Endocrine Thyroid, Pituitary, Adrenal

Nursing Care of the Adult I

Glands of the Endocrine System and the Human Body

Hypothalamus Anterior pituitary (hormones regulate growth,
metabolism & sexual development) Posterior pituitary: (Hormones secrete vasopressin antidiuretic)

Adrenal cortex Adrenal medulla Thyroid Pancreatice islet cells Kidney Ovaries Testes

Endocrine System

Hormones of the Endocrine Systems

Ant. Pituitary: TSH, Adrenal Gland: ACTH, FSH, PRL, Cortisol, GH, MSH aldosterone Post. Pituitary: Pancreas: Insulin, ADH, Oxytocin glucagon, somatostatin Thyroid: T, T, Hypothalamus: Calcitonin CRH, TRH, GnRH, GHIH, MIH

Pituitary Gland Who is really in charge?

Where is it located? What is its main function? Is it really in charge?

Anterior Pituitary Gland

Controls the following hormones: growth hormone (GH, somatotropin), thyrotropin (thyroid-stimulating hormone [TSH], corticotropin (adrenocorticotropic hormone [ACTH], follicle-stimulating hormone [FSH], luteinizing hormone [LH], melanocyte-stimulating hormone [MSH] and prolactin [PRL]

Hypopituitarism
Etiology Clinical signs/symptoms Complications Nursing interventions Nursing rationales

Hypopituitarism
Selective hypopituitarism: Disorder of pituitary gland when only one hormone is affected. Panhypopitutarism: decreased production of all of the anterior pituitary hormones. Etiology------ tumors [benign or malignant], malnutrition, rapid loss of body fat [anorexia nervosa], shock/hypotension, head trauma, infection, radiation, surgery of the head/brain, AIDS, Sheehans syndrome (resulting from postpartum hemorrhage).

Hypopituitarism: Complications
Amenorrhea Hypothyroidism Hypotension Infertility Failure to develop during puberty Osteoporosis Short stature.

(http:www.freemed.com/hypopituitarism/complications.htm)

Growth Hormone (GH) ---- decreased bone density, pathologic fractures, decreased muscle strength, increased serum cholesterol levels Gonadotropins -- Female: amenorrhea, anovulation, low estrogen levels, breast atrophy, loss of bone density, decreased axillary and pubic hair, decreased libido. Male: decreased facial hair, decreased ejaculate volume, reduced muscle mass, loss of bone density, decreased body hair, decreased libido, impotence

Hypopituitarism Clinical Manifestations Anterior

Thyroid Stimulating Hormone (TSH) ----- decreased thyroid hormone levels, weight gain, intolerance to cold, scalp alopecia, hirsutism, menstrual abnormalities, decreased libido, slowed cognition, lethargy Adrenocorticotropic hormone (ACTH) --- decreased serum cortisol levels, pale, sallow complexion, malaise & lethargy, anorexia, postural hypotension, headache, hypoglycemia, hyponatremia, decreased axillary & pubic hair in women

Hypopituitarism Clinical Manifestations Anterior

Care of the patient with Hypopituitarism

Assess for physical appearance changes (males - facial & hair loss, females: amenorrhea Assess for neurological changes/presentation Check lab values: Triiodothyroidine (T3) & Thyroxine (T4) Medications Male: steroid replacement therapy with androgens (testosterone) [IM or patch]. Monitor for adverse side effects. Female: hormone replacement [estrogen & progesterone] therapy

Posterior Pituitary Gland Hypofunction Diabetes Insipidus (DI)

A water metabolism problem caused by deficiency of ADH (vasopressin) secreted by posterior lobe of pituitary gland Caused by brain surgery, head injury, meningitis. Pathophysiology Different types: nephrogenic DI, primary DI, drug related DI Clinical manifestations Hypotension, decreased pulse pressure, tachycardia, weak peripheral pulses, hemoconcentration: elevated h/h & BUN Increased urine o/p, dilute, low specific gravity Poor skin tugor, dry mucous membranes Increased sensation of thirst, irritability, decreased cognition, hyperthermia, lethargy that leads to coma, ataxia.

Caring for the patient with DI

Medical management is the focus:
Desmopressin (DDAVP) Vasopressin Chlorpropamide

Administration of medication & patient teaching most

important aspect Monitor for s/s dehydration I&Os Fluids Daily weights Monitor s/s water intoxification

Hyperpituitarism
Etiology Clinical signs/symptoms Complications Nursing interventions Nursing rationales

Hyperpituitarism
Hormone over-secretion Etiology--- tumors [pituitary adenoma / hyperplasia (tissue growth] or genetics: multiple endocrine neoplasia genet, type I (Melmed & Kleinberg, 2008). Complications Acromegaly Cushing's disease

Clinical Manifestations
Prolactin Oversecretion Hypogonadism (loss of secondary sexual characteristics) Decreased gonadotropin levels Galactorrhea Increased body fat Increased serum prolactin levels Acromegaly (see next slide)
Folding of scalp skin Thickened lips, coarse facial features, increasing hand size, protrusion of the lower jaw Deepening of the voice, enlarged hands/feet, joint enlargement and pain, kyphosis and backache, barrel shaped chest Excessive sweating, airway narrowing, sleep apnea, enlarged heart, lungs & liver

Acromegaly

Clinical Manifestations
Thyrotropin Hormone (TSH) Elevated plasma TSH levels Elevated plasma thyroid hormone levels Weight loss Tachycardia, Dysrhythmias Heat intolerance Increased GI motility Fine tremors Gonadotropins (LH, FSH) Men: elevated LH & FSH levels Hypogonadism or hypergonadism Women: Normal LH & FSH levels

 Disturbed body image r/t illness/treatment Sexual dysfunction r/t loss of libido, infertility impotence Acute/chronic pain r/t compression of tumor Anxiety r/t threat or change in health status Disturbed sensory perception r/t altered sensory reception, transmission or integration

Nursing Diagnosis and Disorders of the Pit Gland

Surgical Management
Transsphenoidal Hypophysectomy
Pre-operative care:

Explain procedure. Nasal packing/mouth breathing.

Post-operative care: Do not bend forward, brush teeth, cough, sneeze, or blow nose. Muscle graft from thigh Check neuro status: mentation, vision, LOC, decreased strength, check for transient diabetes insipidous, CSF leakage (halo sign), infection or IICP. Keep HOB. Check dressing, Keep HOB elevated, check for infection Pt to avoid coughing early after surgery.

Syndrome of Inappropriate Antidiuretic Hormones (SIADH)

Schwartz-Bartter syndrome: A condition characterized by overproduction or oversecretion of ADH (ADH dysfunction). There is an abnormal production or sustained secretion of ADH resulting in fluid retention, serum hypoosmolarity, hyponatremia, hypochloremia, concentrated urine with normal intravascular volume and normal renal function. Thought to be the most common cause of hyponatremia in older adults.

SIADH Risk Factors

Small cell carcinoma Pancreatic cancer Lymphoid cancer Head injury Brain tumors Infection (encephalitis, meningitis) Drug therapy: carbamazepine, chlorpropamide, opioids, oxytocin, thiazide diuretics, general anesthesia agents, tricyclic antidepressants, antineoplastic agents Hypothyroidism Lung infection: pneumonia, TB, lung abscess COPD Positive pressure mechanical ventilation

SIADH Clinical Manifestations

Thirst Dyspnea on exertion Fatigue Dull sensorium As hyponatremia worsens---- abdominal cramps, NV, muscle cramping, decreased neurological function, seizures Decreased urinary o/p Increased body weight

Caring for the patient with SIADH Nursing

Nursing Diagnosis
Fluid volume excess r/t abnormal production & secretion of ADH Thirst r/t fluid restriction Risk for injury r/t possible altered mental status 2 hyponatremia

Management
Restore fluid balance Restrict fluids 800-1000 mL/day Positioning Medications: Lasix Protect from injury Side rails Ambulation assistance Close to nurses station Institute seizure precautions Frequent T & P

Thyroid Gland
Understanding the pathophysiolog y of the function of this gland is critical to understanding the abnormalities..

Thyroid Gland
Hormonal maintenance: T (triiodothyronine) & T (thyroxine) TCT (thyrocalcitonin) Role/functions of thyroid hormones: Control of metabolic rate of cells Promotion of sufficient pituitary secretion of GH & gonadotropins Regulates protein, carbs, & fat metabolism Exerts chronotropic & inotropic cardiac effects Increases RBC production Affects respiratory rate & drive Increase bone formation & decrease bone resorption of calcium Act as insulin antagonists

Hyperthyroidism
Etiology Clinical signs/symptoms Nursing interventions Nursing rationales Patient education

Hyperthyroidism
Excessive thyroid hormone secretion from the thyroid gland (T3 and T4 hormones). Causing the levels of thyroid hormone in the blood to be too high. Characterized by an increased rate of body metabolism. Other names: thyrotoxicosis, Common Cause: Graves disease

Risk Factors for Hyperthyroidism

Autoimmune response Third/fourth decade of life Women > men Emotional trauma, infection, increased stress Overdose of medications used to treat hypothyroidism Use of certain weight-loss products

Clinical Manifestations Hyperthyroidism

Nervousness, mood swings Palpitations Heat intolerance Dyspnea Muscle weakness, tremors, hyperkinesia Goiter Abnormal menstruation Frequent bowel movements

Exophthalmos Warm, moist velvety skin Increased sweating, melanin pigmentation Weight loss VS: increased systolic blood pressure, widened pulse pressure, tachycardia

 Protect from stress.

Care of the patient with hyperthyroidism

Private room, restrict visitors, quiet environment

Promote physical & emotional equilibrium

Quiet, cool Eye care: protective wear, eye drops Diet: high in calories, weigh daily, avoid stimulants

Prevent complications: Give meds as ordered:

propylthiouracil (to block thyroid synthesis), methimazole [Tapazole] (to inhibit thyroid hormone synthesis, Iodine preparation, Propranolol for tachycardia, tremors & anxiety.

Hyperthyroidism & Nursing Diagnosis

Altered nutrition, less than body requirements r/t elevated BMR Risk for injury r/t exophthalmos & tremors Activity intolerance r/t fatigue from over-activity Anxiety r/t tachycardia Sleep pattern disturbance r/t excessive amounts of circulating thyroid hormone. Treatment of Hyperstyroidism: Radiation and thyroidectomy.

Radioactive Iodine Therapy

I is a radioactive isotope of iodine to decrease thyroid activity Its dissolved in water and ingested orally If large doses, patient requires hospitalization Minimal precautions for usual dose: Sleep alone for several nights Flush toilet several times after use Monitor for signs of hypothyroidism

Graves Disease

Complications: Thyroid Storm

Uncontrolled hyperthyroidism Untreated: death 2 CHF Etiology: severe sudden stress---------

Infection Surgery beginning of labor Taking inadequate amounts of antithyroid medications before thyroidectomy
Clinical Manifestations: apprehension, restlessness, elevated temperature (106F), hypotension, extreme tachycardia, respiratory distress, pulmonary edema, weakness & delirium Treatment (medications): propythiouracil or methimazole, IV sodium iodine, propranolol, ASA, steroids, diuretics, digitalis

Complications: Hashimotos Disease

Hashimoto's disease (also known as chronic lymphocytic thyroiditis), is a disorder that affects your thyroid gland. The bodys immune system attacks the thyroid gland. The resulting inflammation often leads to an underactive thyroid gland (hypothyroidism). Hashimoto's disease is the most common cause of hypothyroidism in the United States. It primarily affects middle-aged women,

Complications: Myxedema coma

Myxedema coma, a life-threatening complication of hypothyroidism, characterized by swelling of the hands, face and feet, periorbital tissues. The disease may lead to coma and death. Results from persistently low thyroid production Coma can be precipitated by acute illness, rapid withdrawal of thyroid medication, anesthesia and surgery, hypothermia and the use of sedatives and opiods analgesics. Symptoms include fatigue, mental impairment, cold intolerance, headaches.

Surgical Management Thyroidectomy

Partial removal of thyroid gland (for hyperthyroidism) or Total removal (for malignancy of thyroid) Indicated when there is unsuccessful medical treatment of hyperthyroidism Preop Teaching: Importance of supporting the neck while coughing or moving. Hoarseness of voice may be present for a few days due to endotracheal tube placement.

Thyroidectomy:

Post-op care:

Promote physical & emotional equilibrium. Positioning (Fowlers position to promote venous return head & neck), Immobilization/support of head Prevent complications: Chvosteks sign: Face twitches on one side of mouth, nose, & cheek when tapped just below & in front of the ear (facial nerve). Trousseaus sign: Hand & fingers go into spasm in palmar flexion when BP cuff is inflated to above pts systolic BP & left for 1-4 minutes. Assess for respiratory distress & vocal cords paralysis (sudden stridor and restlessness). Monitor for elevated temperature. Check dressing for hemorrhage Minimize talking/check & minimize laryngeal nerve damage Keep close to nurses station.

Hypothyroidism
Etiology Clinical signs/symptoms Nursing interventions Nursing rationales Patient education

Hypothyroidism (Myxedema)
Occurs when thyroid gland fails to produce sufficient thyroid hormone. Deficiency of circulating thyroid hormone Often a final consequence of Hashimotos thyrioditis and Graves disease. Affects women more than men. Often causes an overall decrease in metabolism. Complications: Myxedema coma, miscarriage. Infertility, Wt gain, Alopecia, bradycardia

Hypothyroidism Risk Factors

Total thyroidectomy Inadequate replacement therapy Genetics Hypophyseal failure Dietary iodine deficiencies Irradiation of thyroid gland Over-treatment of hyperthyroidism

Clinical Manifestations Hypothyroidism

Weakness, fatigue, lethargy. Headache, slowed memory Psychotic beh.avior Loss of interest in sexual activity Menstrual disturbances, depression Depressed BMR Cardiomegaly, bradycardia, hypotension, anemia Dry skin, brittle nails, coarse hair, hair loss Slowed speech, hoarseness, thickened tongue Weight gain, edema, periorbital puffiness

Hypothyroidism: Diagnostic Test Results

Blood chemistry analysis shows: decreased Triiodothyroidine (T3) and Thyroxine (T4), free thyroxine & sodium levels Increased Thyroid Stimulating Hormone (TSH) and cholesterol levels.

Care of the patient with hypothyroidism

Provide for comfort and safety Monitor for infection (vital signs) Prevent heat loss High fiber diet, high protein, low-calorie diet. Encourage fluid intake to maintain hydration Administer thyroid medications: levothyroxine Synthroid] or liothyronine [Cytomel] (Thyroid hormone replacements)

Nursing Diagnosis & Hypothyroidism

Risk for injury r/t hypersensitivity to drugs Activity intolerance r/t fatigue Constipation r/t decreased peristalsis Risk for impaired skin integrity r/t dry skin & edema Social isolation r/t lethargy Hypothermia r/t cold intolerance

Thyroid Diagnostic Test

Ultrasound Biopsy CT/MRI

Adrenal Glands
One on each kidney Mineralcorticoids = help control the bodys NA+ & K+ Glucocorticoids, androgens & estrogens = main cortisol --- carbohydrate, protein & fat metabolism, emotional stability, immune function

Left Adrenal G

Addisons Disease
Etiology Clinical signs/symptoms Complications Nursing interventions Nursing rationales

Addisons Disease Adrenal Hypofunction

Chronic primary adrenocorticortropic hormone (ACTH) insufficiency. Primary cause: atrophy of the adrenal gland. Deficiencies Galore In Addisons Deficiency in mineralocorticoid secretion: Aldosterone Deficiency in glucocorticoid secretion: Cortisol Deficiency in androgen hormone

Risk Factors in Addisons

Autoimmune process Infection Malignancy Vascular obstruction Bleeding Environmental hazards Congenital defects Bilateral adrenalectomy Pheochromocytoma

Clinical Manifestations Addisons Disease

Muscle weakness, fatigue, lethargy Dizziness, fainting Nausea, food idiosyncrasies, anorexia Abdominal pain, cramps Weight loss, salt craving
VS: hypotension, widened pulse pressure, pulse increased & irregular, temperature is low Hyponatremia, hyperkalemia, hypercalcemia Vomiting, diarrhea Tremors Poor skin turgor, excessive pigmentation [bronze tone]

Caring for the patient with Addisons

Decrease stress Quiet non-demanding environment Promote adequate nutrition Diet, fluids Medication regimen Life-long exogenous replacement therapy: glucocorticoids: prednisone, hydrocortisone or mineralocortocoids: fludrocortisone [Florinef] Prevent complications: Addisonian Crisis Bed rest & avoid stimuli High doses of steroids IV to treat shock I&O, VS q15 mins

Addisonian Crisis
(Adrenal Crisis) A very serious condition that can lead to death quickly if untreated. A critical deficiency of mineralo-corticoids and glucocorticoids, follows: Severe hypotension Shock Coma Vasomotor collapse r/t strenuous activity Omission of prescribed medications

Emergency Intervention for Addisonian Crisis

Hormone replacement: rapid infusion NS & hydrocortisone sodium succinate,in addition give hydrocortisone IM concomitantly Hyperkalemia management: insulin IV with D5W, give Kayexalate, give loop diuretics, avoid K+ sparing meds, monitor I&Os, VS, EKG Hypoglycemia management: administer IV glucose (glucagon), monitor BS levels carefully

Nursing Diagnosis & Addisons Disease

Fluid volume deficit r/t decreased sodium level Altered renal tissue perfusion r/t hypotension Decreased cardiac o/p r/t aldosterone deficiency Risk for infection r/t cortisol deficiency Activity intolerance r/t muscle weakness & fatigue Altered nutrition, less than body requirements r/t nausea, anorexia & vomiting

Diagnostic Test for Adrenal Function

Eight hour Intravenous ACTH test Administration of 25 U of ACTH in 500 mL/NS over 8 hours. Collect 24 hr urine before & after drug administration Measuring of 17-ketosteroids & 17hydroxycorticosteroids Addisons Disease: urinary o/p of steroids does not increase after drug administration Cushings Disease: there is an increase in urinary o/p of steroids tenfold

Cushings Syndrome
Etiology Clinical signs/symptoms Complications Nursing interventions Nursing rationales

Diagnostic Testing Plasma cortisol levels, Na levels, Serum K+ levels, BUN, Corticotropin levels, Urinalysis

Cushings Disease Adrenal Hyperfunction

This is the overactivity of the adrenal glands leading to prolonged elevated plasma concentration of adrenal steroids.

Risk Factors for Cushings Disease.

Adrenal hyperplasia Excessive hypothalamic stimulation Tumors: adrenal glands, hypophyseal, pituitary, bronchogenic, gallbladder Excessive steroid therapy

Symptoms of Cushings Disease

Nursing Diagnoses Body image disturbance r/t changes in physical appearance Activity intolerance r/t backache & weakness Risk for injury r/t infection & bleeding Knowledge deficit r/t management of disease Pain r/t headache

Clinical Manifestations Headache, backache Weakness, decreased work capacity Mood swings Hypertension, wt gain, pitting edema, buffalo hump, moon face, hirsutism on face, arms & legs, hyperpigmentation, menstrual changes, impotence

Caring for the patient with Cushings

Promote comfort Assist with prep for diagnostic tests Explain procedures Protect from trauma Prepare for surgery: adrenalectomy [next slide] Prevent complications Maintain fluid balance Check for glucose metabolism (Monitor glucose level) Prevent/manage hypertension Prevent infection: URI, UTI Observe behaviors: mood swings. Give prescribed meds (potassium supplements).

Adrenalectomy
This is the surgical removal of the adrenal glands due to tumors or uncontrolled overactivity of the adrenal glands. May also be done to control metastatic breast or prostate cancer. Prepare patient for surgery: Pre-operative care: Give steroids Stop hypertensive medications Give sedation.

Adrenalectomy
Post-operative care: Monitor VS Monitor for adrenal crisis: pulse that is rapid, weak, thready, elevated temperature, severe weakness & hypotension, headache, convulsions, com Auscultate lungs/bowel sounds IV hydration Maintain NPO status Reposition q2hr, mouth care, ambulation when ordered, teds

Phenochromocytoma
A catecholamin-producing tumor that arises in adrenal medulla. Tumors can occur as single lesion, or can be bilateral. Tumors are usually benign. Cause is unknown, may be inherited. CM: severe headache, palpitations, profuse diaphoresis, flushing appearance, sense of impending doom, pain in chest or abdomen, n&v. Treatment: antidepressants, antihypertensives, surgical removal of one or both adrenal glands.

Question
1. During treatment of a client in Addisons crisis, it is most appropriate for the nurse to administer I.V.
a. b. c. d. Insulin. Normal saline solution. Dextrose 5% in half NS solution Dextrose 5% in water