growth in the thyroid gland RAI is used COMMON LABORATORY PROCEDURES Thyroid Scan Pretest- Check for pregnancy, Thyroid medication may be withheld temporarily, advise NPO Post-test- Ensure proper disposal of body wastes COMMON LABORATORY PROCEDURES The BMR (Basal Metabolic Rate) It measures the oxygen consumption under basal conditions of overnight fast and rest from mental and physical exertion. it can be estimated from the oxygen consumed over a timed interval by analysis of samples of expired air COMMON LABORATORY PROCEDURES BMR The test indirectly measures metabolic energy expenditure or heat production. Results are expressed as the percentage of deviation from normal after appropriate corrections have been made for age, sex, and body surface area. Low values are suggestive of hypothyroidism, and high values reflect thyrotoxicosis. COMMON LABORATORY PROCEDURES FASTING BLOOD GLUCOSE Aids in the diagnosis of Diabetes Pre-test: NPO for 8 hours Normal FBS- 80-109 mg/dL DM- 126 mg/dL and above COMMON LABORATORY PROCEDURES GLUCOSE tolerance test

Aids in the diagnosis of DM Pre-test: Provide highcarbohydrate foods x 3 days, instruct to avoid caffeine, alcohol and smoking, NPO 10 hours prior to test COMMON LABORATORY PROCEDURES GLUCOSE tolerance test Post-test: avoid strenuous activity for 8 hours Normal OGTT- 1 and 2 hours postprandial- glucose is less than 200 mg/dL COMMON LABORATORY PROCEDURES Glycosylated Hemoglobin A 1-C Blood glucose bound to RBC hemoglobin Reflects how well blood glucose is controlled for the past 3 months FASTING is NOT required! COMMON LABORATORY PROCEDURES Glycosylated Hemoglobin A 1-C Normal level- expressed as percentage of total hemoglobin N- 4-6% Good control- 7.5% or less Fair control- 7.5 % to 8.9% Poor control- 9% and above DISORDERS OF THE ENDOCRINE GLAND Disorders are generally grouped into: 1. HYPER- when the gland secretes excessive hormones 2. HYPO- when the gland does not secrete enough hormones Disorders of the PITUITARY GLAND Anterior Pituitary DISORDERS OF the PITUITARY GLAND HYPOPITUITARISM Hyposecretion of the anterior pituitary gland CAUSES: Congenital, Post-partal necrosis, infection and tumor

DISORDERS OF the PITUITARY GLAND HYPOPITUITARISM PATHOPHYSIOLOGY Depends on the major hormone/s depleted DISORDERS OF the PITUITARY GLAND Hypopituitarism: ASSESSMENT Findings 1. Retarded physical growth due to decreased GH dwarfism 2. Low intellectual development 3. poor development of secondary sexual characteristics DISORDERS OF the PITUITARY GLAND NURSING INTERVENTIONS 1. Provide emotional support to the family 2. Encourage client and family to express feelings 3. Administer prescribed hormonal replacement therapy DISORDERS OF the PITUITARY GLAND HYPERPITUITARISM The hyper-secretion of the gland Acromegaly Gigantism CAUSES: tumor, congenital disorder DISORDERS OF the PITUITARY GLAND HYPERPITUITARISM PATHOPHYSIOLOGY Depends on the hormone/s that is/are increased DISORDERS OF the PITUITARY GLAND ASSESSMENT FINDINGS for Hyperpituitarism 1. Increased growth Gigantism or Acromegaly 2. Hand thick hands and feet DISORDERS OF the PITUITARY GLAND ASSESSMENT FINDINGS for Hyperpituitarism 3. Visual disturbances

4. Hypertension, hyperglycemia 5. Organomegaly DISORDERS OF the PITUITARY GLAND NURSING INTERVENTIONS 1. Provide emotional support to clients and family 2. Provide frequent skin care 3. Prepare patient for surgeryremoval of pituitary gland DISORDERS OF the PITUITARY GLAND NURSING INTERVENTIONS Post-operative care 1. Monitor VS, LOC and neurologic status 2. Place patient on Semi-Fowlers DISORDERS OF the PITUITARY GLAND NURSING INTERVENTIONS Post-operative care 3. Monitor for Increased ICP, bleeding, CSF leakage 4. Instruct patient to AVOID sneezing, coughing and noseblowing DISORDERS OF the PITUITARY GLAND NURSING INTERVENTIONS Post-operative care 5. Monitor development of DI- measure I and O 6. Administer prescribed medications- antibiotics, analgesics and steroids Posterior Pituitary Posterior Pituitary DISORDERS OF the PITUITARY GLAND: Posterior gland DIABETES INSIPIDUS A hypo-secretion of ADH CAUSES: Conditions that increase ICP, Surgical removal of post pit. tumor DISORDERS OF the PITUITARY GLAND: Posterior gland D I PATHOPHYSIOLOGY Decreased ADH failure of tubular re-absorption of water

increased urine volume DISORDERS OF the PITUITARY GLAND: Posterior gland ASSESSMENT findings 1. Polyuria of more than 4 liters of urine/day 2. Polydipsia DISORDERS OF the PITUITARY GLAND: Posterior gland ASSESSMENT findings 3. Signs of Dehydration 4. Muscle pain and weakness 5. Postural hypotension and tachycardia DISORDERS OF the PITUITARY GLAND: Posterior gland DIAGNOSTIC TEST 1. Urinary Specific gravity very low, 1.006 or less (very dilute urine) 2. Serum Sodium levels high DISORDERS OF the PITUITARY GLAND: Posterior gland NURSING INTERVENTIONS 1.Monitor VS, neurologic status and cardiovascular status 2. Monitor Intake and Output 3. Monitor urine specific gravity DISORDERS OF the PITUITARY GLAND: Posterior gland NURSING INTERVENTIONS 4. Provide adequate fluids 5. Administer Chlorpropamide or Clofibrate as prescribed to increase the action of ADH if decreased DISORDERS OF the PITUITARY GLAND: Posterior gland NURSING INTERVENTIONS 6. Administer VASOPRESIN. Desmopressin or Lypressin are given intranasal. Pitressin is given IM Posterior Pituitary DISORDERS OF the PITUITARY GLAND: Posterior gland SIADH Hyper-secretion of ADH abnormally

CAUSES: tumor, paraneoplastic syndromes DISORDERS OF the PITUITARY GLAND: Posterior gland SIADH PATHOPHYSIOLOGY Increased ADH Increased water re-absorption water intoxication, hypervolemia DISORDERS OF the PITUITARY GLAND: Posterior gland DIAGNOSTIC TEST for SIADH 1. Urine specific gravity is increased (concentrated urine) 2. Hyponatremia 3. CBC shows hemodilution DISORDERS OF the PITUITARY GLAND: Posterior gland ASSESSMENT findings 1. Signs of Hypervolemia 2. Mental status changes 3. Abnormal weight gain DISORDERS OF the PITUITARY GLAND: Posterior gland ASSESSMENT findings 4. Hypertension 5. Anorexia, Nausea and Vomiting 6. HYPOnatremia DISORDERS OF the PITUITARY GLAND: Posterior gland NURSING INTERVENTIONS 1. Monitor VS and neurologic status 2. Provide safe environment 3. Restrict fluid intake (less than 500cc/day) DISORDERS OF the PITUITARY GLAND: Posterior gland NURSING INTERVENTIONS 4. Monitor I and O and daily weight 5. Administer Diuretics and IVF carefully 6. Administer prescribed Demeclocycline to inhibit action of ADH in the kidney Disorders of the ADRENAL GLAND Adrenal CORTEX Adrenal CORTEX

DISORDERS OF the ADRENAL GLAND Hypo-secretion: ADDISONS Decreased secretion of adrenal cortex hormones, especially glucocorticoids and mineralocorticoids CAUSE: tumor, idopathic DISORDERS OF the ADRENAL GLAND PATHOPHYSIOLOGY Decreased Glucocorticoids decreased resistance to stress DISORDERS OF the ADRENAL GLAND PATHOPHYSIOLOGY Decreased mineralocorticoids decreased retention of sodium and water Hypovolemia Pathophysiology Pathophysiology DISORDERS OF the ADRENAL GLAND ASSESSMENT Findings for Addisons disease 1. Weight loss 2. GI disturbances 3. Muscle weakness, lethargy and fatigue 4. Hyponatremia DISORDERS OF the ADRENAL GLAND ASSESSMENT Findings for Addisons disease 5. Hyperkalemia 6. Hypoglycemia 7. Dehydration and hypovolemia 8. Increased skin pigmentation DISORDERS OF the ADRENAL GLAND NURSING INTERVENTIONS 1. Monitor VS especially BP 2. Monitor weight and I and O 3. Monitor blood glucose level and K 4. Administer hormonal agents as prescribed DISORDERS OF the ADRENAL GLAND

NURSING INTERVENTIONS 5. Observe for ADDISONIAN crisis 6. Educate the client regarding lifelong treatment, avoidance of strenuous activities, stress and seeking prompt consult during illness DISORDERS OF the ADRENAL GLAND NURSING INTERVENTIONS 7. Provide a high-protein, high carbohydrate and increased sodium intake DISORDERS OF the ADRENAL GLAND ADDISONIAN crisis A life-threatening disorders caused by acute severe adrenal insufficiency CAUSES: Severe stress, infection, trauma or surgery DISORDERS OF the ADRENAL GLAND ADDISONIAN crisis PATHOPHYSIOLOGY Overwhelming stimuli mobilize body defense decreased stress hormones inadequate coping DISORDERS OF the ADRENAL GLAND ASSESSMENT Findings for Addisonian Crisis= severe lahat 1. Severe headache 2. Severe pain 3. Severe weakness 4. Severe hypotension 5. Signs of Shock DISORDERS OF the ADRENAL GLAND NURSING INTERVENTIONS 1. Administer IV glucocorticoids, usually hydrocortisone 2. Monitor VS frequently 3. Monitor I and O, neurological status, electrolyte imbalances and blood glucose

DISORDERS OF the ADRENAL GLAND NURSING INTERVENTIONS 4. Administer IVF 5. Maintain bed rest 6. Administer prescribed antibiotics Adrenal CORTEX DISORDERS OF the ADRENAL GLAND Hyper-secretion: CUSHINGS DISEASE A condition resulting from the hyper-secretion of glucocorticoids from the adrenal cortex CAUSES: Pituitary tumor, adrenal tumor, abuse of steroids DISORDERS OF the ADRENAL GLAND Hyper-secretion: CUSHINGS PATHOPHYSIOLOGY Increased Glucocorticoids exaggerated effects of the hormone Pathophysiology Pathophysiology DISORDERS OF the ADRENAL GLAND ASSESSMENT FINDINGS for Cushing 1. Generalized muscle weakness and wasting 2. Truncal obesity DISORDERS OF the ADRENAL GLAND ASSESSMENT FINDINGS for Cushing 3. Moon-face 4. Buffalo hump 5. Easy bruisability DISORDERS OF the ADRENAL GLAND ASSESSMENT FINDINGS for Cushing 6. Reddish-purplish striae on the abdomen and thighs 7. Hirsutism and acne 8. Hypertension DISORDERS OF the ADRENAL GLAND

ASSESSMENT FINDINGS for Cushing 9. Hyperglycemia 10. Osteoporosis 11. Amenorrhea DISORDERS OF the ADRENAL GLAND DIAGNOSTIC TESTS 1. Serum cortisol level 2. Serum glucose and electrolytes Hyperglycemia Hypokalemia Hypernatremia DISORDERS OF the ADRENAL GLAND NURSING INTERVENTIONS 1. Monitor I and O , weight and VS 2. Monitor laboratory valuesglucose, Na and K DISORDERS OF the ADRENAL GLAND NURSING INTERVENTIONS 3. Provide meticulous skin care 4. Administer prescribed medications like aminogluthetimide to inhibit adrenal hyperfunctioning DISORDERS OF the ADRENAL GLAND NURSING INTERVENTIONS 5. Prepare client for surgical management- pituitary surgery and adrenalectomy 6. Protect patient from infection DISORDERS OF the ADRENAL GLAND NURSING INTERVENTIONS 7. Improve body image 8. Provide a LOW carbohydrate, LOW sodium and HIGH protein diet DISORDERS OF the ADRENAL GLAND Hyper-secretion: CONNS DISEASE Hyper-secretion of Aldosterone from the adrenal cortex CAUSES: pituitary tumor, adrenal tumor DISORDERS OF the ADRENAL GLAND

Hypersecretion: CONNS DISEASE PATHOPHYSIOLOGY Increased Aldosterone exaggerated effects DISORDERS OF the ADRENAL GLAND ASSESSMENT findings in CONNS disease 1. Symptoms of HYPOkalemia 2. Hypertension 3. Hypernatremia DISORDERS OF the ADRENAL GLAND ASSESSMENT findings in CONNS disease 4. Headache, N/V 5. Visual changes 6. Muscles weakness, fatigue and nocturia DISORDERS OF the ADRENAL GLAND DIAGNOSTIC TEST 1. Urine gravity- low (due to polyuria) 2. Serum Sodium- high 3. Serum Potassium- very low 4. Increased urinary Aldosterone DISORDERS OF the ADRENAL GLAND NURSING INTERVENTIONS 1. Monitor VS, I and O and urine sp gravity 2. Monitor serum K and Na 3. Provide Potassium rich foods and supplements DISORDERS OF the ADRENAL GLAND NURSING INTERVENTIONS 4. Administer prescribed diureticSpironolactone 5. Maintain sodium-restricted diet DISORDERS OF the ADRENAL GLAND NURSING INTERVENTIONS 6. Prepare patient for possible surgical interventions Adrenal medulla DISORDERS OF the ADRENAL GLAND

Hyper-secretion: Pheochromocytoma Increased secretion of epinephrine and nor-epinephrine by the adrenal medulla CAUSE: tumor DISORDERS OF the ADRENAL GLAND Hypersecretion: Pheochromocytoma PATHOPHYSIOLOGY Increased Adrenergic hormones exaggerated sympathetic effects DISORDERS OF the ADRENAL GLAND ASSESSMENT Findings in Pheochromocytoma 1. Hypertension 2. Severe headache 3. Palpitations 4. Tachycardia DISORDERS OF the ADRENAL GLAND ASSESSMENT Findings in Pheochromocytoma 5. Profuse sweating and Flushing 6. Weight loss, tremors 7. Hyperglycemia and glycosuria DISORDERS OF the ADRENAL GLAND NURSING INTERVENTIONS 1. Monitor VS especially BP 2. Monitor for HYPERTENSIVE crisis 3. Avoid stimulation that can cause increased BP DISORDERS OF the ADRENAL GLAND NURSING INTERVENTIONS 4. Administer Anti-hypertensive agents like alpha-adrenergic blockers- Phenoxybenzamine 5. Prepare Phentolamine for hypertensive crisis DISORDERS OF the ADRENAL GLAND 6. Monitor blood glucose and urine glucose 7. Promote adequate rest and sleep periods

DISORDERS OF the ADRENAL GLAND 8. provide HIGH calorie foods and Vitamins/mineral supplements 9. Prepare patient for possible surgery Disorders of the THYROID GLAND thyroid thyroid DISORDERS OF the THYROID GLAND HYPOsecretion: HYPOTHYROIDISM A hypothyroid state characterized by decreased secretions of T3 and T4 CAUSES: Hypofunctioning tumor, IDG, Pituitary tumor, Ablation therapy, Surgical removal of thyroid DISORDERS OF the THYROID GLAND HYPOTHYROIDISM PATHOPHYSIOLOGY Decreased T3 and T4 decreased basal metabolism DISORDERS OF the THYROID GLAND ASSESSMENT findings for Hypothyroidism 1. Lethargy and fatigue 2. Weakness and paresthesia 3. COLD intolerance DISORDERS OF the THYROID GLAND ASSESSMENT findings for Hypothyroidism 4. Weight gain 5. Bradycardia 6. Constipation DISORDERS OF the THYROID GLAND ASSESSMENT findings Hypothyroidism 6. Dry hair and skin, loss of body hair 7. Generalized puffiness and edema around the eyes and face DISORDERS OF the THYROID GLAND

ASSESSMENT findings for Hypothyroidism 8. Forgetfulness and memory loss 9. Slowness of movement 10. Menstrual irregularities and cardiac irregularities DISORDERS OF the THYROID GLAND NURSING INTERVENTIONS 1. Monitor VS especially HR 2. Administer hormone replacement: usually Levothyroxine( Synthroid)-should be taken on an empty stomach DISORDERS OF the THYROID GLAND NURSING INTERVENTIONS 3. Instruct patient to eat LOW calorie, LOW cholesterol and LOW fat diet 4. Manage constipation appropriately 5. Provide a WARM environment DISORDERS OF the THYROID GLAND NURSING INTERVENTIONS 6. Avoid sedatives and narcotics because of increased sensitivity to these medications 7. Instruct patient to report chest pain promptly thyroid DISORDERS OF the THYROID GLAND HYPERfunctioning: HYPERTHYROIDISM Called GRAVES DISEASE A hyperthyroid state characterized by increased circulating T3 and T4 DISORDERS OF the THYROID GLAND HYPERfunctioning: HYPERTHYROIDISM CAUSES: Auto-immune disorder, toxic goiter and tumor DISORDERS OF the THYROID GLAND HYPERfunctioning: HYPERTHYROIDISM

PATHOPHYSIOLOGY Increased hormone activity increased Basal Metabolism DISORDERS OF the THYROID GLAND ASSESSMENT Findings for Hyperthyroidism 1. Weight loss 2. HEAT intolerance 3. Hypertension DISORDERS OF the THYROID GLAND ASSESSMENT Findings for Hyperthyroidism 4. Tachycardia and palpitations 5. Exopthalmos 6. Diarrhea DISORDERS OF the THYROID GLAND ASSESSMENT Findings for Hyperthyroidism 7. Warm skin 8. Diaphoresis 9. Smooth and soft skin Oligomenorrhea to amenorrhea DISORDERS OF the THYROID GLAND ASSESSMENT Findings for Hyperthyroidism 10. Fine tremors and nervousness 11. Irritability, mood swings, personality changes and agitation DISORDERS OF the THYROID GLAND NURSING INTERVENTIONS 1. Provide adequate rest periods in a quiet room 2. Administer anti-thyroid medications that block hormone synthesisMethimazole and PTU 3. Provide a HIGH-calorie diet, HIGH protein DISORDERS OF the THYROID NURSING INTERVENTIONS 4. Manage diarrhea 5. Provide a cool and quiet environment 6. Avoid giving stimulants 7. Provide eye care

Hypoallergenic tape for eyelid closure DISORDERS OF the THYROID GLAND NURSING INTERVENTIONS 7. Administer PROPRANOLOL for tachycardia 8. Administer IODIONE preparation- Lugols solution and SSKI to inhibit the release of T3 and T4 DISORDERS OF the THYROID GLAND NURSING INTERVENTIONS 9. Prepare clients for Radioactive iodine therapy 10. Prepare patient for thyroidectomy 11. Manage thyroid storm appropriately DISORDERS OF the THYROID GLAND Thyroid storm An acute LIFE-threatening condition characterized by excessive thyroid hormones in the body DISORDERS OF the THYROID GLAND Thyroid storm CAUSE: Manipulation of the thyroid during surgery causing the release of excessive hormones in the blood DISORDERS OF the THYROID GLAND ASSESSMENT Findings for Thyroid Storm 1. HIGH fever 2. Tachycardia and Tachypnea 3. Systolic HYPERtension DISORDERS OF the THYROID GLAND ASSESSMENT Findings for Thyroid Storm 4. Delirium and coma 5. Severe vomiting and diarrhea 6. Restlessness, Agitation, confusion and Seizures

DISORDERS OF the THYROID GLAND NURSING INTERVENTIONS 1. Maintain PATENT airway and adequate ventilation 2. Administer anti-thyroid medications such as Lugols solution, Propranolol, and Glucocorticoids DISORDERS OF the THYROID GLAND NURSING INTERVENTIONS 3. Monitor VS 4. Monitor Cardiac rhythms 5. Administer PARACETAMOL ( not Aspirin) for FEVER DISORDERS OF the THYROID GLAND NURSING INTERVENTIONS 6. Manage Seizures as required. 7. Provide a quiet environment DISORDERS OF the THYROID GLAND THYROIDECTOMY Removal of the thyroid gland DISORDERS OF the THYROID GLAND PRE-OPERATIVE CARE Thyroidectomy 1. Obtain VS and weight 2. Assess for Electrolyte levels, glucose levels and T3/T4 levels DISORDERS OF the THYROID GLAND PRE-OPERATIVE - Thyroidectomy 3. Provide pre-operative teaching like coughing and deep breathing, early ambulation and support of the neck when moving 4. Administer prescribed medications- Lugols to decrease size Major complications DISORDERS OF the THYROID GLAND POST-OPERATIVE CARE Thyroidectomy 1. Position patient: Semi-Fowlers, neck on neutral position

2. Monitor for respiratory distress- apparatus at bedsidetracheostomy set, O2 tank and suction machine! DISORDERS OF the THYROID GLAND POST-OPERATIVE CARE Thyroidectomy 3. Check for edema and bleeding by noting the dressing anteriorly and at the back of the neck DISORDERS OF the THYROID GLAND POST-OPERATIVE CARE Thyroidectomy 4. LIMIT client talking 5. Assess for HOARSENESS Expected to be present only initially, limit excess vocalization If persistent, may indicate damage to laryngeal nerve! DISORDERS OF the THYROID GLAND POST-OPERATIVE CARE Thyroidectomy 6. Monitor for Laryngeal Nerve damage Respiratory distress, Dysphonia, voice changes, Dysphagia and restlessness DISORDERS OF the THYROID GLAND POST-OPERATIVE CARE Thyroidectomy 7. Monitor for signs of HYPOCALCEMIA and tetany due to trauma of the parathyroid 8. Prepare Calcium gluconate 9. Monitor for thyroid storm PARATHYROID PARATHYROID DISORDERS OF the PARATHYROID GLAND Hypo-functioning: HYPOPARATHYROIDISM Hypo-secretion of parathyroid hormone

DISORDERS OF the PARATHYROID GLAND Hypo-functioning: HYPOPARATHYROIDISM CAUSES: tumor, removal of the gland during thyroid surgery DISORDERS OF the PARATHYROID GLAND Hypo-functioning: HYPOPARATHYROIDISM PATHOPHYSIOLOGY Decreased PTH deranged calcium metabolism DISORDERS OF the PARATHYROID GLAND ASSESSMENT Findings for HypoParaThyroidism 1. Signs of HYPOCALCEMIA 2. Numbness and tingling sensation on the face 3. Muscle cramps DISORDERS OF the PARATHYROID GLAND ASSESSMENT Findings for HypoParaThyroidism 4. (+) Trosseaus and (+) Chvosteks signs 5. Bronchospasms, laryngospasms, and dysphagia DISORDERS OF the PARATHYROID GLAND ASSESSMENT Findings for HypoParaThyroidism 6. Cardiac dysrhythmias 7. Hypotension 8. Anxiety, irritability ands depression DISORDERS OF the PARATHYROID GLAND NURSING INTERVENTIONS 1. Monitor VS and signs of HYPOcalcemia 2. Initiate seizure precautions and management DISORDERS OF the PARATHYROID GLAND NURSING INTERVENTIONS 3. Place a tracheostomy set. O2 tank and suction at the bedside 4. Prepare CALCIUM gluconate

5. Provide a HIGH-calcium and LOW phosphate diet DISORDERS OF the PARATHYROID GLAND NURSING INTERVENTIONS 6. Advise client to eat Vitamin D rich foods 7. Administer Phosphate binding drugs DISORDERS OF the PARATHYROID GLAND Hyper-functioning: HYPERPARATHYROIDISM Hyper-secretion of the gland CAUSE: Tumor DISORDERS OF the PARATHYROID GLAND Hyper-functioning: HYPERPARATHYROIDISM PATHOPHYSIOLOGY Increase PTH increased CALCIUM levels in the body DISORDERS OF the PARATHYROID GLAND ASSESSMENT Findings for Hyperparathyroidism 1. Fatigue and muscle weakness/pain 2. Skeletal pain and tenderness 3. Fractures DISORDERS OF the PARATHYROID GLAND ASSESSMENT Findings for Hyperparathyroidism 4. Anorexia/N/V epigastric pain 5. Constipation DISORDERS OF the PARATHYROID GLAND ASSESSMENT Findings for Hyperparathyroidism 6. Hypertension 7. Cardiac Dysrhythmias 8. Renal Stones DISORDERS OF the PARATHYROID GLAND NURSING INTERVENTIONS 1. Monitor VS, Cardiac rhythm, I and O

2. Monitor for signs of renal stones, skeletal fractures. Strain all urine. DISORDERS OF the PARATHYROID GLAND NURSING INTERVENTIONS 3. Provide adequate fluids- force fluids 4. Administer prescribed Furosemide to lower calcium levels 5. Administer NORMAL saline DISORDERS OF the PARATHYROID GLAND NURSING INTERVENTIONS 6. Administer calcium chelators 7. Administer CALCITONIN 8. Prepare the patient for surgery Selected Endocrine PHARMACOLOGY Endocrine Medications Anti-diuretic hormones Enhance re-absorption of water in the kidneys Used in DI 1. Desmopressin and Lypressin intranasally 2. Pitressin IM Endocrine Medications Anti-diuretic hormones SIDE-effects Flushing and headache Water intoxication Thyroid Medications Thyroid hormones Levothyroxine (Synthroid) and Liothyroxine (Cytomel) Replace hormonal deficit in the treatment of HYPOTHYROIDSM Thyroid Medications Thyroid hormones Side-effects 1. Nausea and Vomiting 2. Signs of increased metabolism= tachycardia, hypertension Thyroid Medications Thyroid hormones Nursing responsibility 1. Monitor weight, VS

2. Instruct client to take daily medication the same time each morning WITHOUT FOOD Thyroid Medications Thyroid hormones Nursing responsibility 3. Advise to report palpitation, tachycardia, and chest pain 4. Instruct to avoid foods that inhibit thyroid secretions like cabbage, spinach and radishes ANTI-Thyroid Medications ANTI-THYROID medications Inhibit the synthesis of thyroid hormones 1. Methimazole (Tapazole) 2. PTU (prophylthiouracil) 3. Iodine solution- SSKI and Lugols solution ANTI-Thyroid Medications ANTI-THYROID medications Side-effects N/V Diarrhea AGRANULOCYTOSIS Most important to monitor ANTI-Thyroid Medications ANTI-THYROID medications Nursing responsibilities 1. Monitor VS, T3 and T4, weight 2. The medications WITH MEALS to avoid gastric upset ANTI-Thyroid Medications ANTI-THYROID medications Nursing responsibilities 3. Instruct to report SORE THROAT or unexplained FEVER 4. Monitor for signs of hypothyroidism. Instruct not to stop abrupt medication ANTI-Thyroid Medications ANTI-THYROID medications Lugols Solution Used to decrease the vascularity of the thyroid T3 and T4 production diminishes Given per orem, can be diluted with juice Use straw STEROIDS

Replaces the steroids in the body Cortisol, cortisone, betamethasone, and hydrocortisone STEROIDS Side-effects HYPERglycemia Increased susceptibility to infection Hypokalemia Edema STEROIDS Side-effects If high doses- osteoporosis, growth retardation, peptic ulcer, hypertension, cataract, mood changes, hirsutism, and fragile skin STEROIDS Nursing responsibilities 1. Monitor VS, electrolytes, glucose 2. Monitor weight edema and I/O STEROIDS Nursing responsibilities 3. Protect patient from infection 4. Handle patient gently 5. Instruct to take meds WITH MEALS to prevent gastric ulcer formation STEROIDS Nursing responsibilities 6. Caution the patient NOT to abruptly stop the drug 7. Drug is tapered to allow the adrenal gland to secrete endogenous hormones Quick Review Diabetes insipidus Decreased ADH secretion Common causes: tumor, pituitary surgery Manifestations: Polyuria, polydipsia, hypoT Lab exam: Diluted urine (gravity) Nursing management Fluid replacement Medications- ADH

SIADH INCREASED ADH secretion Common causes: tumor, pituitary surgery Manifestations: Oliguria, fluid overload, HPN Lab exam: concentrated urine Nursing management Fluid restrictions Anti-ADH medications Salt supplements ADDISONs Decreased Steroid hormone secretion Common causes: tumor, idiopathic S/S: HYPO (tension, Na+, glycemia, volemia) Hyperkalemia Lab exam: K+, Decreased steroid level Nursing management Fluid replacement Steroid replacement Potassium restriction Monitoring glucose, PREVENT INFECTION to avoid addisonian crisis CUSHING INCREASED Steroid hormone in body Common causes: tumor and exogenous S/S: HYPER (tension, Na+, glycemia, volemia) Hypokalemia, moon facie, hump, fracture Lab exam: K+, increased steroid level Nursing management Fluid restriction Antibiotics Potassium supplements Monitoring glucose, K, Na, I & O PREVENT INFECTION (because pt is immunosuppressed) Hypothyroidism Hyposecretion of thyroid hormones Common causes: Iodine deficiency, Hashimotos Manifestations: related to hypometabolic state: constipation, weight gain, cold intolerance, poor appetite, mental slowness Nursing Management:

Provide warm environment LOW calorie diet, HIGH fiber Avoid sedatives Drugs: Hormone replacement Hyperthyroidism Hyper-secretion of thyroid hormones Common cause: Graves, Toxic goiter Manifestation: increased metabolism: weight loss, diarrhea, heat intolerance, hypertension Nursing Management: Adequate rest and sleep Cool environment HIGH calorie foods Eye care Drugs: anti-thyroid: PTU and methimazole, propranolol Care of patients after thyroidectomy

Fluids and elec Fluids and Electrolytes Review Philippine Integrated Nurse Licensure Examination Sample Question The nurse is caring for a client with Congestive Heart Failure. On assessment, the nurse finds the client complaining of dyspnea and that rales are heard on auscultation. The nurse suspects fluid volume excess. Which additional sign would the nurse expect if fluid volume excess is present? A. Flat neck and hand veins B. Weight loss C. Increased central venous pressure D. Hypotension Key to Success! Confidence + Adequate test Preparation and review +

Effective test taking strategy + Good study habits + Working Knowledge of Basic Nursing concepts = Success in passing PINLE Fluids and Electrolytes Outline Fluids Electrolytes Acids and Bases Important Concepts Remember the ABC Safety of the patient Maslows Hierarchy of needs Utilize the NURSING PROCESS A-D-P-I-E Summary of Subtopics Basic Definition Body Proportions and Distributions Sources Dynamics Regulation by 3 systemsrenal, endocrine & GIT Balance Imbalances Application of the Nursing Process in the discussion THE BODY FLUIDS A solution of solvent and solutes Our body is made up of fluids and solids About 50-60% of the body weight is WATER In a 70 Kg adult male: 60% X 70= 40-42 Liters Note that 1 kg body weight= 1 liter of water The body has two major compartments: 1 Intracellular 2. Extracellular THE BODY FLUIDS Solute and solvents 1 gram= 1 cc The Proportion of Body Fluids

Major Fluid Compartments (60%) The Intracellular Fluid Found inside the cell surrounded by a membrane This is compartment with the highest percentage of water in adults The Extracellular Fluid Fluid found outside the cells 1. INTERSTITIAL FLUID Found in between the cells 2. INTRAVASCULAR FLUID Found inside the blood vessels and lymphatic vessels 3. TRANSCELLULAR FLUID Found inside body cavities like pleura, peritoneum, CSF Sample question 1. A client with CHF is assessed by the nurse. Upon reviewing the chart, it is determined that his weight increased by 4.5 pounds. The nurse estimates that client has gained how many liters of fluid? A. 3 B. 1 C. 2 D. 0.5 Sources of Fluids: Fluid Input 1. Exogenous sources Fluid intake- water from foodstuffs IVF Medications Blood products 2. Endogenous sources By products of metabolism secretions Fluid Losses Routes of Fluid output Urine Fecal losses Sweat

Insensible losses though the skin and lungs as water vapor Sample question 2. A nurse reads a doctors progress notes in the clients chart which states insensible fluid loss approximately 800 ml. The nurse understands that this fluid loss may occur through: A. The Gastrointestinal tract B. Urinary output C. Wound drainage D. The skin Sample question A nurse is administering IVF as ordered to a patient who sustained second-degree burns. In evaluating the adequacy of fluid resuscitation, the nurse understands that the most reliable indicator for fluid adequacy is the: A. Blood pressure B. Mental status C. Urine output D. Peripheral pulses Sample question The nurse receives the following endorsements. She is certain that which patient is at most risk for the development of fluid volume deficit? A. The client who came from the OR after a hemorroidectomy B. The client who has Renal failure undergoing dialysis C. The client with AIDS taking corticosteroids D. The client with Rheumatic fever taking diuretics Fluid Dynamics The movement of fluids (solutes and solvents) in the body compartment Diffusion Osmosis Filtration Active transport

Diffusion Cell swelling Osmosis Filtration The Concept of TONICITY This is the concentration of solutes in a solution A solution with high solute concentration is considered as HYPERTONIC A solution with low solute concentration is considered as HYPOTONIC A solution having the same tonicity as that of body fluid or plasma is considered ISOTONIC hypertonic hypotonic Isotonic Helpful Hints In a HYPERTONIC solution, fluid will go out from the cell, the cell will shrink In a HYPOTONIC solution, fluid will enter the cell, the cell will swell In an ISOTONIC solution, there will be no movement of fluid. DIFFUSION The movement of SOLUTES or particles in a solution from a higher concentration to a lower concentration If a sugar is placed in plain water, the glucose molecules will dissolve and diffuse distribute in the solution OSMOSIS The force that draws water or solvent from a less concentrated solution into a more concentrated solution through a semi-permeable membrane The pressure that draws water inside the vessel

which is more concentrated is called Osmotic pressure A special type of osmotic pressure is exerted by the proteins in the plasma. It is called ONCOTIC PRESSSURE Sample question The nurse is caring for a psychiatric patient who ingested high-sodium containing foods. She suspects hypernatremia in this patient and expect to note: A. Hyperactive deep tendon reflex B. Chovsteks Sign C. Dry skin and sticky mucous membrane D. Decreased muscle tone FILTRATION The movement of both solute and solvent by hydrostatic pressure, ie, from an area of a higher pressure to an area of a lower pressure An example of this process is urine formation Increased hydrostatic pressure is one mechanism producing edema Active transport This is the movement of solutes across a membrane from a lower concentration to a higher concentration with utilization of energy Example is the SodiumPotassium pump- a primarily active transport process Sample question The nurse reviews the laboratory report of a patient with fluid volume deficit. Which of the following laboratory findings will support this condition? A. WBC count of 9,000 B. Creatinine of 1 mg/dl

C. Sodium of 140 mEq/L D. Hematocrit of 58% Sample question The client is taking a high dose of Furosemide. To determine the progress of the therapy, the nurse performs which of the following important action? A. Monitor urinary pH B. Check the temperature periodically C. Weight the patient daily D. Obtain a serial serum Sodium level Regulation of Body fluid balance 1. The Kidney Regulates primarily fluid output by urine formation Releases RENIN Regulates sodium and water balance Regulation of Body fluid balance 2. Endocrine regulation Regulates primarily fluid intake by thirst mechanism ADH increase water reabsorption on collecting duct Aldosterone increases Sodium retention in the distal nephron ANF Promotes Sodium excretion and inhibits thirst mechanism Regulation of Body fluid balance 3. Gastro-intestinal regulation The GIT digests food and absorbs water Only about 200 ml of water is excreted in the fecal material per day The ELECTROLYTES Electrolytes are charged ions capable of conducting electricity and are solutes in all compartment

ANIONS are Negatively charged ions: Bicarbonate, chloride, PO4 CATIONS are positively charged ions: Sodium, Potassium, magnesium, calcium Helpful mnemonics PI-SO Potassium is inside Phosphate is inside Sodium is outside Chloride is outside Regulation of Electrolyte Balance 1. Renal regulation Occurs by the process of glomerular filtration, tubular reabsorption and tubular secretion Urine formation If there is little water in the body, it is conserved If there is water excess, it will be eliminated Regulation of Electrolyte Balance 2. Endocrinal regulation Hormones play a role in electrolyte regulation Aldosterone promotes Sodium retention and Potassium excretion ANF promotes Sodium excretion Parathormone promotes Calcium retention and Phosphate excretion Calcitonin promotes Calcium excretion and Phosphate excretion THE CATIONS SODIUM POTASSIUM CALCIUM MAGNESIUM SODIUM

The MOST ABUNDANT cation in the ECF Normal range is 135-145 mEq/L Major contributor of plasma osmolarity FUNCTIONS 1. participates in the Na-K pump 2. assists in maintaining blood volume 3. assists in nerve transmission and muscle contraction Aldosterone increases sodium retention ANF increases sodium excretion POTASSIUM MOST ABUNDANT cation in the ICF Normal range is 3.5-5.0 mEq/L Major electrolyte maintaining ICVF balance FUNCTIONS 1. maintains ICF Osmolality 2. nerve conduction and muscle contraction 3. metabolism of carbohydrates, fats and proteins Aldosterone promotes renal excretion of K+ Acidosis promotes exchange of K+ for H+ in the cell CALCIUM Majority of calcium is in the bones and teeth Normal serum range 8.5-10 mg/dL FUNCTIONS 1. formation and mineralization of bones/teeth 2. muscular contraction and relaxation 3. cardiac function 4. blood clotting

 5. enzyme activation CALCIUM Regulation: GIT absorbs Ca+ in the intestine with the help of Vitamin D Kidney Ca+ is filtered in the glomerulus and reabsorbed in the tubules PTH increases Ca+ by bone resorption, Ca+ retention and activation of Vitamin D Calcitonin released when Ca+ is high, it decreases Ca+ by excretion in the kidney MAGNESIUM Second to K+ in the ICF Normal range is 1.3-2.1 mEq/L FUNCTIONS 1. intracellular production and utilization of ATP 2. protein and DNA synthesis 3. neuromuscular irritability THE ANIONS CHLORIDE PHOSPHATES BICARBONATES CHLORIDE The MAJOR Anion in the ECF Normal range is 95-108 mEq/L FUNCTIONS 1. major component of gastric juice aside from H+ 2. together with Na+, regulates plasma osmolality 3. participates in the chloride shift 4. acts as chemical buffer PHOSPHATES The MAJOR Anion in the ICF Normal range is 2.5-4.5 mg/L FUNCTIONS 1. component of bones 2. needed to generate ATP

3. components of DNA and RNA PTH decreases PO4 in blood by renal excretion Calcitonin increases renal excretion of PO4 BICARBONATES Present both in ICF and ECF Normal range- 22-26 mEq/L FUNCTION 1. regulates acid-base balance 2. component of the bicarbonate-carbonic acid buffer system IMBALANCE: EXCESS 1. HYPERNATREMIA More than 145 mEq/L Fluid moves out of cell crenation Etiology: sodium intake, IVF, water loss in excess of water, diarrhea S/SX: dry, sticky tongue, thirst IMBALANCE: EXCESS 2. HYPERKALEMIA K+ more than 5.0 mEq/L Etiology: IVF with K+, acidosis, Hyperalimentation and K+ replacement ECG: peaked T waves and wide QRS IMBALANCE: EXCESS 3. HYPERCALCEMIA Serum calcium more than 10.5 mg/dL Etiology: Overuse of calcium supplements, excessive Vitamin D, malignancy, prolonged immobilization, thiazide diuretic ECG: Shortened QT interval IMBALANCE: EXCESS 4. HYPERMAGNESEMIA Serum magnesium more than 2.1 mEq/L

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Etiology: use of Mg antacids, Renal failure, Mg medications S/SX: depressed tendon reflexes, oliguria, RR IMBALANCE: EXCESS HYPERCHLOREMIA Serum chloride more than 108 mEq/L Etiology: sodium chloride excess IMBALANCE: EXCESS HYPERPHOSPHATEMIA Serum PO4 more than 4.5 mg/dL Etiology: Tissue trauma, chemotherapy. PO4 containing medications, osteoporosis IMBALANCE : DEFICIENCY HYPONATREMIA Na level is less than 135 mEq/L Water is drawn into the cell cell swelling Etiology: prolonged diuretic therapy, excessive burns, excessive sweating, SIADH, plain water consumption S/SX: nausea, vomiting, seizures IMBALANCE : DEFICIENCY HYPOKALEMIA K+ level less than 3.5 mEq/L Etiology: use of diuretic, vomiting and diarrhea ECG: flattened , depressed T waves, presence of U waves IMBALANCE : DEFICIENCY HYPOCALCEMIA Calcium level of less than 8.5 mg/dL Etiology: removal of parathyroid gland during thyroid surgery, Vit. D deficiency, Furosemide, infusion of citrated blood S/SX- Tetany, (+) Chovsteks (+) Trousseauss

ECG: prolonged QT interval ACID-BASE CONCEPTS Acid- substance that can donate or release hydrogen ions Carbonic acid, Hydrochloric acid ACID-BASE CONCEPTS Base- substance that can accept hydrogen ions Bicarbonate ACID-BASE CONCEPTS Buffer- substance that can accept or donate hydrogen Hemoglobin buffer Bicarbonate : carbonic acid buffer Phosphate buffer ACID-BASE CONCEPTS Acid- substance that can donate or release hydrogen ions Carbonic acid, Hydrochloric acid Base- substance that can accept hydrogen ions Bicarbonate Buffer- substance that can accept or donate hydrogen Hemoglobin buffer Bicarbonate : carbonic acid buffer Phosphate buffer Helpful Hints Carbon dioxide is considered to be ACID because of its relationship with carbonic acid pH measures the degree of acidity and alkalinity. It is inversely related to Hydrogen. Normal ph 7.357.45 Decreased pH- ACIDICincreased HydrogenpH below 7.35 Increased pH- ALKALOSISdecreased hydrogenpH above 7.45 remember

a high hydrogen acidic pH is low a low hydrogen alkalosis pH is high a high CO2may mean acidic a low CO2 may mean alkalosis Dynamics of Acid and bases Acids and bases are constantly produced in the body They must be constantly regulated CO2 and HCO3 are crucial in the balance A ratio of 20:1 is maintained (HCO3:H2CO3) Respiratory and renal system are active in regulation Ways to balance the acids and bases Excretion Acid can be excreted, and Hydrogen can be excreted in ACIDOTIC condition Bicarbonate can be excreted in ALKALOTIC condition Ways to balance the acids and bases Production Bicarbonate can be produced in ACIDOTIC condition Hydrogen can be produced in ALKALOTIC condition Ways to balance the acids and bases The respiratory system compensates for metabolic problems CO2 (acid) can be exhaled from the body to normalize the pH in ACIDOSIS CO2 (acid) can be retained in the body to normalize the pH in ALKALOSIS Ways to balance the acids and bases

The kidney can compensate for problems in the respiratory system The Kidney reabsorbs and generates Bicarbonate (alkaline) in ACIDOSIS The Kidney can excrete H+ excess (Acidosis) to normalize the pH in ACIDOSIS Ways to balance the acids and bases The kidney can excrete bicarbonate (alkali) in conditions of ALKALOSIS The kidney can retain H+ (acid) in conditions of ALKALOSIS Ways to balance the acids and bases Chemical buffers can also participate in the balance of acidbase 1. Carbonic acidbicarbonate buffer 2. Phosphate buffer 3. protein buffer- ICF and hemoglobin The action is immediate but very limited