Endocrine system and disorders

Endocrine System Overview

• The objective is to understand the location and function of endocrine glands.
• Discussion of actions of hormones that the endocrine glands excrete.
• To understand the procedure for completing a history and physical assessment of the patients and how that correlates to diagnostic exams.
• An explanation of nursing considerations for diagnostic studies.
• Recognize the epidemiology of Pituitary Disorders.
• Correlate clinical manifestations to pathophysiological processes of hypopituitarism, hyperpituitarism, diabetes insipidus (DI), and syndrome of inappropriate antidiuretic hormone (SIADH).
• Distinguish between diagnostic results used to confirm pituitary and thyroid disorders.
• Discuss the management of hypopituitarism, hyperpituitarism, diabetes insipidus (DI), and syndrome of inappropriate antidiuretic hormone (SIADH).
• Develop comprehensive nursing care plans for patients with pituitary and thyroid disorders that include pharmacology, dietary, and lifestyle considerations.
• To recognize the clinical manifestations to pathophysiological processes of hypothyroidism and hyperthyroidism.

Endocrine System: Organs and Glands

• Endocrine glands include hypothalamus, pituitary, adrenal, thyroid, and parathyroid glands, gonads, and the islet cells of the pancreas
• Endocrine glands secrete hormones directly into blood

Endocrine Hormones

• Dysfunction at the endocrine gland is classified as primary.
• When the anterior Pituitary gland has a dysfunction it's classified as secondary.
• If the hypothalamus has a dysfunction it’s classified as tertiary.
• The inability of target tissues to respond to hormones is classified as quaternary.
• Hormone release coordinates sexual functions and blood glucose control.
• Hormones regulate metabolism, growth and development.
• Under or overproduction of select hormones lead to endocrine dysfunction.
• The function of the endocrine system links to the nervous system through hormone secretion.
• Hormone secretion is regulated by a negative feedback loop and neuroendocrine regulation.
• Located beneath the Thalamus, hormones secreted by the hypothalamus work directly on other endocrine glands.
• The hypothalamus regulates the anterior pituitary.
• Hormones secreted by the hypothalamus target the pituitary gland tissue.

Pituitary Gland: Hormones Secreted

• The anterior pituitary secretes two gonadotropin hormones: follicle-stimulating hormone (FSH) and luteinizing hormone (LH).
• The anterior pituitary also releases the thyroid-stimulating hormone (TSH), adrenocorticotropic hormone (ACTH), prolactin, growth hormone (GH), and melanocyte-stimulating hormone.
• Nerve fibers compose the posterior pituitary.
• The Posterior Pituitary is responsible for the neruoendocrine reflexes the result in hormone secretion in response to signals from the nervous system.
• The posterior pituitary secretes antidiuretic hormone (ADH) and oxytocin.

Adrenal Glands: Cortex and Medulla

• The outer cortex makes up 90% of the adrenal gland, secreting mineralocorticoids such as aldosterone, glucocorticoids (e.g., cortisol), and androgens (male sex hormones).
• The adrenal medulla is controlled by the sympathetic nervous system (SNS).
• The adrenal medulla secretes epinephrine and norepinephrine—not essential to life as the SNS also produces them.

Other Glands

• The anterior neck contains the thyroid gland underneath the cricoid cartilage
• The thyroid gland produces triiodothyronine (T3), thyroxine (T4), and thyrocalcitonin (calcitonin).
• T3 and T4 regulate heart rate/contractility, respiration rate/depth, oxygen/glucose use, glycolysis, protein synthesis, fatty acid metabolism, and cholesterol/phospholipid levels.
• Parathyroid glands partially are embedded in the thyroid gland, and above the Hyoid Bone.
• Parathyroid Glands secreting parathyroid hormone (PTH), raises serum calcium with bone reabsorption plus renal reabsorption/vitamin D activation.
• PTH lowers serum phosphate by reabsorption in the kidneys, bone resorption, and absorption in the small intestine.
• The Gonads have a function of sexual development, follicle-stimulating hormone (FSH) and luteinizing hormone (LH) stimulate the maturation of male and female sex organs.
• In males, follicle-stimulating hormone (FSH) and luteinizing hormone (LH) combine are testosterone.
• In females follicle-stimulating hormone ( FSH) and luteinizing hormone (LH) are Estrogen/Progesterone.
• The pancreas is located in the upper left quadrant of the abdomen.
• Islet cells have endocrine/exocrine functions that control blood glucose with the use of insulin, and glucagon;

Assessment and Diagnostics

• An endocrine assessment involves a comprehensive history, a family history for genetic links, and a physical assessment of the overall exam.
• During the general physical exam specific attention to inspection (manifestation), auscultation (heart rate & rhythm + carotid/thyroid bruits) and palpation (thyroid, testes and size, node texture, shape and symmetry)
• Diagnostic studies include a table 40.3, lab work (serum hormone levels, TSH, T3, T4, stimulation and suppression testing), and imaging via CT, X-ray, MRI, and thyroid scans.

Pituitary Gland Disorders

• Anterior pituitary gland disorders include hypopituitarism and hyperpituitarism.
• Posterior pituitary gland disorders include diabetes insipidus (DI) and the syndrome of inappropriate antidiuretic hormone (SIADH).

Hypopituitarism

• Hypopituitarism stems from hyposecretion in the anterior pituitary or hypothalamus
• Hypopituitarism results in less than 200k individuals and is caused by by damage, compression, inflammation, tumor or damage to the hypothalamus.
• Deficiencies in anterior pituitary hormones from hypopituitarism, will cause changes in sexual function/metabolism.
• Decreases of a anterior Pituitary hormone, ACTH, decreases aldosterone and affects the adrenal cortex.
• With hypopituitarism, with a TSH decrease, thyroid stimulation goes down which effects the hormone.
• A lack of Luteinizing Hormone (LH) & Growth Hormone (GH), causes changes in sexual and reproductive activity. Clinical Manifestations :
  • Decreased Mineralocorticoids causes Hypotension, Hyperkalemia and Hyponatremia.
  • Lower GH causes; decreased bone density/muscle strength and an increased fracture risk.
  • Female effects with a decrease in LH and FSH; amenorrhea, irregular menses, and decreased ovulation.
  • Lower levels of T3 & T4; decreased metabolic rate, thinning of hair, weight gain and decreased libido.

Hypopituitarism: Diagnosis and Management

• Diagnosis of hypopituitarism depends on the suspected missing hormone.
• Includes hormonal studies, ACTH stimulation test, TSH, LH, FSH prolactin and GH levels, and CT/MRI to rule out tumors.
• Additional diagnostic test to rule out other problems, may be done via blood testing.
• Hormone management is based on restoring the hormone levels to their normal range, and supportive therapies for replacement of Electrolytes, Vitamins and minerals.
• Hypopituitarism effects the following: Panhypopituitarism and a lack of TSH & ACTH.
• Panhypopituitarism causes hyposecretion of hormones from the hypothalamus.
• ACTH, when there is a lack of it causes an inability to maintain fluid volume resulting in circulatory collapse.
• The lack of TSH causes decreased metabolism.
• Women diagnosed with hypopituitarism utilizing estrogen replacement have a risk for HTN and DVT.

Hypopituitarism: Nursing Management

• The nursing management for a patient with hypopituitarism is to assess, analyze, dependent on the hormone deficiency, and the nursing diagnosis and problems identified.
• Nursing problems include: Fluid volume deficit, risk for injury, hypoglycemia, impaired mobility, hyponatremia, hyperkalemia or osteoporosis.
• Nursing interventions include: assessments of Vitals, monitoring of serum glucose levels, and changes to fertility.
• Actions also include safety implementation, increasing vitamin D/Calcium, hormone replacement, physical therapy, support from dietician.

Hyperpituitarism

• Hyperpituitarism often is related to hypersecreting tumors and has a higher frequency with increased tumor amounts and more individuals with autoimmune diagnosis.
• Pathophysiology is secondary to hypersecretion of hormone leading to specific dysfunction.
• It is dependent upon the increase in certain hormones.

Hyperpituitarism: Manifestations

Clinical Manifestations: - increased glucose and cortisol levels can occur, - coarse facial features and menstrual irregularities - elevated hormone levels

• Diagnostic testing includes hormone evaluation with TSH, FSH, ACTH, and Prolactin.
• Also diagnostic is to test stimulation as well as rule out the presence of a possible tumor.
• Treatment focuses on the assessment, diagnosis, evaluation, and treatment of the identified hyperactive cells.
• If identified, medications are utilized to restore hormone levels, along with potential intervention to remove any tumors.
• Some common medications are the use of the brand name drug Bromocriptine and somatostatin.

Hyperpituitarism: Surgical Management

• Transsphenoidal Hypophysectomy for surgical management can be performed
• Surgery can be performed with a transeptal approach or with a endoscopic approach
• Stereotactic radiosurgery is also used as a surgical management

Hyperpituitarism: Complications and Nursing

• Complications, such as; cardiac hypertrophy, enlarged liver/colon/hands/feet, s/s of hyperglycemia/HTN/headache/visual changes/irritation.
• There are pharmacological and nonpharmacological interventions.
• Pharmacological interventions, after or/in lieu of surgical action may be needed to prevent issues with the disorder as a result of the pressure on organs or functions.
• Also the potential for severe Hyperthyroidism needs to be monitored with interventions and actions administered.
• Assessment to nursing diagnosis/problems and interventions with potential surgery and actions need to be taken.
• It is important is to assess the patient post operative vital signs, neurological status, intake output, the membranes of the mouth and measure serum sodium and osmolality.

Hyperpituitarism: Post-Op Care

• Post operative Actions for nursing intervention include, monitoring of vital signs and neurological status are vital to ensure good circulation and brain function.
• Ensure humidified oxygen if needed, access to IV fluids, regulate pain through narcotics and if needed use a warmer to maintain.
• There are many diagnosis associated with the disorder, a few are: fluid volume, body image, pain, and hyperglycemia
• Monitor and teach the patient signs and symptoms with treatment or actions that will maintain and prevent.

Diabetes Insipidus (DI)

• Central DI may lead to decrease in ADH with a primary focus.
• Nephrogenic DI has kidney resistant to ADH
• Inability to concentrate urine makes up about approximately 30% of the DX with DI as Idiopathic cause in inter cranial surgery (20%) and Brain Tumors %25 of DX.

Diabetes Insipidus (DI): Pathophysiology, Manifestations, Diagosis and Meds

• With minimal ADH production, the hypothalamus will not function nor work within collection of kidneys.
• In result, kidneys will not be permeable and excrete large volumes of very diluted urine.
• The individual will have with weight loss, polyuria, nocturia and hemoconcentration as a manifestations.
• DIagnosis is to test electrolytes, and due to hemoconcentration do a urine and serum osmolality test.
• Medication used in the management will vary, the first is Desmopressin which is a synthetic ADH hormone. Vasopressin is also used.
• Due to loss of fluid with minimal ADH and kidneys, the patient will experience hypotension, and tachycardia.
• So, monitor electrolyte and urine tests to maintain the function of the kidneys and the homeostasis of the body systems.
• The main concerns if undiagnosed are dehydration, hypovolemia, hypernatremia and risk for hypovolemic shock, and need for hormone replacement.

Diabetes Insipidus (DI): Care Plan

Nursing interventions: - the first being assessment of the electrolytes and values - second is to assess the blood pressure, and lastly the pulse.

• If there are irregular vital signs or lab values, the patient will need education.
• Patients should track and maintain the assessment to the proper interventions, medications and support for the disorder if not corrected.
• In general it is to teach the patient what do to, how to maintain the body systems, the side effects, monitoring and management of the treatment to prevent long term damage.

Syndrome of Inappropriate Antidiuretic Hormone (SIADH): Overview

• With epidemiology relating to ADH, the pathophysiology results in overload of water.
• The hemodilution with increase in ADH causes electrolyte disruptions.
• The diagnosis is through trending the values associated with Hyponatremia (135), ADH increases that lead to:
• CNS disorders (tumors in brain or neck), medication effects, psychotropic interventions and bronchogenic carcinoma will be a cause of the syndrome.

SIADH: Clinical Manifestations and Management

• With this there are many symptoms that will occur with the first observation including:
• headaches, anorexia, weakness and irritability
• with severe observation of signs and symptoms including seizures that may become coma
• A Potential of seizures or coma occurs when sodium levels become 120 MEq/L.
• In severe hyponatremia (fluid sift in the brain), neurological issues can occur, and there might be the possibility for cerebral adema.
• Trending is to observe, monitor and maintain through medications and fluid restriction to promote the balance. This is done through diuretics.
• The main assessment parameter with SIADH is to check levels, as well as fluid overload.
• This is implemented and achieved through recording, checking lungs, heart/neuro, and trending vital signs, also through labs. A major concern with SIADH, is the hyponatremia.

Hypothyroidism: Overview and Pathophysiology

• Epidemiology of hypothyroidism includes control by the anterior pituitary gland and hypothalamus.
• Autoimmune diseases, thyroid/radio iodine therapy and Tyrosine Deficciences are among the other associated factors of Hypothyroidism.
• All these factors impact Metabolism/Body functions.
• In result of one of the factors, one may cause hypothyroidism, such as a thyroidectomy or malfunction and medication side effect.

Hypothyroidism: Clinical Manifestations and Medical Management

• Clinical manifestations include: swelling of the skin, cardiac and gastrointestinal side effect, increase lethargy, and more issues associated with mood changes.
• Medical management is through diagnoses of Thyroids in the body.
• This is done through thyroid scan in the neck to rule out tumors/nodules/hyperstimulation.
• Treatment occurs after the determination and it needs to be a balance with hyper and hypo.
• This is done through replacement hormones and balance.

Hypothyroidism: Medical Management

• As in the case of diabetes, there are medications that will be required to be taken to prevent or maintain.
• One medication often used and needed for an extended period of time is Levothyroxine.
• There are specific instructions and concerns in those with cardiovascular issues associated with them.
• One with Low T4 and High TSH, in result causes a decreased function in the body systems resulting in Hypothermia, hypoxia, glucose, and confusion.
• Low function from T3 and T4, this imbalance can cause heart issues/ failure.
• Other items such as retaining of CO2, electrolyte imbalance, or a lack of temp regulation and a decrease cardiac function are a concern.
• If this become too irregular in function and severe it will cause a myxedema Coma

Hypothyroidism. Nursing Management

• During a care plan development, one with decreased cardio, altered nutrition, and mental dis function are some concerns/focus.
• To intervene, the nurse will want to have the patient use the medication regiment and actions needed to keep in good status.
• Some of those actions is to asses, provide and act on low and slow/decreased function to give the support needed.
• Oxygen will need to be on stand by, and to replace warm items to support circulation and prevent rapid drop in vitals.
• One should be very cautious in treating low vitals like BP/HR.
• Actions such as low dose for everything need to be considered and a plan to maintain will prevent a severe decompensation.
• The most important in planning is to teach signs of high/low in the patient.

Hyperthyroidism: Overview and Pathophysiology

• Hyperthyroidism is more commin in females aged 20-40 and Grave's disease is the most common cause.
• This happens with overactive thyroid and excessive production of T3 and T4 hormones.
• Or to little TSH Hormone to maintain balance.

Hyperthyroidism: Manifestations and Care Considerations

• Clinical manifestations include: high HR and metabolism
• Body function high, Heat issues, weight loss, bowel movement, increased heart rate and vision issue are a concern.
• Also fatigue, sleep and over stimulus.
• Diagnostic/Treatments would be to control the symptoms and treat, that would cause high or low and put them in the middle.
• When hyper, there is rapid function to maintain through cooling and medication regiment.
• One of this includes radioactive iodine or remove tumor/hormone in the way.

Hyperthyroidism: Medical and Post-Operative Management, Thyroid Storm

• Th function goal is to achieve balance and for the hormones and electrolytes .
• There are medication in take such as a beta block to decrease heart rate during high function.
• The medical team during surgical interventions needs to be ready to do everything such as the prior conditions before that needs to be achieved.
• Another priority includes, positioning and assessing the patient with a decrease of trauma that will disrupt stability.
• During these procedure there always is a risk for thyroid storm, to prevent a thyroid storm:
• Manage levels and be on the look out hyperthyroidism .
• Be mindful of any changes in the vitals, like High HR, low blood pressure, over hypertheima, and a change in mental functions is also a high concern.
• If thyroid storm occurs, medication and medical interventions must be done to stabilize .
• The major teaching points is to prevent complications in the long term.
• Actions such as managing vitals and monitoring lab values need to be stressed with communication from the nurse.