Untitled

• The slides provided are study notes for NRSG311 Week 3 pertaining to the Endocrine System

What is the Endocrine System?

• A critical communication and coordination system in the body
• Hormones regulate and facilitate communication of activities within the system
• Interconnected with nervous and immune systems allowing for bidirectional immune-neuroendocrine communication
• Helps regulate internal and external environment responses

General Roles and Functions of Endocrine System

• Reproductive and CNS development in the fetus
• Stimulating growth and development during childhood and adolescence
• Sexual Reproduction
• Maintaining homeostasis
• Responding to emergency demands

Endocrine Glands

• Hypothalamus
• Pineal gland
• Pituitary gland
• Thyroid gland
• Parathyroid glands
• Thymus gland
• Adrenal glands
• Pancreas
• Ovaries
• Testes

Structures and Functions of the Endocrine System: Glands

• Produce hormones which control and regulate specific target tissues
• The thyroid gland synthesizes thyroxine, affecting many target tissues
• Two types of glands exist
• Exocrine glands secrete substances into ducts that empty into a body cavity or onto a particular surface
• Salivary glands producing saliva through salivary ducts represents this type
• Endocrine glands secrete substances directly into the blood, as opposed to using ducts
• Adrenal glands producing epinephrine and norepinephrine is an example, releasing these into the bloodstream regulating the body’s stress response

Role and Function of the Thyroid Glands

• Located in the anterior neck, midline, straddling the trachea, and are highly vascular
• Consists of two encapsulated lateral lobes connected by a narrow isthmus
• Responsible for production, storage, and release of Thyroxine (T4), Triiodothyronine (T3), and Calcitonin
• Hormones from the thyroid exert wide effects, stimulating cell metabolism and activity in nearly every organ system
• Regulation occurs through a negative feedback cycle
• Low circulating levels of thyroid hormone stimulate the hypothalamus to release TRH, stimulating the anterior pituitary gland to release TSH
• High circulating levels of thyroid hormone inhibit TRH release from the hypothalamus and TSH from the anterior pituitary gland

Role and Function of the Parathyroid Glands

• Four small, oval structures typically found in pairs located behind each thyroid lobe
• Responsible for secreting parathyroid hormone (PTH or parathormone), regulating blood calcium levels
• PTH affects bone and kidneys and indirectly affects the GI tract
• Regulation occurs through negative feedback
• Low serum calcium or magnesium levels stimulate PTH secretion
• High serum calcium or active Vitamin D levels inhibit PTH secretion

Role and Function of the Pancreas

• Positioned anterior to the 1st and 2nd lumbar vertebrae
• A long, tapered, lobular, and soft gland
• The Islets of Langerhans denote the hormone-secreting portion
• Exhibits an exocrine function, producing enzymes important for digestion
• Exhibits an endocrine function, regulating the level of glucose in the blood
• Four types of hormone-secreting cells present
• Alpha (α) cells produce and secrete Glucagon
• Beta (β) cells produce and secrete insulin and amylin
• Delta (D) cells produce and secrete somatostatin
• Gamma (F or PP) cells secrete pancreatic polypeptide (PP)

Structures and Functions of the Endocrine System: Hormones

• Chemical substances synthesized and secreted by endocrine glands
• Paracrine action means acting locally on nearby cells, like sex steroids on the ovary
• Autocrine action involves acting on the cell that produced the hormone, insulin secreted from the pancreas inhibits further insulin release from same cells
• Secretion occurs in small amounts at variable but predictable rates, regulated by feedback systems
• Able to bind to specific target cell receptors
• Control varied physiological activities, such as reproduction, response to stress/injury, electrolyte balance, energy metabolism, growth, maturation, aging, and regulating nervous/immune systems

Functions of Thyroid Hormones

• T3 and T4:
• Thyrotropin-releasing hormone (TRH) from the hypothalamus triggers the pituitary to make thyroid-stimulating hormone (TSH)
• TSH stimulates the thyroid to capture iodine from blood to synthesize, store, and release thyroxine (T4)
• T4 reaches target cells, becoming triiodothyronine (T3)
• T4 reaching adequate circulating levels leads to the hypothalamus and pituitary reducing TRH and TSH output
• If T4 levels drop, the hypothalamus and pituitary resume output of TRH and TSH
• These hormones effect metabolic rate, caloric requirements, oxygen consumption, carbohydrate and lipid metabolism, growth and development, brain function, and nervous system activity
• Calcitonin:
• Produced in response to high circulating calcium levels
• Inhibits calcium resorption (loss) from bone, increasing calcium storage in bone, and increasing renal excretion of calcium and phosphorous reducing serum calcium and phosphate levels
• Works as counter-mechanism to PTH but it does not play a critical role in calcium balance

Functions of Parathyroid Hormone

• Target Tissues:
• Bone: resorption of calcium inhibits bone formation, releases calcium and phosphate into the blood
• Kidneys: increase calcium reabsorption and phosphate excretion, stimulate renal conversion of Vitamin D to active form
• Intestine: Indirect action on GI tract via Vitamin D enhancing intestinal calcium absorption
• Functions:
• Regulates calcium and phosphorus blood levels
• Promotes bone demineralization, increasing intestinal absorption of Ca2+ and serum Ca2+ levels

Functions of Pancreatic Hormones

• Glucagon:
• Increases blood glucose, providing fuel during fasting when ingested glucose is not readily available
• Insulin:
• An essential hormone, being the principal regulator of metabolism and storage of carbohydrates, fats, and proteins
• Facilitates glucose transport across cell membranes in most tissues, responsible for how ingested nutrients are used for energy and stored (anabolism)

Pathophysiology of Insulin and Glucagon Secretion

• Governed by a reciprocal negative feedback loop to maintain normal blood glucose levels
• Low blood glucose, protein ingestion, and/or exercise triggers glucagon synthesis and release from pancreatic α cells
• Increased blood glucose from catabolism stimulates:
• Glycogenolysis: breakdown of glycogen into glucose
• Gluconeogenesis: formation of glucose from noncarbohydrate molecules
• Ketogenesis: breakdown of fatty acids and amino acids to produce ketone bodies
• Mechanisms carefully modulate insulin secretion to prevent hypo and hyperglycemia
• Increased blood glucose stimulates insulin synthesis and secretion
• Decreased blood glucose and glucagon inhibits insulin secretion
• Insulin is essential for blood glucose regulation
• Acts as principal regulator of metabolism, storage of carbohydrates, fats, and proteins
• Facilitates glucose transport across cell membranes in most tissues

Endocrine System Assessment: Health History and Subjective Data

• Personal/family history: conditions, surgeries, hospitalizations, treatments, and medications
• Overall health status: changes in appetite, weight, activities, and fatigue
• Eyes, ears, nose, mouth, and throat: blurred/double vision, difficulty swallowing, enlarged neck
• Cardiovascular: heart palpitations
• Musculoskeletal: shaky hands, difficulty holding things
• Gastrointestinal: bowel changes, constipation
• Genitourinary: nocturia, kidney stones, water at bedside
• Neurological: increased nervousness, stress, anxiety, memory, and concentration changes
• Integumentary: change in hair distribution, skin colour/texture
• Female reproductive: menarche, menstrual cycle, fertility, children born/weight, gestational diabetes, breastfeeding, and menopause
• Male reproductive health: changes in ability to have erections and fertility
• ADLs: activity, mobility, sleep/rest, relationships, coping/stress, occupational health, self-care, and health promotion

Endocrine System Assessment: Objective Data

• Vital signs, and height/weight
• Mental/emotional status: orientation, alertness, memory, affect, personality, anxiety, appropriateness of dress, and speech pattern
• Head/face: Size, contour, facial symmetry with assessment for eye position, symmetry, shape, movement, edema, buccal mucosa, teeth, and tongue size and movements
• Neck: position, swallowing, trachea midline, symmetry plus bulging over thyroid assessment
• Thorax: shape, skin, and gynecomastia in men with lung and heart sounds, and fluid overload or heart failure
• Abdomen: contour, symmetry, colour, skin condition plus assessment for auscultating bowel sounds
• Extremities: size, shape, symmetry, proportion of hands/feet assessment along with skin, lesions/edema, muscle strength, and deep tendon reflexes plus assessing tremors in the upper extremities
• Genitalia: hair distribution, palpation of testes plus assessment for clitoral enlargement
• Integumentary: colour/texture of skin, hair, nails along with hair distribution, pigmentation, and ecchymosis plus palpating for moisture

Laboratory and Diagnostics: Blood and Urine

• TSH: usually first diagnostic test for thyroid dysfunction using the most sensitive method
• T4 Total: helpful in evaluating thyroid function and monitoring thyroid therapy
• Free T4: better indication of thyroid function as it is the active component of total T4 (level remains constant)
• T3: helpful to diagnose hyperthyroidism if T4 levels are normal
• PTH: evaluates hypercalcemia or hypocalcemia which is interpreted with serum calcium level
• Total serum calcium: helps detect bone and parathyroid disorders
• Cortisol (blood): evaluates status of adrenal cortex function
• Cortisol (urine): assesses free (unbound) cortisol with suspected hyper- or hypofunction of adrenal gland, further evaluating hypercortisolism
• ACTH: determine if under-/overproduction of cortisol caused by adrenal or pituitary dysfunction with plasma level of ACTH
• Calcitonin: helpful with diagnosis of medullary thyroid cancer
• CBC (RBC, WBC, platelets, Hg, hematocrit, MCV), Electrolytes, BUN, Cr
• Thyroid peroxidase antibodies may suggest autoimmune origin of hypothyroidism disorder
• Elevated cholesterol and triglyceride levels, anemia, and increased creatine kinase level may be related to hypothyroidism

Laboratory and Diagnostics: Imaging

• MRI: visualize CNS, bony spine, joints, extremities, and breasts
• CT scan with contrast: detect presence of tumour
• Ultrasonography: evaluate thyroid nodules and determine if fluid filled (cystic) or solid
• Thyroid Scan: radioactive isotopes (PO/IV) emitting radiation is recorded by a scanner as it passes over the thyroid to evaluate nodules
• Benign nodules appear as warm spots (take up radionuclide), while malignant tumours appear as cold spots (tend not to take up radionuclide)
• Radioactive iodine uptake (RAIU): measures thyroid activity/function useful for evaluation of solitary thyroid nodules
• Radioactive iodine is taken PO/IV, with a scanner measuring uptake by the thyroid gland at intervals

Disorders of the Thyroid Gland

• Thyroid hormones regulate energy metabolism, growth, and development
• Disorders of thyroid gland include:
• Enlargement (Goitre)
• Benign and malignant nodules
• Inflammation (Thyroiditis)
• Hyperfunctioning and hypofunctioning states

Hyperthyroidism Vs. Hypothyroidism

• Hyperthyroidism:
• Hyperactivity of the thyroid gland causing an increased synthesis and release of thyroid hormones
• Hypothyroidism:
• Hypoactivity of the thyroid gland causing insufficient circulating thyroid hormones

Causes of Hyper- and Hypothyroidism

• Hyperthyroidism:
• Graves' disease
• Toxic nodular goitres
• Thyroiditis
• Hypothyroidism:
• Iodine deficiency (most common worldwide)
• Atrophy of thyroid gland (most common in Canada)
• Amiodarone or lithium use
• Treatment for hyperthyroidism (e.g. surgical removal)
• Discontinuing thyroid hormone therapy
• Destruction of thyroid gland which can be related autoimmune disease (e.g. Hashimoto's thyroiditis, Graves' disease)
• Hypothyroidism can be:
• Primary: destruction of thyroid tissue or defective hormone synthesis
• Secondary: pituitary disease with decreased TSH secretion or hypothalamic dysfunction
• Transient: factors such as thyroiditis and discontinuing thyroid hormone therapy

Clinical Manifestations of Hyper- and Hypofunction of the thyroid

• Symptoms vary depending on severity, duration, and age, spanning every body system
• Hyperfunction of the thyroid includes affects of excess circulating hormones such as:
• Increased metabolism and tissue sensitivity to SNS Stimulation
• Cardiovascular effects like angina, atrial fibrillation/dysrhythmias palpitations, bounding/rapid pulse, hypertension or systolic murmurs
• Respiratory effects including dyspnea on mild exertion and increased respiratory rate
• Gastrointestinal effects including diarrhea/frequent defecation, hepatomegaly, increased appetite/thirst/bowel sounds, increased peristalsis, splenomegaly as well weight loss
• Integumentary such as clubbing of fingers, diaphoresis, fine/silky hair, hair loss, palmar erythema, thin and brittle nails detached from nail bed, and warm/smooth/moist skin
• Musculoskeletal effects including dependent edema, fatigue, muscle weakness, osteoporosis, as well proximal muscle wasting
• Nervous effects include personality changes, lability of mood, nervousness/irritability/depression/apathy, fatigue, insomnia, and difficulty focusing eyes plus fine tremor
• Reproductive including amenorrhea, decreased fertility, and menstrual irregularities plus decreased libido/erectile dysfunction/gynecomastia in men
• Other effects encompassing goitre or intolerance of heat as well elevated basal temperature, responsiveness to stimulant medications, and exophthalmos, stare eyelids
• Hypofunction of the thyroid includes affects of decreased circulating hormones such as:
• Insidious, non-specific slowing of body processes
• Cardiovascular effects including anemia, cardiac hypertrophy plus decreases/changes to rate/force of cardiac contractions and output plus increased capillary fragility
• Respiratory including breathing capacity and dyspnea
• Gastrointestinal effects including celiac disease, constipation, decreased appetite/distended abdomen/weight gain, enlargement or scaly tongue, and nausea/vomiting
• Integumentary effects including decreased sweating, dry and sparse hair, dry/thick/inelastic/cold skin, generalized interstitial edema, poor turgor of mucosa, rough face, and thick/brittle nails
• Musculoskeletal effects including arthralgia, muscular fatigue, aches and pains, slow movements, and weakness
• Nervous effects encompassing depression, anxiety, apathy, personality/mood changes, lethargy, or paresthesias and forgetfulness/slow/slurred speech plus slowed mental processes
• Reproductive comprising decreased libido, infertility, plus prolonged menstrual periods or amenorrhea
• Other: hearing impairment, hypothermia, and an increased sensitivity/sleepiness plus possible goitre due to the overstimulation from the pituitary gland.

Hyperthyroidism: Interprofessional Care

• The goal is to block adverse effects of thyroid hormones and stop over-secretion
• The plan involves history, physical exam, electrocardiography, lab tests, and ophthalmological examination, as well as a RAIU test (Radioactive iodine uptake)
• Radiation therapy can use radioactive iodine and surgical therapy can include a subtotal thyroidectomy
• Frequent meals with high calories and protein help with nutritional intake
• Medications can include antithyroid medications methimazole and propylthiouracil, as well iodine and beta-Adrenergic blockers (e.g., propranolol)

Hyperthyroidism: Nursing Interventions

• Complete Assessment while reviewing health history and physical examination
• Identify possible Nursing Diagnoses, focusing on reduced stamina resulting from physical deconditioning
• Planning goals focus on symptoms and maintaining wellbeing
• With regards to Implementation, patients are treated on an outpatient basis with acute care for thyroidectomy or severe symptoms
• Evaluation should assess and verify the effectiveness of interventions

Thyroidectomy

• Indications involve a large goitre causing tracheal compression otherwise to resolve non-responsive anti-thyroid therapy, Thyroid cancer which isn’t a candidate for RAI
• Common types of thyroid surgery are subtotal or endoscopic
• Sub Total: this is the preferred method, removing a portion (90%) of the thyroid gland
• Endoscopic: is minimally invasive which means reduced scaring and potentially faster recovery
• Postoperative complications: entail hypothyroidism or damage to other areas that have been operated on

Thyroidectomy: Nursing Interventions

• Have O2, suctioning, and a tracheostomy kit available ready in case of airway obstruction
• Watch every 2 hours for 24 hours for irregular bleeding, swelling in the neck, or tension
• Keep the bed in a semi-Fowler's position, and protect the top of the head with cushions
• Test regularly for hypocalcemia, monitor vitals and signs of tetany
• Use medication to control post-operative pain and check signs of dysphonia and hoarseness
• Ambulate is requested soon and eating is encouraged when fluids are fully tolerable

Thyroidectomy: Patient/Family Teaching

• Comfort and safety measures, deep breathing and coughing, plus leg exercises
• Possible distress through incision appearance plus possible speaking difficulties may occur soon after
• A post-operative outline may be provided, following ongoing monitoring to ensure normal thyroid function returns
• A support group may be helpful to ensure patient comfort with coughing and other functions
• Watch for problems which include: complications, problems, and swelling soon after
• Sufficient liquid intake, less amount of calories to discourage rapid weight gain
• High care, avoiding sun, continuing thyroid care long-term

Hyperthyroidism Complication: Thyrotoxic Crisis or Thyrotoxic Storm

• Life threatening rare but is a life-threatening condition caused by intensifying by thyroid hormones
• Often caused a stress on the body from the thyroid hormones, trauma, or surgery from the body
• High rates of rapid heartbeat, heart failure, shock, fever, nausea, with potential for a coma

Acute Thyrotoxicosis: Treatment and Management, Nursing Implications

• Reduce Circulating hormone function: which causes heart complications or lack of oxygen, lack of fluids
• Exophthalmos: will require care and prevent corneal problems with saline, elevating the head, or avoiding excessive radiation

Hypothyroidism: Interprofessional Care

• A major goal is to slowly restore the amount that is lost, and test regular samples of hormones levels or antibodies related to thyroxine.
• Also avoid weight gain and receive regular checkups.

Hypothyroidism: Patient Education and Family Teaching

• Focus is now to give detailed instructions along with support when complications do arrive with any additional problems that arrive in skin or nerve function

Hypothyroidism: Complications

• There is an impairment to temperature, a risk of infection or possible coma due to over dosage

Hyperparathyroidism Vs. Hypoparathyroidism

• Hyperparathyroidism is where the levels of the thyroid hormone levels rise drastically.
• Hypoparathyroidism is where the levels of phosphate are drastically reduced,

Signs of Hyperparathyroidism

• Muscle issues, bone pain or muscle tone
• Heavy calcium levels throughout regular and irregular heart rhythms
• Vomiting, Constipation, loss of appetite
• Skin problems, and low levels of metabolism of the body.

Treatment

• With regular management and medication the problem can be solved, even through operation to remove it

Hypoparathyroidism

• This condition is where the levels of the thyroid hormone levels suddenly drop.
• Musculoskeletal: skeletal radiograph changes, osteosclerosis; soft tissue calcification; difficulty walking, fatigue plus weakness
• Neurological: disorientation, confusion, memory impairment, personality changes
• Headache, Hyperactive deep tendon reflexes or Paresthesias with tetany
• Renal: urinary frequency and urinary incontinence
• Other: eye changes with cataracts, papilledema (optic disc swelling), or lenticular opacities.

Treatment

• Administer IV injections but at slow rates
• Administer more electrolytes, while also controlling the heart to prevent potential cardiac arrest

Long Term Management:

• Reduce electrolyte imbalances, and watch for regular improvements and have a plan.

Diabetes

• Prediabetes
• Type 1 and 2
• Hypoglycemia and Diabetic Ketoacidosis
• Insipidus
• Gestational

Prediabetes

• Intermediate stage before complete issues persist and damage has already been done to the body.

Etiology and Pathophysiology of Diabetes Mellitus

• Normally, insulin produced by β cells known as Islets of Langerhans causes some damage by triggering the release of glucose,
• It's possible to have small Increments where released insulin stabilizes rapid blood glucose levels, and chronic forms may lead to additional problems.
• However, for type 2 and some type 1 problems, cells become resistant

Clinical Manifestations of Uncontrolled Diabetes Mellitus

• Type 1 Diabetes presents with more classic symptoms including frequent polyuria/urination, excessive polydipsia/thirst or polyphagia/hunger, weakness and fatigue, and may result with rapid weight loss.
• Type 2 Diabetes tends to present with subtle symptoms, and they may include rapid fatigue levels.

Diabetes Mellitus Potential Diagnostics

• Lab measurements of AIC count, may show regular blood counts over a high timeline, may show some forms of plasma glucose over standard testing, may give readings up to 11mmol/L

Potential Caregivers with Diabetes

• There are many medical workers who could help the patient during treatment, including physicians, nurse educator, dietitian and ophthalmologist.

Collaborative Approach with Diabetes

• One focus plan is to slow or stop the condition from speeding up.
• Some are for checking with dieticians for food, medications or blood levels to see what is appropriate in patient care plus constant glucose monitoring alongside fitness

Management Options

• To increase the levels of insulin by maintaining a plan, and setting new steps.

Patient and Family Education

• Self-monitoring of glucose may be helpful to understand glucose readings.
• High importance on good hygiene and skin and care is required.

Managing a New Diabetes Diagnosis

• It is important to address the patient's physical and cognitive skills.
• They require the information to be effective and supportive over a time period for best care available.

Complications of Diabetes

• Can lead to vascular or kidney problems, with possible nerve endings being damaged from high blood sugar

Diabetes Mellitus: Medical Nutrition

• Can be a challenging process to provide as many high GI or GI levels may fluctuate rapidly based on meal changes
• It is important to get this done to support well-being and general comfort

Dietary Care Plans

• Eating well is key for maintaining good long-term health for these situations with potential focus on avoiding high fat.

Exercise

• It’s important to encourage regular body usage with the increased release of insulin receptors and reduce the risk of high fat levels

Daily Routine Checks may help you maintain results

• Encourage and teach people about glucose meters to track, report, and to manage levels through physical activity.

• A high carb diet may cause a delayed recovery

• Insulin Injections: may also require several checkups every day to monitor function, and to look at any abnormalities of the body.

Insulin Therapy

• High to low shots may also regulate fat intake and improve glucose, and should be administered to reach maximum levels, especially around carbohydrates after a meal

The Plan

• Injections via the subcutaneous layer helps with administration, and also to help keep everything else regular at any time.

• Insulin types have different effects by different levels of metabolism and timing

Medication Management:

• By assessing health function the healthcare provider can monitor for heart issues, and ensure correct information for a steady recovery

Helping Others:

• By receiving and understanding instructions that fit an active recovery time and by providing accurate information in the situation.
• Plan effectively to make each session as pleasant as you possibly can for the patient, and look for signs of rapid recovery.

What could go Wrong:

• A medical examination to see the next steps would require a proper assessment and treatment to minimize the risk factors