Endocrine Disorders: GH, ADH, and Acromegaly

Disorders

• Excess ACTH causes Cushing's Disease.
• Excess GH manifests as gigantism in children and acromegaly in adults.
• Insufficient GH leads to dwarfism.
• Low ADH is found in Diabetes Insipidus (DI) and results in excessive urination.
• Excess ADH is called SIADH, which stops urination.

Acromegaly

• Overgrowth affects the forehead, jaw, feet, hands, heart, and liver due to excessive GH in adults.
• Risk factors include age and benign tumors.
• Findings include thick lips, joint pain, hyperglycemia, lower jaw protrusion, and a bulging forehead.

Growth Hormone Suppression Test

• Glucose should suppress GH.
• Obtain baseline GH and glucose levels, administer glucose, and monitor follow-up levels 10, 60, and 120 minutes post-administration.
• Restrict consumption to only water, 6 to 8 hours after the test.

Medications for Acromegaly

• Bromocriptine mesylate and cabergoline are dopamine agonists that inhibit GH release; providers should be notified if dizziness or nasal drainage occurs.
• Octreotide and lanreotide are somatostatin analogs that inhibit GH release.

Hypophysectomy

• This procedure involves removing the pituitary gland through a transnasal or orinasal approach.
• Preoperatively avoid teeth brushing, nose blowing, and waist bending to minimize increased Intracranial Pressure (ICP).
• Postoperatively, the patient should be placed in a semi- to high-Fowler's position, neurological status should be assessed frequently, and watery drainage from the mustache dressing should be observed. Encourage mouth-breathing and discourage coughing.

Client Education Post-Hypophysectomy

• Lifelong hormone replacement therapy is required.
• Avoid activities that increase ICP.
• Rinse mouth frequently, report nose dripping, and consume a high-fiber diet.

Diabetes Insipidus (DI)

• ADH deficiency prevents kidney's urine concentrating, resulting in diluted urine excretion, excessive thirst, and electrolyte imbalance. Neurogenic DI is caused by brain damage; nephrogenic DI by direct kidney damage.
• Expected findings include polyuria, polydipsia, and polyphagia.
• Physical assessment reveals tachycardia, hypotension, poor skin turgor, weak peripheral pulses, weight loss, and a dry mucous membrane.
• Lab tests show urine specific gravity below 1.005, urine osmolality under 275, and blood osmolality above 300 with elevated Na and K.
• Care involves monitoring vital signs, urine output, weight, prescribed diet, IV therapy for hydration, and fall precautions.
• Desmopressin, a synthetic ADH, can be given intranasally, orally, or parenterally to help the kidney conserve urine. Vasopressin, used in neurogenic DI, may cause vasoconstriction, requiring Cardiac Artery Disease (CAD) management.

Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

• Excess ADH leads to water retention with hyponatremia and decreased blood osmolarity.
• Risk factors include head injuries, meningitis, and medications that cause excess ADH release.
• Findings include headache, weakness, anorexia, muscle cramping, weight gain without edema, personality changes, dark yellow urine, nausea, vomiting, and diarrhea.
• Physical assessment may reveal Cheyne-Stokes respirations indicating a crisis; seizures, coma, and potential death may result from low sodium levels. Tachycardia, bounding pulse, edema, distended neck veins, hypertension, and pulmonary or peripheral edema may also occur.
• Lab tests reveal increased urine levels and decreased blood osmolality levels.
• Care emphasizes fluid restriction and diluted feedings; monitor vital signs, BP, tachycardia, hypothermia, lung sounds for pulmonary edema, and Na levels, implementing seizure precautions as needed.
• Tetracycline or demeclocycline may stimulate urine flow but are not suitable with kidney problem; they can cause diarrhea or yeast infection. Vasopressin antagonists cause water loss without Na loss, requiring monitoring of Na, glucose, intake, output, and bowel patterns. Hypertonic solutions like 3% NaCl reduce edema and elevate Na levels, useful for dyspnea due to pulmonary edema.

Water Intoxication

• Overconsumption of water can cause cerebral or pulmonary edema, death, or shortness of breath (SOB).

Hyperthyroidism

• When T3 and T4 levels decrease, the body releases TSH to increase them. T4 affects metabolism, energy production, the breakdown of fats, proteins, and carbohydrates.
• Calcitonin decreases calcium levels in the blood.
• Excessive T3 and T4 release describes hyperthyroidism.
• Common causes include Graves' disease, thyroiditis, toxic nodular goiter, and iodine-induced conditions.
• Findings include weakness, fatigue, heat intolerance, weight loss, diarrhea, and exophthalmos (bulging eyes).
• Lab tests show increased blood TSH in Graves' disease and elevated free T4 and T3 in the blood. A thyroid scan identifies thyroid size, needing pregnancy and iodide use checks.
• Nursing involves reducing room temperature, reporting temperature increases, and providing cold showers or sponge baths.
• Thionamides like methimazole and propylthiouracil inhibit thyroid hormone production, used to treat Graves’ disease over radioactive iodine therapy; hypothyroidism should be monitored for.
• Medications should be taken with meals and not stopped abruptly. Methimazole must be stopped if pregnancy occurs.
• Beta-blockers like metoprolol, propanol, and atenolol decrease hyperthyroidism symptoms, requiring monitoring of blood pressure, heart rate, and orthostatic changes.

Iodine Solutions

• Lugol's solution, with 5% elemental iodine and 10% potassium iodide solution, inhibits thyroid hormone release.
• Iodine should be taken 1 hour after antithyroid medications, mixed with juice or liquids, and taken with food; notify the provider for fever, sore throat, metallic taste, or mouth ulcers.

Radioactive Iodine Ablation Therapy

• A single dose of radioactive iodine destroys hormone-producing cells; lifelong replacement may be needed.
• Avoid in pregnant patients and monitor for hypothyroidism signs such as edema, cold intolerance, bradycardia, weight gain, and depression.
• Therapy effects may take 6 to 8 weeks, and patients should stay away from infants and pregnant individuals. Use separate toilet for 2 weeks, flush 3 times after use, take a laxative, and avoid sharing cups.

Thyroidectomy

• This is partial or total thyroid gland removal for cancer or if radiation therapy fails.
• Methimazole or propylthiouracil is given 4 to 6 weeks pre-surgery, followed by iodine 10 to 14 days before the procedure.
• Post-procedure, support the head with neck pillows, promote deep breathing, and ensure oral or tracheal care. Tracheostomy supplies should be available due to potential edema and hemorrhage; check for hypocalcemia via Chvostek's and Trousseau's signs and prepare IV calcium gluconate and calcium chloride. Monitor for hypothyroidism signs and report fever or chest palpitations.

Thyroid Storm

• Large amounts of thyroid hormone release with stress, infection, or trauma, leading to hyperthermia, hypertension, delirium, abdominal pain, chest pain, and dyspnea; cool blankets, thionamides, sodium iodide, and propanol are used.

Airway Obstruction

• Can result from hemorrhage, tracheal collapse, or edema; manage with high Fowler's position, neck swelling reduction, and humidified air.

Hypothyroidism

• Condition where diminished T3 and T4 decrease metabolic rate; autoimmune thyroiditis, medication, and thyroid gland damage or removal, are the most common causes.
• Secondary hypothyroidism arises from tumors decreasing thyroid release. Lithium, amiodarone, thalidomide, rifampin, phenobarbital, phenytoin, and carbamazepine can decrease thyroid hormone release, and radiation therapy can also cause hypothyroidism.
• Expected findings includes fatigue, lethargy, cold intolerance, pallor, weight gain, bradycardia, hypotension, slow speech, hair loss, and swelling of face, tongue, hands, and feet.
• Nurses should monitor for bradycardia and hypotension alongside weight gain, and use antiembolism socks and monitor respiratory status, provide a low-calorie diet, and stool softeners.
• Carefully use barbiturates and sedatives to avoid worsening respiratory depression.
• Levothyroxine increases warfarin effects and the need for insulin and digoxin. It should be used cautiously with CAD patients since it forces the heart to work harder, and chest pain and palpitations should be monitored. Antacids, calcium, and iron can affect its absorption. Take on an empty stomach 30 to 60 minutes before breakfast.

Myxedema Coma

• This is a life-threatening condition from hypothyroidism, leading to respiratory failure, hypotension, hypothermia, hypoglycemia, bradycardia, and coma.
• Administer fluids, manage airway, monitor ABGs and temperature, and administer levothyroxine and glucose.

Complications of Diabetes Mellitus

• DKA results from not following insulin regimen, infection, or increased cortisol, glucagon, or epinephrine release. The patient exhibits the 3 P's: polydipsia, polyuria, and polyphagia, with weight loss because the body is in a catabolic state. Lack of glucose to the brain results to neurological dysfunction. Other symptoms include blurred vision, headache, and weakness.
• Ketones are found in the blood, causing acidosis, nausea, vomiting, abdominal pain, and fruity breath. Ketones may also be present in the urine. Polyuria can lead to orthostatic hypotension from excessive fluid depletion. DKA presents with blood glucose greater than 300. Sodium will be low due to excessive urination and potassium may be normal or low initially, then deplete with treatment. Respirations will be Kussmaul due to metabolic acidosis.

HHS

• Characterized by glucose levels over 600, caused by poorly managed diabetes, fluid intake, or stress. Symptoms include the 3 P's, orthostatic hypotension from fluid loss, altered mental status, and blurred vision. Sodium is low, while Potassium may be high initially. BUN and creatinine may be elevated, but ketones are not found in urine or blood. Blood osmolarity is high due to elevated glucose and electrolytes. Metabolic acidosis is not present, but bicarbonate levels may be normal or high.

Nursing Care for DKA and HHS

• Monitor vital signs every 15 minutes, then every 4 hours for dehydration or infection. Rehydrate with 6L to 10L of IV fluids in 24 hours. Start with 0.9% NaCl initially, switching to 0.45% NaCl for high sodium related to dehydration. Hypotonic solutions like 0.45% NaCl can replenish lost body fluids.
• When glucose reaches 250, add IV dextrose 5% to prevent hypoglycemia and cerebral edema. Administer insulin at 0.1 to 0.15 unit/kg IV bolus, followed by continuous IV infusion at 0.1 unit/kg/hr, IV administration is faster than subcutaneous absorption.

Hypertension (HTN)

• Blood pressure averages above 140/90, confirmed after two tests. Risk management involves a low-sodium diet, exercise, weight management, smoking cessation, and reduced alcohol intake.
• African Americans and Hispanics are disproportionately affected. Primary hypertension has no identifiable cause, while secondary hypertension does. Hypertension and cardiac output are inversely related.
• Geriatric considerations include increased plaque, elastin, and collagen buildup in blood vessels, impairing vasodilation and kidney function causing Systolic Hypertension.
• Clinical symptoms include retinal changes like hemorrhage, exudate, and papilledema. Increased BUN and creatinine can manifest as nocturia.
• Check BP at least twice and consider home or ambulatory BP monitoring. Masked hypertension shows HTN outside the hospital setting, white-coat syndrome shows high BP in the hospital. Rest and void coffee or alcohol intake for 30 minutes.
• Untreated hypertension can lead to heart failure and CKD. Calcium Channel Blocker's (CCB's) amlodipine decreases calcium release, administer on an empty stomach and monitor for edema, constipation, and irregular heartbeat.

Congestive Heart Failure (CHF)

• This is when the heart cannot pump enough blood to meet metabolic needs. Dysfunction includes systolic failure which prevents adequate contraction, and diastolic failure which prevents ventricle filling. Managed with meds and lifestyle changes, prevalent in African American and Hispanic communities, risk increases with age.
• Other disorders include hypertension, cardiomyopathy, valvular disorders, or kidney disorders.
• Atherosclerosis and ischemia deprive oxygen, reducing contractility and promoting muscle necrosis. Systemic and pulmonary hypertension requires the heart to work harder.

CHF Pathophysiology

• Systolic heart failure triggers baroreceptors. Renin to angiotensin I conversion occurs in the kidneys, converted by ACE to angiotensin II, causing aldosterone increase which affects Na and fluid retention vasoconstriction.
• ANP and BNP promote diuresis. Ventricular remodeling enlarges the heart.

Left-Sided Heart Failure Manifestations

• Inability to pump through the aorta causes blood to flow backward into the lungs, impairing gas exchange and leading to pulmonary interstitial edema.
• Symptoms include dyspnea, cough, crackles, and low SpO2 with possible S3 gallop. The patient may feel orthopnea, so the patient wants to be in upright positions to feel comfortable. May also cause dry cough with pink frothy sputum. Basilar crackles indicate the development of left sided heart failure and fluid backup.

Right-Sided Heart Failure Manifestations

• Inability to draw blood to the heart causes jugular vein distention (JVD) and hydrostatic pressure, leading to edema, hepatomegaly, and ascites.
• Congestive heart failure begins with left-sided failure, extending to right-sided failure with edema, hepatomegaly, ascites, and JVD.
• Increased atrial pressure causes pulmonary edema; patients experience low O2 saturation, shortness of breath, and tachypnea. In severe cases, there may be skin coolness, clamminess, and suffocation.
• Ejection fraction, normally 55% to 65%, measures blood volume left in the ventricle. Reduction correlates with systolic heart failure. Preserved ejection fraction, around 50%, correlates with diastolic heart failure. Reduced score is 40-49%. BNP levels aid heart failure evaluation.

Medical Management

• Reduce alcohol and smoking.
• Lifestyle changes needed are weight reduction with healthy eating habits and reduced sodium.

Pharmacologic Therapy for Heart Failure

• Reduce fluid buildup with loop diuretics like furosemide and thiazide diuretics like metolazone or hydrochlorothiazide that block Na reabsorption.
• Both loop and thiazide may cause hyperkalemia and orthostatic hypotension.
• Aldosterone antagonists include spironolactone blocks Reabsorption of fluids and potassium retention, monitor K Make sure to monitor for elevated creatinine since this indicates kidney damage.
• ACE inhibitors like lisinopril lower blood pressure, monitor for cough, dizziness, and hyperkalemia. For cough, administer ARBs like valsartan or losartan.
• Sacubitril-valsartan (ARNIs) are expensive, better than ACE and ARBs for HF treatment.
• Beta-blockers like labetalol to counteract SNS, can cause dizziness, hypotension, depression, and bronchoconstriction, administer Beta blockers with caution for asthma, COPD, bronchitis, and diabetes patients.
• Hydralazine isosorbide nitrate for patients with systolic BP over 90.
• Digitalis/ Digoxin may cause cardiac effects, it is crucial to monitor Kidney and potassium levels, improves diuresis by increasing blood flow to the kidneys. Digoxin toxicity causes visual disturbances, confusion, and bradycardia.

Other Heart Failure Medications

• Dopamine used in cases of left ventricle heart failure.
• Milrinone vasodilates severe heart failure cases.
• Caution patients with Hypotension should not receive Vasodilators like nitroglycerin and nitroprusside to bring relief symptoms.

Heparin Toxicity

• Protamine to treat IV Heparin toxicity 20mg/min or 50mg in 10 mins do not exceed from 10mg every 2 hours since it shows risk of protamine toxicity
• Bleeding, increased HR, decreased BP, bruising, petechiae, hematoma, and black and tarry stool aPTT is 1.5 to 2 X of base line.

Peripheral Artery Disease (PAD)

• Narrowing of blood vessels in the lower extremities.Thickening of blood vessel or plaque build up Atherosclerosis(harding of the arterial walls) Diet with diabetes, hyperlipidemia sedentary

• Pain and numbness in legs/feet, Pain elevation, lowed (ruber) or extreme redness, Thicked tow nail

• Arteriography injection look out for bleeding, Exercise tolerance, Plethysmography and MRA Contrast decrease Blood Flow

• Rebuild Circulation, Heat use and insulated socks, low caffeine and Nicotine in-between Avoid, Positioning Balloon angio

• Plate Anticoagulant like aspirin, clopidogrel

• Laser area plaque monitor Bleeidng

• Athereetomy scraping plaque monitor bleeding for 2.6 hours

• Revascularization for loosing Limp make sure to compare pulses and dopper shift

Compartment Syndrome

• tissue block blood glow Monitor by 6Ps assessment

Peripheral Venous Disorders

Blood caused by lack of blood glow cause by VTE

• Venous weak caused obesity/prutitis ,dark ankle ,socks avoid thight clothe or elevate
• Trilemberg/scerlothesis
• Vte clot or lack of glow/ PE chest or SOB encourage movement

Dysrhythmia Treatments

• Bradycardia is treated with atropine, then dopamine or epinephrine.
• Electrical management can use pacemeaker
• Afib uses Amiodarone, adenosine, and Cardiversion
• VTACH no pulse uses amiodarone , lidaccinne and Defibrillation

Heart Attack

• Check troopin after 10 days or monitor myglobin for cardia
• Heart use MONA morphine, O2, Nitrites, and Asprin

Stroke

• Watch for Slurred Speech (monitor)Dizzness and Fall
• Check 2 Times

Pacemaker

• Electrically Stimulate Temporary
• Trans Attach, Painful , After medication
• Epicadirectly is Heart Used with open Surgery
• Permanent or ICDS internic that cirectly Sends electricity area
• Place it in the Pectoral last long
• Fixed Rates
• Demand rate is low
• Check the heart rate or signs
• Report Hicuups signs of Pressures

Cardiac intervention

• Removes Plaque
• AngionBalloon use = Strent bare

Stroke

• FAST check
• Unilateral Neglert one side you dont feel
• 123 check Lox and Aways

Shock

• Cordogenic is the heart and not pumping blood caused by a lot of factos
• Hypo decrease fluid in ICF / obstrutive hard is to get thier
• Distributing is vasodilating . Education health life style and wear seait belts

Aneuresom

• Arteries Balooning two Saccular one side effect entire artery Abd pain with feeling bruti is aneurysms thoratic sevr pain cough brweath

Acurd kideny

• Rifle/ risking of kidney loss or ESKD is severty use of AKD
• Pre Kidney kidney is actual dammage of afterkidney absturtuion of Kidneys or spesis can also be BPH -Oliguria /Electrolyte diuresis back to normal kid will not let Kid work
• Give med for hyper k - Sodium bicarbonate to kaxylate and k glucontate
• Can see burn and creatine protein is brocken down
• Nephrosis

Urinary track

• lower/pelvis pelvis turn to septic
• Female short uti statis dbt inipidus

Pyelonephritis

• Uric/untreatued or 2 year and in uti,headache or naucea vomit 1 Anitbos are 2 L of glucono. glomerur nephitis respitory lead to glomerur neaphis

Peritoneal dialess

utri to kidney faitl

Opiod

• Analgestaics are good

Hep C

• Hiv blood stick Liver b

Aloc

• Decrese ammoun in the body/Diuirees / beta is for paracen

Scerlosis

• Live scar issue channel make over lap and junodice Tioxin and acloho

Cilitica

• Immmue respinise food leads diatrrha/stem /atigue wheret

Ostomise

• lleom /in ileuem liquid stoom / colo up liquid/trans verse solid ,decinding near /s normal is pin nk /odor fixhe/gacars No high after stoimies

Pendcitus

• Inflammed in quadrant

Bown d

• Gl to food caugh to pouch

Clorehtis

Anemia /sufula must check allergic rxn Monitor CBC

• Preditons
• Sahrp/ murhyi Celoium intaltionlder / bilirubin

Extraperial

• shock.

Celiac Disease

• This is caused because it is Animmune response to eatting gluten, Symptoms arediarhhea steatorrhea fatigue avoid Bareley and rye or wheretm
  Mlonitre food and bleendind eat dfor rffood

Ostomies

• This for ilem and in has liquid to stop chromoes or ulcerated colits and then place if the patient.

Can have Ascending/transerse/ decineing

• No high fibre

Can be pialkn or balck and bbulish .

Meterproide

• Prometiv mecs
• Tumor
• Upper body protends /tests sea and psA ca detext
• Appnciits Quad
• c. angro checkkid and allerkies/