Endocrine System and Glandular Function

Endocrine System Overview

• The endocrine system consists of ductless endocrine glands that secrete hormones directly into the bloodstream.
• These hormones regulate various bodily functions by coordinating with the nervous system using feedback loops.
• Under or overproduction of certain hormones can cause endocrine dysfunction.
• Key endocrine glands incude, the hypothalamus, pituitary, thyroid, parathyroid, adrenals, gonads, and sections of the pancreas.

Endocrine Hormone Classifications

• Endocrine hormones travel through the blood stream affect target cells.
• Endocrine disorders can be classified into 4 types, Primary, Secondary, Tertiary, and Quaternary:
• Primary disorders originate at the endocrine gland.
• Secondary disorders are caused by dysfunction of the anterior pituitary gland.
• Tertiary disorders are caused by dysfunction of the hypothalamus.
• Quaternary disorders result from the inability of target tissues to respond to hormones.

Endocrine System Functions

• Functions of the endocrine system include the regulation of body process:
• Coordinates various bodily functions, like growth, development, sexual functioning,
• Controls blood glucose levels and regulates metabolism.
• The function of the endocrine system is linked to the nervous system through neuroendocrine regulation.
• Feedback loop regulates this hormonal secretion.

Hypothalamus

• The hypothalamus is located in the brain beneath the thalamus.
• Secreted hormones directly affect the other endocrine glands functionality.

Pituitary Gland - Anterior

• Anterior pituitary hormone production is regulated by the hypothalamus.
• Hormones secreted by the hypothalamus target pituitary gland tissue.
• The anterior pituitary secretes two gonadotropin hormones, follicle-stimulating hormone (FSH) and luteinizing hormone (LH).
• The anterior pituitary also secretes thyroid-stimulating hormone (TSH), adrenocorticotropic hormone (ACTH), prolactin, growth hormone (GH) and melanocyte-stimulating hormone.

Pituitary Gland - Posterior

• The posterior pituitary differs from the anterior since it's made of nerve fibers.
• It's responsible for the neuroendocrine reflexes where hormones are secreted in response to signals from the nervous system.
• Secreted hormones are antidiuretic hormone (ADH) and oxytocin.

Adrenal Glands

• The adrenal glands have two main parts, cortex and medulla.
• The adrenal cortex makes up 90% of the adrenal gland.
• The adrenal cortex secretes three main types of hormones, including mineralocorticoids (aldosterone), glucocorticoids (cortisol), and androgens (male sex hormones).
• The sympathetic nervous system (SNS) controls the adrenal medulla.
• The adrenal medulla secretes epinephrine and norepinephrine.
• SNS produces epinephrine (Epi) and norepinephrine (NorEpi), and the adrenal medulla isn't essential to life.

Thyroid Gland

• The thyroid gland sits in the anterior neck underneath the cricoid cartilage.
• The thyroid gland produces three hormones: triiodothyronine (T3), thyroxine (T4) and thyrocalcitonin (calcitonin).
• T3 and T4 regulate heart rate, contractility, rate, depth of respirations, oxygen use, glucose intake, glycolysis, protein synthesis, fat/lipid metabolism, and cholesterol/phospholipid synthesis.

Parathyroid Gland

• Parathyroid glands can be found partially embedded in the thyroid gland or above the hyoid.
• The main hormone secreted is the parathyroid hormone (PTH).
• PTH increases serum calcium levels, bone reabsorption, and stimulates renal reabsorption of calcium and activation of Vitamin D.
• PTH decreases serum phosphate by reabsorption of phosphate in the kidneys, bone resorption and small intestine absorption of phosphate.

Gonads

• Sexual development / function rely on hormones the gonads secrete.
• The two sex glands are testes and ovaries.
• Both sex organs are controlled by tropic hormones the anterior pituitary gland releases.
• This release is based on the designated gonadotropin releasing hormone from the hypothalamus.
• The female hormones involved in sexual maturation are follicle-stimulating hormone (FSH) and luteinizing hormone (LH).
• For males, Follicle-stimulating hormone (FSH) and luteinizing hormone (LH) equal testosterone.
• For females, Follicle-stimulating hormone (FSH) & LH equal estrogen and progesterone.

Pancreas

• The pancreas has both endocrine and exocrine functions.
• Endocrine functions come from the islet cells controls blood glucose levels using insulin and glucogon.
• Insulin is released when glucose levels are too high.
• Glucagon is released when glucose levels are too low.

Endocrine System Assessment

• Endocrine system assessment:
  • A thorough history, including family history of genetic endocrine disorders, and physical assessment is necessary for an endocrine assessment.
  • Physical assessment includes an inspection and head-to-toe exam.
  • Auscultation of heart rate, rhythm, carotid and thyroid bruits is also importnat.
  • Palpation for the size, shape, symmetry, and any nodules or texture changes to the thyroid or testes can take place.

Diagnostic Studies

• Diagnostic studies used in evaluating the endocrine system:
• Lab studies for serum hormone levels, thyroid stimulating hormone, T3, T4, and stimulation / suppression testing.
• Imaging such as CT scans, X-rays, MRI and thyroid scans aid in diagnostic analysis.

Disorders of the Pituitary Glands

• Disorders of the pituitary gland are divided into anterior and posterior pituitary gland disorders.
• Anterior pituitary gland disorders include hypopituitarism and hyperpituitarism.
• Posterior pituitary gland disorders include diabetes insipidus (DI) and syndrome of inappropriate antidiuretic hormone (SIADH).

Hypopituitarism - Pituitary Insufficiency

• Hypopituitarism defined: hypo secretion of hormones from the anterior pituitary gland.
• Hypopituitarism can result in decreased bodily functions.
• Epidemiology shows that hypopituitarism is a rare condition where less than 200,000 individuals within the U.S. have this diagnosis.
• Possible causes include damage, compression, or gland inflammation, from a pituitary tumor, or hypothalamus damage.
• The pathophysiology results in deficiency of one or more anterior pituitary's hormones.
• This can result in changes in the metabolic or sexual function.
• Pathology can be determined decreased amounts of corresponding hormones.

Hypopituitarism Clinical Manifestations

• Adrenocorticotropic hormone (ACTH) deficiency leads to decreased release of aldosterone and cortisol from the adrenal cortex.
• Thyroid stimulating hormone (TSH) deficiency causes decreased thyroid hormone.
• Luteinizing hormone (LH) and growth hormone (GH) deficiencies lead to changes in sexual and reproduction functioning.

Hypopituitarism Diagnosis and Treatment

• Diagnosis is dependent on the suspected missing hormone.
• Diagnostic methods included hormone studies, such as ACTH stimulation test TSH, FSH, LH, prolactin and GH labs.
• A CT or MRI can rule out a brain tumor or other pituitary abnormalities.
• Blood testing can determine alternate causes of corresponding symptoms like weakness.
• Medical management is to restore hormone levels to normal with hormone replacement such as Corticosteroids, thyroid hormone, testosterone or estrogen) and supportive therapies involving electrolyte replacement, Vitamin D & Calcium.

Hypopituitarism - Complications

• Panhypopituitarism is the hyposecretion of all hormones from the hypothalamus.
• Lack of ACTH causes inability to maintain fluid volume and circulatory collapse.
• Lack of TSH leads to decreased metabolism.
• Estrogen replacement therapy puts women at risk for hypertension (HTN) and deep vein thrombosis (DVT).
• Deficient anterior pituitary hormones can lead to hypotension and circulatory issues
• These issues are associated with reduced ACTH levels and decreased production of aldosterone, which causes water and sodium loss through kidneys

Nursing Management for Hypopituitarism

• Nursing management involves both assessment and analysis:
• Assessment, dependent on the hormone deficiency.
• Diagnose fluid volume deficit and risk for injury.
• The diagnosis is determined by the hormone deficiency.
• Interventions include monitoring vital signs and serum glucose levels.
• Monitor for changes in fertility and signs of decreased bone density.
• Nursing actions / teaching include to implement safety measures, increase intake of vitamin D and calcium intake, Hormone replacement therapy, and collaboration with physical therapy is necessary.
• Consult dietitians for nutritional needs, to teach the importance of taking hormone supplements in the morning when it's most natural within a normal sleep pattern.

Hyperpituitarism

• Hyperpituitarism is often related to a hypersecreting tumor and is more common among females.
• It can be diagnosed in the early-teen years, or can be diagnosed in adults.
• It has been identified as having a possible genetic link
• Hyperpituitarism can be secondary to hypersecretion of a specific hormone caused by dysfunction.
• This will be hormone dependent from the increased levels.

Hyperpituitarism Clinical Manifestations

• ACTH excess causes increased levels of glucocorticoids (hyperglycemia and increased cortisol levels) and mineralocorticoids (Hypernatremia, Hypertension, Hypokalemia)
• Growth Hormone (GH) excess causes increased bone density, coarse facial features and menstrual irregularities.
• Prolactin excess causes hypogonadism, galactorrhea (milky nipple discharge) and increased body fat.
• TSH excess increases T3 & T4 hormones, and causes increased metabolic rate, weight loss and exophthalmos.

Hyperpituitarism Diagnosis, Treatments & Actions

• Diagnosis focuses on the hormone or target cells the increased hormone affects.
• ACTH stimulation tests help determine the source(s).
• Measurement of TSH, FSH, LH, Prolactin and GH levels necessary for diagnosis and treatment.
• Possible tumors need to be identified through imaging.
• Additional assessment is checking the patient hands, feet, and facial bones for broadening.
• Medications include symptom treatment, secretion limitation, and targeting identified glands or cell hyperfunction.
• Dopamine agonists (Bromocriptine mesylate) can inhibit the release of anterior hormones.
• Growth hormone receptor blockers & somatostatin analogs can impede GH release
• Medication assists if there is a tumor, reducing the size and severity of surgical removal.
• Surgery can include transsphenoidal hypophysectomy used to resect the Pituitary gland or Stereotactic radiosurgery.

Hyperpituitarism - Complications

• Increased ACTH levels can result in hyperglycemia, hypertension, and acromegaly.
• Increased GH levels can result in organ overgrowth and hypertrophy of the heart, thyroid, liver and kidneys.
• Nerve entrapment, pain, and changes in sensation are also related to increased hormone. Surgical intervention can also result in related side effects based around manipulation during surgery.

Nursing Management for Hyperpituitarism

• Initial patient assessment takes vitals, and neurological status which includes vision.
• Patient Assessment is dependent on the specific hormone that is affected.
• Diagnoses with emphasis on altered output and excessive hormone secretions.
• Subsequent diagnoses include, Fluid volume excess, body image disturbance, pain, organ related issues, and post operative concerns and risk factors.
• Interventions include continual assessments and evaluations.
• Monitor vision, intake and output and neurological functions, as well as neurovascular status.
• Actions are focused on drug administration of dopamine agonist, somatostatin analogs and hormone supplements.
• Teaching will review the disease process and adherence to pharmaceuticals for side effects and quality of life measures.

Post Transsphenoidal Hypophysectomy

• Post - surgical and surgical assessment involves vital signs.
• Continually monitor neurological status with neuro checks.
• Monitor intake and output volumes.
• Check mucous membranes and mouth as well as monitoring Urine Specific Gravity and Serum Sodium / osmolality.
• Administer humidified oxygen and maintain IV access w/ IV solutions as ordered.
• Administer desmopressin or vasopressin also as ordered

Post Transsphenoidal Hypophysectomy Teaching

• Maintain head of bed at 45-60 degrees.
• Provide adequate oral fluids, and mouth care, focus on minimizing infection.
• Discuss Sings of meningitis as well as Signs and Symptoms of Diabetes Insipidus.
• Actions include a soft toothbrush and avoiding certain activities. It is important to report any increased drainage from nose of clear fluid.

Diabetes Insipidus (DI)

• Diabetes Insipidus is 30% of the causes are idiopathic and about 25% are secondary to brain tumors.
• Approximately 20 % of cases occur after intercranial surgery, and 20% happen after head trauma.
• Classifications split between, Central and Nephrogenic.
• Central DI results when ADH secretion decreases.
• In Nephrogenic, the kidneys resistant to ADH with an inability to concentrate urine.
• The Pathophysiology of diabetes insipidus revolves hormone levels.
• A lack of the presence of ADH results from production in the hypothalamus ADH allows for water reabsorption and circulation.
• Decreases amounts of hormones causes kidneys to become less permeable result in and increase in water being excreted/diluted.

Diabetes Insipidus Manifestations & Lab Values

• Diabetes insipidus clinical manifestations:
• Hypovolemia results in hypotension, increased weight loss and tachycardia.
• Polyuria and Nocturia
• Hemoconcentration causing increased serum sodium levels, and hematocrit levels.
• Fluid Volume Deficit that presents through decreased skin turgor is coupled with an alteration of thirst and fatigue.

Diabetes Insipidus Diagnosis & Medications

• Serum Electrolyte- Sodium
• Lab Tests- Urine Electrolyte tests for dilution. -Urine osmolality is less than 200 mOsm/kg.
• Urine specific gravity- Less than 1.005.
• CT/MRI of head can verify central contributions to diabetes insipidus.
• Fluid management includes x/o of fluid replacement of both 4 with unconscious patient.
• Medication of Desmopressin or Vasopressin
• Medication of choice is DDAVP for its function- its primary analog with SubQ routes, Shorter acting and frequent monitoring of fluid status, lab values, and urine output of both will be of increased relevance to ongoing assessment measures.

Diabetes Insipidus - Complications

• Dehydration and hypernatremia are the most common complications.
• Hypovolemia and the need for replacement hormones increases that risk for both and possibly.
• Hypovolemic shock.
• Nursing Assessment includes Polyuria, as well as lab values of high to low volumes and low/decreased blood pressures.
• Heart Rate, compensation.
• Nursing Diagnoses involves and integrates Sensory and regulatory systems.
• Deficient Fluid Volume regulation as primary and ineffective replacement and management.
• Nursing Goals and actions revolve around assessing. Vital Signs, Intake and Output as well as visual acuity and serum sodium testing, through continued measurements for regulatory needs.
• Nursing actions prioritize the maintenance of medical devices and interventions .

Syndrome of Inappropriate Antidiuretic Hormone (SIADH)

• SIADH also involves hormone secretion, but in this instance deals with a pathology caused or directly tied to, an increase of ADH.

Risks of SIADH

• CNS disorders, medication / side effects, Psychotropics and bronchogenic carcinoma.
• Manifests through fluid imbalances- causes overload of water, as well as Hemodilution, ultimately resulting in both; Hyponatremia Hyposmolality.

SIADH Symptoms

• Early Symptoms of SIADH are generally Anorexia, Nausea, Malaise, Headache, and Irritability.
• Possible Additional findings could be that of neurological origins potentially becoming of threat to patient health.
• Altered mental processes / decreased sodium levels can trigger seizures coma, fluid shifts in cranial structures can facilitate edema and possible inter cranial pressure increases.

Diagnosing SIADH

• The process for diagnosis includes the monitoring and the trending of:
• Urine specific gravity and urine output, in addition to serum and urine osmolality balances.
• Diagnostics also assess changes with specific Electrolytes- Hyponatremia/ Sodium below 135 mEq/L.
• SIADH and Fluid maintenance are primarily linked.

Nursing Management

• Treatment can come in Tetracycline as well as Diuretics loop.
• Fluid Management involves the management of Hyponatremia through accurate management, regulation Medications. Treat Hyponatremia Fluid restriction: < 1000 mL/day

SIADH - Nursing Care

• SIADH Assessment:
  • Focuses on Oliguria and accurate measurements for specific gravity.
  • Urine / Serum levels and accurate recognition of normal verses abnormal trends and levels.
  • Monitor for altered sensory and emotional states within the patient's presentation.
• Diagnoses primarily covers Electrolyte imbalances, Fluid imbalances/ regulatory mechanisms, and a possible, high risk for injury primarily.
• Interventions are designed aroud the diagnoses through assessment focused initiatives.
• Continuous assessment of all the aforementioned as well as focus on Neurological checks as a priority with integument checks ongoing.

Patient Teaching and Actions

• Focus on Nursing actions to Maintain /Regulate medication interventions
• Regulation of the appropriate levels, balance and volumes of body mechanisms and components as well a side-by-side regulation of medical interventions with continued evaluation of the patient's individualistic presentation for patient care based support.

HYPOTHYROIDISM

• TSH is controlled by the anterior pituitary gland and affected by the hypothalamus.
• It is commonly associated with- Autoimmune diseases commonly include Hashimoto's thyroiditis, with thyroid surgery, and possibly a result of Radioactive therapies.
• Not typical in the US for Iodine insufficiencies due to levels within iodized salt.
• Pathophysiological is described as a primary sign if Metabolism is low /decreased is the hallmark diagnosis.
• This commonly also Develops because of a disorder of the thyroid.
• It would be seen to be the direct result with the anterior pituitary gland- lack of communication creates a deficiency in the hypothalamus for a tertiary cause.

Clinical Indications

• Primary symptoms include issues with lowered Energy, and consistent states of lowered function.
• Clinical Indications of hypothyroidism
• This is noted through the need to sleep throughout the day, fatigue being ever-present, increasing weight and lack constant appetite.
• Increased levels of susceptibility to cold temps with little to no regulation is also noted.
• Clinical observations include Skin changes, and the lacking or lack of function with- Skin changes, and lack of function along with, Hair thinning and /or increased losses.
• Observationally, these are physical indicators of edema, as well has cardiovascular alterations that can manifest through heart rate variability, with noted gastrointestinal effects.

Diagnosis and Treatment

• Diagnostic actions include Medical Evaluation through lab testing.
• Checking T3&T4 for a baseline, with a similar initial assessment of TSH levels, and understanding feedback/regulation relationships.
• When lab values are gathered and indicate primary issues with hormone, the lab assessment can target autoimmune responses.
• Medical regulation is commonly regulated through pharmaceuticals.
• Management and Medications begin with baseline hormones.
• As Thyroid balances directly effect and support several regulation processes and bodily functions that can further be interrupted by underlying conditions it is safest to work alongside a pharmaceutical option that does not compromise the integrity of other systems.
• Increased cardio rate can further stress the body; as it would be affected by metabolism decreases.

Hypothyroidism Complications

• Lowered regulation results and impacts several processes of the body through feedback.
• Lower regulation leads toward an increase for Myocardial Coma risk/levels through several issues that compound due to primary issues. Hypoxemia- Lack of oxygenation
• Increase to excess within Body of fluids, imbalance / retention caused by lack of regulatory efforts
• Extreme sensitive and reactive actions to external stimuli are exacerbated due to a lack of regulation- such as temperature control, chemical regulation, metabolic.
• Hypothermia levels increase patient’s risk of additional health concerns as well as the sensitivity of those issues.

Nursing Management for Hypothyroidism

• Nursing interventions revolves aroud baseline vitals.
• Emphasis should be placed on recognizing any sensory changes or alterations to baseline assessments.
• Assess the patient's overall health, and for s/s of hypothyroidism.
• A key observation will be generalized edema. Assess and establish level of edemas and areas with most prominence. (hands, feet, between shoulder blades , around facial features such as around the eyes, throat.
• Focus should remain on assessments for cardiac output with the intention of providing interventions based on the patient's needs rather than general assumptions, or commonalities.
• Goals should be to provide the most ideal, least dangerous, and quality driven outcomes with the patient. Interventions should be directed toward optimizing function within systems.

Hyperthyroidism Review

• Is More common in females aged 20-40 years.
• Grave's disease is most common cause.
• Primary causes overactive thyroid levels excessive T3 and T4 production.
• Secondary issues include increased secretion of TSH- in the result of feedback mechanisms Tertiary:Excessive secretion of thyrotropin-releasing hormone from the hypothalamus.

Hyperthyroidism Manifestations

• Due to increased metabolism levels: HR and Cardiac Dysrhythmias, resulting in a bruit through thyroid and intolerance Increased levels and results hyper levels/function and process can and will be associated with many issues. Can be noted through heat intolerance or exophthalmos.

Hyperthyroidism Treatment

• Diagnose of a primary thyroid through lab works focused on regulatory and balancing hormone functions, levels will indicate to causes, primary is an autoimmune disease.
• Management involves Treatment to both diagnose as wells control issues from the beginning.
• Labs are used for a multitude of factors through out and may dictate pharmaceutical management practices, (with emphasis in medication management).
• Goals commonly resolve around achieving “normality,” or achieving “norm levels".

Hyperthyroidism Medications

• In this situation it can be said there are “Normal function that is altered to function with some form of intervention that is “more acceptable”, based in patient individuality. Common drugs in this situation include Thyroid Hormone regulation pills as well as more direct actioned drugs. Longer term and acute, the treatment revolves around, medical management/medication administration and regulation and control of feedback and balancing mechanisms.

Hyperthyroidism After Surgery

• In most patient’s post surgery assessment will commonly include the evaluation the use and need for all areas.
• This included both post intervention as well as pre intervention areas of concern through levels and or trends that were previously noted.
• High priority should be given to maintaining head position, reduce tension through positioning and support for stabilizing systems.
• Maintaining supplies at bedside reduces complications risks.

Hyperthyroidism - Thyroid Storm

• Thyroid Storm stems directly from a base level assessment with poorly managed baseline parameters.
• Assess for high levels of a variability within a dysregulation framework.
• High potential for both Tachycardia, and Hyperthermia related, and /or indicated events.
• Action/Interventions focus- Medication, as well as maintaining and/or establish a regulation schedule with consistent monitoring and assessment standards.
• Treatment interventions include- Beta blockers beta-adrenogenic, T3 & T4, hormone assessments.

Nursing Management for Hyperthyroidism

• Diagnostic criteria is dependent on symptoms with assessments to correlate causes to a primary point with secondary considerations.
• Interventions primarily revolve around and are limited/dependent on, the actions that focus on or are dependent medical intervention and management.
• Nursing Action include focus on support, and medication timing and awareness towards medication and the medication's related complications.
• Actions include both monitoring and action and are correlated to the level of assessment and understanding of potential complications within the system.
• Teach the key areas and elements of regulation, maintenance and balance of baseline vitals and functions.