HHNP 2: Endocrine Module 3 Part 1

• HHNP 2 is the second module focusing on endocrine conditions, specifically Part 1 of Module 3.

Reminders

• The group contract regarding clinical experience is due at the end of week 3.
• Quiz #1 on MyCanvas is due at the end of week 3.
• Preparation for seminar is required.

Learning Outcomes

• Common nursing responsibilities include assessing, intervening, providing rationales, and teaching patients how to manage chronic endocrine conditions.
• Age-related changes in the endocrine system correspond to differences in assessment findings.
• It's important to distinguish between normal and abnormal physical assessment findings of the endocrine system.
• Understanding the purpose and significance of diagnostic studies for the endocrine system is essential for nurses.
• Nursing responsibilities are related to diagnostic studies of the endocrine system
• Nurses should understand the etiology, pathophysiology, risk factors, and clinical signs/symptoms of hormone imbalances, specifically in the adrenal cortex.
• Knowledge of interprofessional care and nursing management for patients with hormone imbalances is required for hormones produced by adrenal glands.
• Thyroid dysfunction includes understanding etiology, pathophysiology, clinical signs/symptoms, and nursing management.
• Understanding the etiology, pathophysiology, and clinical signs/symptoms and interprofessional care for imbalances of hormones produced by the parathyroid glands is vital.
• Health conditions across the lifespan include understanding their etiology, pathophysiology, and clinical manifestations.
• Common assessments, diagnostics, interventions, and expected outcomes are explained in order to care for clients with chronic health conditions.
• Foundational nursing knowledge and the nursing process are required when providing care to clients with chronic health conditions.

Endocrine System

• Hormones are the primary means of communication within the endocrine system
• The main components are communication, playing a role in reproduction, growth, sexual reproduction, maintaining homeostasis and responding to emergency demands.

Endocrine System Overview

• The endocrine system includes the hypothalamus, pineal, pituitary, thyroid, thymus, adrenal glands, pancreas, testes (male), and ovaries (female).

Hypothalamus

• Communication is integrated between the nervous and endocrine systems by the hypothalamus and pituitary gland.
• The hypothalamus is part of the brain
• It secretes many hormones
• Contains neurons that receive input from the brainstem and limbic system, translating nerve impulses to hormone secretion
• Table 50.2 in the textbook lists the hormones of the hypothalamus

Pituitary Gland

• The pituitary gland is also called the hypophysis.
• It is typically small in size and located under the hypothalamus
• The anterior pituitary makes up two-thirds of the gland and contains trophic and growth hormones as well as prolactin.
• The posterior pituitary contains antidiuretic hormone and oxytocin

Thyroid and Parathyroid Glands

• The thyroid produces thyroxine (T4), triiodothyronine (T3), and calcitonin.
• The parathyroid glands produce parathyroid hormone.

Thymus Gland

• The thymus gland is most active during childhood, shrinking with age
• It is positioned behind the sternum and has both immune and endocrine functions

Adrenal Glands

• The adrenal medulla produces epinephrine and norepinephrine (adrenaline).
• The adrenal cortex produces cortisol, aldosterone, and adrenal androgens.

Cortisol Secretion

• Cortisol levels in blood plasma change throughout the day, correlating with sleep and wake cycles.

Pancreas

• The pancreas is a long, tapered, lobular, soft gland located behind the stomach.
• It has both exocrine and endocrine functions
• Glucagon increases blood glucose
• Insulin facilitates glucose transport.

Age-Related Considerations

• Considerations include decreased hormone production and secretion, altered hormone metabolism and biological activity, decreased responsiveness of target tissues to hormones, and alteration in circadian rhythms.

Disorders of the Adrenal Cortex

• Glucocorticoids (e.g., Cortisol) regulate metabolism, increase blood glucose, and influence the immune response; they are critical to the physiological stress response.
• Mineralocorticoids (e.g., Aldosterone) regulate electrolyte and fluid balance, regulating electrolyte and fluid balance.
• Androgens promote growth and development in both genders and influence sexual desire and satisfaction in women.
• Cushing's syndrome involves excessive hormone production
• Addison's disease involves insufficient hormone production.

Cushing's Syndrome: Etiology and Pathophysiology

• Cushing’s Syndrome presents a spectrum of clinical abnormalities
• It's typically caused by an excess of corticosteroids, particularly glucocorticoids
• Possible causes include an ACTH-secreting pituitary tumour (Cushing's disease), cortisol-secreting adrenal neoplasm, excess ACTH secretion from a lung carcinoma, and prolonged administration of corticosteroids
• ACTH secreting pituitary tumour is also known as Cushing's Disease

Clinical Manifestations

• Cushing's syndrome is related to excess corticosteroids impacts multiple body systems.
• Table 51.14 lists of clinical manifestations.
• Weight gain is the most common feature.
• Key signs include truncal obesity, generalized obesity, "moon face," purplish red striae on the abdomen, breasts, or buttocks, hirsutism, menstrual disorders, hypertension, and unexplained hypokalemia.

Clinical Manifestations (Cont.)

• Excessive glucocorticoids can cause hypertension, hypervolemia, and edema.
• Fluid and electrolyte imbalances include sodium and water retention, edema, and hypokalemia.
• Physical appearance changes: central obesity, thin extremities, moon face, and buffalo hump.
• Immune suppression, inhibition of inflammation, and delayed wound healing can occur
• Hyperglycemia stems from glucose intolerance due to cortisol-induced insulin resistance.
• Protein wasting includes catabolic effects from which muscle wasting leads to weakness, especially in extremities and protein loss and bone loss in the bones leading to osteoporosis, bone, and back pain
• The skin becomes weaker and thinner from loss of collagen, bruising easily
• Mood disturbances which can range from irritability, anxiety, or euphoria.
• Mental effects range from insomnia, to irrationality, and occasionally to psychosis.

Clinical Manifestations (Cont.)

• Too much mineralocorticoids lead tohypertension due to fluid retention and sodium/water retention with edema.
• Too much androgens can lead to pronounced acne, hyperpigmentation, reduced libido, fertility complications, menstrual problems, hirsutism, and erectile dysfunction.

Diagnostic Studies

• A diagnosis is made using at least 2 of the 3 different screening tests: 24-hour urine for free cortisol, late-night/bedtime salivary cortisol levels, or a 1 mg overnight dexamethasone suppression test.
• False-positives can occur with exercising to capacity, depression, acute stress, and alcoholism
• Diagnostic tools include CT scans, MRI of pituitary and adrenal glands, and a plasma ACTH test.
• ACTH levels may be low, normal, or elevated depending on the problem
• Ectopic ACTH syndrome and adrenal carcinoma cause hypokalemia and alkalosis.

Interprofessional Care

• The primary goal is to normalize hormone secretion
• Treatment depends on the underlying cause of pituitary adenoma, adrenal tumours, ectopic ACTH-secreting tumours, or prolonged administration of corticosteroids.
• Treatment options include surgical tumour removal, radiation, adrenalectomy, treating primary neoplasm, and dose reduction.
• Medication therapy is indicated when surgery is contraindicated or as an adjunct to surgery
• The goal of medication therapy is inhibition of adrenal function.

Cushing's Syndrome: Nursing Assessment

• Past medical history should be taken which includes pituitary tumour, adrenal, pancreatic or pulmonary neoplasms, gastrointestinal bleeding, frequent infections or use of corticosteroids
• Subjective symptoms include amenorrhea, erectile dysfunction, anxiety, mood disturbances, psychosis, headaches or pain in back, joints, bone, or ribs, poor concentration and memory, insomnia, poor sleep quality, weight gain or anorexia, polyuria, prolonged wound healing, easy bruising, weakness, fatigue Objective data includes truncal obesity (buffalo hump) as well as moon facies

Clinical Manifestations (Cont.)

• Objective data collected on head, face and skin should show hirsutism, thinning of head hair, friable skin, acne, petechiae, purpura and hyperpigmentation as well as edema of the lower extremities and purple striae on breasts, buttocks and the abdomean.
• Hypertension, muscle wasting, thin extremeties, awkward gait and gynaecomastia can be observed during a physical examination
• Testicular atrophy (in men) and enlarged clitoris (in women) can be noted in the genital area

Cushing's Syndrome: Nursing Planning

• Patient goals include experience relief of symptoms, avoid serious complications, maintain positive self-image, and actively participate in a therapeutic plan.

Cushing's Syndrome: Nursing Implementation

• Identify patients at risk for Cushing's syndrome during health promotion
• Monitor long-term exogenous cortisol therapy, as it is a major risk factor.
• Patients should be taught about medication use and how to monitor for adverse effects.

Nursing Implementation (Cont.)

• Perform acute interventions by assessment signs and symptoms of hormone and medication toxicity, as well as complicating conditions such as cardiovascular disease, diabetes and infection.
• Monitor these clinical findings and any thromboembolic phenomena, as well as provide emotional support and education
• Perform ongoing health teaching.

Cushing's Syndrome: Nursing Evaluation

• It is expected these patients will experience no signs or symptoms of infection, attain weight appropriate for height, have increased acceptance of appearance, and have healing and maintenance of intact skin.

Addison's Disease: Adrenocortical Insufficiency

• Insufficiency is also known as hypofunction

Etiology and Pathophysiology

• Hypofunction in the adrenal cortex has either a primary cause (Addison's disease) or a secondary cause (lack of pituitary ACTH secretion)
• Supply of all three classes of adrenal corticosteroids is lessened in Primary Adrenocorticol Insufficiency also known as Addison's Disease
• The adrenal cortex is targeted and destroyed by antibodies as part of an autoimmune response, which is the most common cause in industrialized nations.
• Genes may cause Genetic Susceptibility
• Demographics show that white women are more commonly impacted if autoimmune cause.
• Tuberculosis globally causes Addison's Disease.

Other causes of Adrenocorticol Insufficiency

• Infarction, fungal infection (histoplasmosis), AIDS as well as metastatic cancer are other causes
• Iatrogenic Addison's disease occurs through adrenal hemorrhage, anticoagulant therapy antineoplastic chemotherapy, ketoconazole therapy for AIDS or a bilateral adrenalectomy

Clinical Manifestations of Addison's Disease

• More than ninety percent of the adrenal cortex must be destroyed before the disease becomes evident and advances
• Manifestations occur very slowly and will include progressive weakness, fatigue, weight loss and anorexia
• Skin hyperpigmentation on the extremities, pressure points, joins and creases
• Hypotension, hyponatremia, hyperkalemia. from cardiac and electrolyte disturbances
• Nausea, vomiting and diarrhea from gastrointestinal issues
• Psychological effects are irritability and depression

Clinical Manifestations (Cont.)

• Too little Glucocorticoids (cortisol) will cause hypotension, vasodilation, hyponatremia, hypovolemia, dehydration hyperkalemia, weight loss, bronzed smoky hyperpigmentation, anorexia, nausea and vomiting, cramping abdominal pain
• Patient will also experience diarrhea, anemia, immune issues, hypoglycemia, insulin sensitivity, exhaustion, irritability, confusion or delusions.

Clinical Manifestations (Cont.)

• Too little mineralocorticoids cause hypovolemia, lead to decrease cardiac output, heart size and tendency toward shock.
• These also create sodium loss, decreased volume of extracellular fluid, hyperkalemia, salt craving
• Too little Androgens lead to decreased axillary and pubic hair for women
• Muscle size and tone will decrease as well as decreased libido in women and no effect in men

Diagnostic Studies

• The diagnostic indicator when looking at the cortisol is a subnormal or failure to rise above baseline with ACTH stimulation test indicating primary adrenal pathology
• Hyperkalemia, Hypochloremia and Hyponatremia are other lab values
• Anemia patients will have low blood glucose levels and higher BUN (blood urea nitrogen)

Diagnostic Studies

• Urine results will be low levels of aldosterone and free cortisol
• The EKG findings are low voltage, vertical QRS axis and peaked T-Waves (Indicative of hyperkalemia)
• Tumors identified through imaging studies like CT and MRI show that patients will present with adrenal calcifications or assess enlargement

Interprofessional Care

• It is important to focus on management of the underlying cause
• Treatment for adrenocortical deficiency is replacement therapy (Table 51.17).
• Hydrocortisone will be the most use medication followed by mineralocorticoid called fludrocortisone acetate for daily use and increase of salt in diet

Nursing Management: Addison's Disease

• Immediate and continuous care of VS for proper respiration and perfusion is required
• Fluid and Electrolyte Balance assessment requires attention to BP, HR and RR
• It's important to implement regular assessments for imbalances
• Monitoring Serum Glucose, Sodium and potassium trends should be completed frequently
• Comprehensive medical history and record of mental status provides reference to current state

Nursing Management: Addison's Disease

• Life long monitoring by a clinician will be needed
• Patient and family teaching is important
• Management of stress and medication management is required

Medication Administration

• It is important to administer Glucococorticoids by dividing doses for best reaction
• Two thirds should be give in the morning and one third should be given in the afternoon
• Take Mineralcoticoid(s) once daily in the morning
• Follow dosage schedule and administer with food

Medication Administration and Health Teaching

• Remember dose and effect by: proportional balance between stress and the hormone administered
• It would be important to recognize situations that require adjustment, such as a fever, influenza, or dental work
• Stress events increase the daily dose by a double/triple if need be

Nursing Interventions: Health Teaching

• It's important to teach patients Long-term care involves knowing they need an increase of drugs when stress arises
• Teaching a patient to notify a provider in emergency situations due to electrolyte imbalance is key
• Encourage adherence to medication for normal healthy life
• Emergency kits are critical
• IM injections should be taught to patients and caregivers

Disorders of the Thyroid Gland

• Hyperthyroidism is excessive thyroid hormones
• Euthyroid is normal thyroid function
• Hypothyroidism is insufficient thyroid levels

Goitre

• An abnormal growth of the thyroid gland can be asscoaited with normal, decreased or increased levels of thyroid hormone production

Thyroiditis

• Viral infections/inflammatory processes can cause it
• Treatment depends on cause, symptoms, and phases
• Enforce client teaching about the treatments

Hyperthyroidism

• Excessive activity of thyroid gland

Etiology and Pathophysiology

• An autoimmune disease caused by an unknown etiology is called Graves disease.
• Thyroid hormone secretion and excessive thyroid enlargment is what causes Graves
• TSH hormone production in both T 3 AND T4 is mimicked by antibodies which is 90 per cent a feature
• More common for women between 20 and 40 is the diagnosis of Graves
• Genetics and the enviroment of insufficient iodine supply is a cause for diagnosis
• Patients of age 40+ have a higher incidence of toxic nodular goitre thyroid secreating nodules

Clinical Manifestations

• The clinical manifestations of thyroid dysfunction are covered in Table 51.6
• Presentation will vary depending on the age of the patient and how chronic it is
• The thyroid hormone production increases

Lab and diagnostics

• Labs will show decreased TSH levels and rise in Free T4 levels but are not considered as definitive
• RAIU's (radio active iodine uptake) will differentiate disease for thyroiditis
• 35 - 90 per cent of absorption takes places in thyroiditis
• Homogenous in patients of less than 20 years of age

Interprofessional Care

• Stopping oversecretion and block effects is the goal
• Thyroidectomy, Rai(radio active iodine) and antithyroid may be a option

Interprofessional Care

• Medication therapy includes inhibiting the synthesis of thyroid hormones, and using antithyroid medications, iodine, and B-adrenergic blockers.
• The treatment of choice for non pregnant adults will be radioactive iodine therapy but improvement only begins after a week or so of treatment

Interprofessional care

• Removing a significant portion of gland is done through Surgical therapy
• The goal of choosing a treratment is the size of the goiter and the patients other health issues, treatment depends on the cases
• Increased calorie nutrients through high protein , cabs and mins/vits are provided

Complications

• Thyrotoxic crisis (Thyroid storm) happens beacuse of intense hyerthyroidism and stressors
• Stressors are surgery, trauma and infection
• This increase in thyroid hormone will create heart failure, shock and tachycardia

Nursing Care: Assessment

• Patients and nurse would collect data, from Lab(hormones) reviews, Subjective hx and objective symptoms

Nursing care: Planning

• The goal is to reduce symptoms and ensure the patient follows plan of care

Nursing care: Interventions

• Treatment is split into acute interventions and ambulatory care
• Critical care is for treating severe thryotoxis
• Patients would go through post op and follow up care

Hypothyroidism

• Results from lack of thyroid hormone

Etiology and Pathophysiology

• Insufficient hormones present in the body would make the patient have this
• Transient from thyroiditits, and from desisting medicine

Clinical Manifestations

• Varying degrees of problems
• SLOW body precesses

Complications

• Mental impairments
• Progression to Coma

Diagnostic Stidies

• History and exam
• Lab rests for T4 TSH FREE T4
• Antibodies for enzymes

Interprofessional Care

• Goal to correct issues wiht Synthoid hormones
• Monitor for cardaic signs!
• Patient takes meds and knows what they do

Nursing Management: Nursing Assessment

• Assess health in these pt's.
• Subjective assessment: WEIGHT!!, fatigue, mental and skin
• Objective assessment: Bracy, distention, skin, thick skin, hair, nails and cold

Nursing Management: Planning

• Pt. experiences relief
• Is an active state
• • self image
• adhere to regime

Nursing Management: Nursing Implementation

• Health promotion can be done for at risk patients
• Nurse individuals on outpatient basis

Nursing Management: Nursing Implementation

• Reassurance through home support.
• Teach proper thyroid medication and care with them

Disorders of the Parathyroid Glands

• Parathyroid hormone contributes to regulated calcium and phosphate in the body Hypoparathyroidism patients secrete a decreased hormone

• Decreased secretion of hormone, which will create hypocalcemia.