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Endocrine A&P Review

• Anterior Pituitary: GH, TSH, ACTH
• Posterior Pituitary: ADH
• Thyroid: T3, T4
• Parathyroid: PTH, Calcium, Phosphate.
• Adrenal Cortex: Corticosteroids, Mineralocorticoids, Androgens
• The hypothalamus stimulates the pituitary gland

Thyroid Hormones

• Iodine is necessary to produce thyroid hormones
• TSH normal range: 0.5-5.0
• T4 is also known as Thyroxine
• T3 is also known as Triiodothyronine
• It is important to assess for iodine and shellfish allergies before tests with contrast media.

Hyperthyroidism

• Characterized by excess T3 and T4
• Decreased levels of TSH
• Graves' disease is the most common cause
• Symptoms of hyperthyroidism include nervousness, restlessness, insomnia, anxiety, fatigue, palpitations, tachycardia, fine tremor, weight loss, heat sensitivity, sweating, increased appetite, amenorrhea, diarrhea, and ophthalmopathy (exophthalmos).
• Ophthalmopathy (Exophthalmos), or bulging eyes, is common with Graves' Disease
• Glands may be soft, enlarged, and tender

Hyperthyroidism Treatment

• Anti-Thyroid Medications prescribed for 1 year include Propylthiouracil (PTU) and Methimazole
• Propranolol is a Beta-Blocker for BP
• Radioactive Iodine Therapy aims to eliminate thyroid cells with one dose and may cause hypothyroidism
• Side effects of Radioactive Iodine Therapy: neck soreness, nausea, upset stomach, dry mouth, change in taste, tender/swollen glands
• Increase fluid intake immediately after Radioactive Iodine Therapy
• Avoid kissing/sex, sharing bed/food, and avoid kids & pregnant women after Radioactive Iodine Therapy
• Goitrogen rich foods to avoid: red wine, soy, peanuts, teas, cauliflower, broccoli, mustard, strawberries
• Procedures include Subtotal or total thyroidectomy, where Levothyroxine may be needed for life for thyroid hormone replacement
• May need Calcium/Vitamin D due to damage/removal of parathyroid glands
• Assess for Hypocalcemia for tetany and Trousseau/Chvostek's sign
• With thyroidectomy expect hoarseness for 1 week
• Maintain Semi-Fowler position post thyroidectomy
• Complications post thyroidectomy include Hemorrhage, Airway Obstruction, Laryngeal Nerve Damage

Hyperthyroidism Nursing Care

• Assess daily weights, I&O, lab values
• Provide a High calorie & protein diet
• Lubricate eyes
• Implement cooling measures

Toxic Multinodular Goiter

• It is a benign tumor, typically large
• There is a risk of overproduction of T3 & T4

Thyroid Storm/Thyrotoxicosis

• Requires Medical Emergency intervention because it is Fatal if untreated
• It is a severe hyperthyroidism with a sudden onset
• Causes include infection, stress, PE, abrupt discontinuation of meds, and metabolic disorders
• Symptoms: Temp >101.3, HR >130, exaggerated hyperthyroid s/s, altered mental status

Hypothyroidism

• Characterized by decreased T3 and T4
• Excess TSH
• Primary cause: dysfunction of thyroid gland, most commonly Hashimoto's disease
• Secondary cause: Dysfunction of pituitary or hypothalamus
• Symptoms include extreme fatigue, hair loss, dry skin, brittle nails, change in voice/hoarseness, menorrhagia or amenorrhea, weight gain, cold intolerance, and constipation
• Severe Signs/Symptoms include Myxedema -> coma, Bradycardia, Low body temp, High cholesterol
• Is treated with Thyroid Replacement, Levothyroxine, LIFELONG
• Levothyroxine dosage is based on TSH
• Levothyroxine is best taken on empty stomach in the AM
• Med overdose looks like S/S hyperthyroidism

Hypothyroidism Nursing Care

• Assess mental status
• Monitor daily weight & I&O
• Monitor Cardiac Status
• Monitor Bowel Elimination

Thyroid Cancer

• Has a Good prognosis
• Papillary carcinoma is the most common
• Symptoms include a Hoarse voice and Dysphagia
• Diagnosis is made via Ultrasound, Radioactive Iodine Uptake Scan, CT, MRI, PET Scan, Fine needle biopsy, Labs
• Treatment involves Radioactive Iodine & surgery with best survival rate
• Complications of Thyroid Cancer include Hypocalcemia, Infection, Hemorrhage, Airway obstruction, and Thyrotoxicosis (d/t stress of surgery)

Pituitary & Adrenal Gland Disorders: Anterior Pituitary

• Involves TSH, GH, ACTH

Growth Hormone Insufficiency

• Also known as "Dwarfism"
• Has a Genetic Association
• Average height: 4 ft
• Treatment involves Synthetic GH injections, Spinal stabilization surgery

Growth Hormone Excess

• Caused by Hypersecreting tumor: pituitary adenoma
• Genetic association
• Results in Gigantism in Childhood, presenting Tall & Obese with Proportionate bone growth
• Results in Acromegaly in Adulthood, presenting bone growth with increased width and thickness
• Acromegaly Treatment: Decrease GH secretion with meds, radiation therapy to decrease size of adenoma

Pituitary & Adrenal Gland Disorders: Posterior Pituitary

• Involves Antidiuretic Hormone (ADH) also known as Vasopressin
• A potent vasoconstrictor
• Keeps water IN
• Regulates fluid volume via kidneys
• Diabetes Insipidus causes "diuresis increases"
• The most common disorder of posterior pituitary is a LACK of ADH
• Results in Excessive diuresis, fluid loss, which leads to hypovolemia
• Types of DI: Central (neurogenic) is most common, Nephrogenic affecting kidneys, Psychogenic causing excessive water intake
• Symptoms include dilute urine (Increased UO), Polydipsia, Dehydration, Decreased skin turgor in adults, Weight loss, Hemoconcentration of blood, Decreased BP, Increased HR, CNS changes, and Hypernatremia
• Treatment includes Replace fluids, correct hypernatremia, synthetic ADH, and Hormone replacement
• Syndrome of Inappropriate Antidiuretic Hormone (SIADH) means “too many letters.. too much fluid"
• Results from Over secretion of ADH and Fluid retention causing hypervolemia
• Causes of SIADH: Lung Cancer, Head trauma, Brain surgery/tumor, Infection
• Symptoms: Hyponatremia, Anorexia, nausea, muscle cramps, weakness, irritability, confusion, LOC changes (Decreased reflexes), Fluid retention, Concentrated Urine (Decreased UO and/or weight gain without edema), Hemodilution
• Treatment involves Replace Na Slowly with Seizure precautions due to hyponatremia
• Fluid restriction requires monitoring for s/s fluid volume overload, weight, I&O
• Administer Diuretics and Monitor K and Tx underlying condition

Adrenal Gland Disorders

• Adrenal Cortex (Inner Portion): produces epi & norepi
• Adrenal Cortex (Outer Portion): produces mineralcorticosteroids & glucocorticosteroids
• Glucocorticosteroids “sugar hormones" such as Cortisol (Stress hormone)
• Mineralcorticosteroids "salt hormones" such as Aldosterone
• Adrenal Cortex Hyposecretion: Addison's Disease requires to "add" hormone
• Results from Adrenal Insufficiency, Hypo-Cortisolism, "too little" cortisol and/or aldosterone
• Symptoms (slow onset): "Too little "Cortisol (Muscle weakness, Anorexia, n/v, weight loss, Hypoglycemia, Hyper-pigmentation of the skin/mucous membranes), "Too little” Aldosterone (Dehydration, blood volume depletion, decreased cardiac output, Hypotension, Hyponatremia - confusion, Hyperkalemia - cardiac arrest)
• Medical Causes: Autoimmune disease, Infections, Surgical removal of adrenal glands, Anterior pituitary gland damage
• Diagnostics show Decreased Cortisol & Sodium, Increased ACTH & potassium and Decreased BS
• Treatment includes Hormone Replacement (Steroids for insufficient cortisol) and Encourage high Na diet
• Adrenal Cortex Hypersecretion: Cushing's Syndrome means having "extra cushion" of hormone
• Results from Hyper-Cortisolism and Excess production of steroids by adrenals
• Signs/Symptoms: Truncal obesity, Buffalo Hump, Moon Face, Hirsutism (facial hair), Bone demineralization, Hyperglycemia, Mood changes, HTN, Heart failure, edema
• Diagnostics: Increased cortisol levels & Sodium and Decreased Potassium
• Treatment: Wean steroid use, Restrict Na, Adrenalectomy (if tumor is cause), Trans-Sphenoidal hypophysectomy (Monitor nasal packing/dressing, Watch for CSF leak = clear/white drainage, Watch for DI, and Lifelong hormone treatment)

Adrenal Medulla Hypersecretion

• Results in Pheochromocytoma, which is a Benign Tumor (excess epi & norepi)
• Symptoms: Severe HTN, Severe headache, Hyperhidrosis (severe sweating), Palpations, Angina
• Treatment include lower BP to prevent HTN crisis with Multiple meds , Surgical removal of tumor and Lifelong steroids

Hematology

• Plasma works as a Transport vehicle for materials carried in blood
• Erythrocytes: The Most abundant cell that is Produced in bone marrow
• Hemoglobin (Hg): Protein in RBCs that Carries oxygen to organs and tissues, returning carbon dioxide from organs and tissues to lungs

Bone Marrow Biopsy

• Involves Aspiration of fluid and BM cells
• Used for Dx of anemia, thrombocytopenia, leukemia, tumors, causes of infections, to stage diseases
• Complete Blood Count (CBC) includes WBC, RBC (measures # of RBC in 1 mm of blood, RBC Indices, Hemoglobin = total amount of Hg in blood, Hematocrit (% of RBCs in total volume of blood), Platelets

RBC Abnormalities

• Normocytic & Normochromic = Normal size & color
• Macrocytic & Normochromic= Large size & normal color, caused by B12/Folic acid deficiency
• Microcytic & Hypochromic = Small size & pale color, caused by Iron deficiency anemia
• Anemia is Not a disease, but a Deficiency in # of erythrocytes (RBCs), Quantity of Hg, Volume of packed RBCs (Hct)
• Causes: Blood loss, Decreased RBC production, Destruction of RBCs

Iron Deficiency Anemia

• Most Common
• Caused by Decreased production of RBCs by bone marrow from Blood loss (menses, GI, anticoagulants), Inadequate dietary intake vegetarians, Malabsorption
• Signs/Symptoms: Smooth, red tongue sometimes swollen, Brittle ridged nails, Fatigue, Activity intolerance, Dyspnea, Pallor, Palpitations, Cardiac arrhythmias, Tachycardia, Tachypnea
• Labs: Decreased Ferritin, Decreased Hg & Hct
• Treatment: Treat underlying disease and Replace Iron in Meats, dried fruits, dark green vegetables, beets, beans, raisins, whole grains
• Oral supplements: Ferrous Sulfate (Give on empty stomach, Increase vitamin C intake to increase absorption)
• Sources of Iron: Citrus, tomatoes, broccoli
• Can give Parenteral Iron Venofer & InFed or Transfusion of PRBCS

Anemia of Inflammation

• "Anemia of Chronic Disease"
• 2nd Most common
• Decreased production of RBCs
• Low iron levels in blood
• Causes: Chronic Inflammation, Chronic Kidney Disease (d/t decreased production of erythropoietin), Autoimmune Disorders, Infectious Diseases and Malignant Diseases
• Treatment: Treat underlying disease with Medication: Erythropoietin (Procrit, Epogen) a Synthetic form of erythropoietin for SubQ/IV use to Increase production or RBCs especially with CKD and cancer pts

Pernicious Anemia

• Deficiency of Vitamin B12
• Lack of intrinsic factor
• At Risk Population: Inadequate dietary intake = vegans, Malabsorption, Old Age, Alcoholism
• Symptoms: Anorexia, N/V, Abdominal pain, Sore, red, beefy tongue, Paresthesia of feet/hands, Ataxia, Muscle Weakness
• Labs: Decreased Hg/Hct & B12
• Treatment: B12 Oral replacement, Increase dietary sources of animal protein

Folic Acid Anemia

• "Megaloblastic Anemia" with Large, abnormal RBCs
• At Risk: Diet deficiency, Malabsorption, Alcohol abuse
• Symptoms: Same as B12 Deficiency: Anorexia, N/V, Abdominal pain, Sore, red, beefy tongue, Ataxia, Muscle Weakness
• Treatment: Replacement therapy and a High folic acid diet with Leafy green vegetables, citrus, breads, cereals, rice, pasta, nuts

Aplastic Anemia

• Causes: Damage to bone marrow stem cells
• Pancytopenia – decreases all blood cell types meaning it is Rare, but critical
• Symptoms: Fatigue, Dyspnea, Glossitis, Bleeding gums, Infection risk, Bruising, Bleeding
• Labs: CBC/Low neutrophils, Hg, PLTs
• Treatments: Identify and remove cause, Prevent complications including infection & hemorrhage, Immunosuppressive therapy and Stem Cell transplant

Hemolytic Anemia

• Occurs when RBCs are destroyed faster than they can be made = hemolysis

Sickle Cell Anemia

• "S" shaped RBC
• Cells sickle in response to low O2
• Causes vaso-occulsion (Decreased blood flow to organs and tissues and Can be fatal)
• Causes: Genetic Link, African Americans (1 in 36)
• Symptoms: Hypoxia, Pain, Jaundice, Thrombosis
• Risk for MI and stroke
• Risk for crisis (SCC): Hypoxia, Infection, Stress and High Altitude
• Treatment: Prevention of SCC, Stem Cell transplant, Hydration, Oxygenation, Pain relief and Transfusions

Hemochromatosis

• "Iron overload" with Causes of Genetic/Excess Fe deposits in organs – liver, skin, pancreas and Excess absorption from GI tract – too much Hg
• Symptoms: Fatigue, Arthralgia, Abdominal pain, Weight loss, Bronze or darkened skin color, Cardiomyopathy, Arrhythmias, Diabetes, Hepatomegaly and Cirrhosis
• Labs: Increased ferritin & transferrin, Iron and Hg
• Treatment: Periodic Therapeutic Phlebotomy and Decrease Fe in diet

Therapeutic Phlebotomy

1. Removes RBCs from the body
2. Bone marrow is stimulated to produce more RBCs
3. Iron stores are depleted as iron is used to produce RBCs

Polycythemia

• Increased volume of RBCS
• Primary: (Polycythemia Vera) – neoplasm
• Secondary: Response to hypoxia (COPD, OSA)
• Results in Hyperviscosity (Hypercoagulation and impaired circulation)
• Symptoms: Visual disturbances, Paresthesia, TIAS, Thrombophlebitis, Angina and Skin changes causing a ruddy complexion (plethora)
• Treatment: Therapeutic phlebotomy to Treat underlying cause, Decrease blood volume is the GOAL