Endocrine Dysfunction PDF

A l l E l s e Chapter 47...

A l l E l s e Chapter 47 v i e r i ENDOCRINE DYSFUNCTION t e m s a Sara Headley, DNP, CPNP-PC, CNE n d d e r i v e d i t e m s The Endocrine System 2  The Endocrine System ► Three components ► Cells send chemical messages using hormones ► Target cells or end organs that receive the message ► Environment through which chemicals are transported (e.g. Blood, lymph, extracellular fluids) ► Hormones ► Complex chemical substances that exert controlling effect on other cells ► Endocrine glands (see Table 47.1) ► Master gland: anterior pituitary  4 The Endocrine System  5 Pituitary Gland ► Anterior lobe ► Growth hormone ► Prolactin ► Follicle stimulating hormone ► Posterior lobe ► Oxytocin ► Antidiuretic hormone All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  6 Disorders of Pituitary Function ► Disorders may be due to organic defects or have an idiopathic cause ► Problem may involve a single hormone or a combination of several hormonal deficiencies ► Clinical manifestations depend upon the hormone involved ► Disorder may result in an overproduction or hormone deficiency All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  7 Hypopituitarism: Growth Hormone Deficiency ► Deficient secretion of pituitary hormones ► Inhibits somatic growth and development of secondary sex characteristics ► Consequences: depend upon the degree of dysfunction ► Gonadotropin deficiency ► Growth hormone (GH) deficiency ► Thyroid-stimulating hormone (TSH) deficiency ► Corticotropin deficiency All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  8 Diagnostic Evaluation of Growth Hormone Deficiency ► Family history ► Growth patterns and previous health status ► Normal growth the first ► Slowed growth after infancy ► Delayed sexual development ► Physical examination ► Psychosocial evaluations ► Radiographic survey ► Endocrine studies All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  9 Therapeutic Management of Growth Hormone Deficiency ► Treatment is directed toward correction of the underlying disease process ► Replacement with GH is successful in 80% of affected children ► Therapy is ended when growth rates are less than 1 inch per year ► Girls: at 14 years of age ► Boys: at 16 years of age ► Care Management: ► Child and family support ► Preparation for testing and medication administration All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  10 Pituitary Hyperfunction ► Excess GH before closure of epiphyseal shafts results in overgrowth of long bones ► Patients can reach heights of 8 feet or more ► Vertical growth is accompanied by increased muscle ► Weight is generally in proportion to height All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  11 Pituitary Hyperfunction: Acromegaly ► Excess GH after epiphyseal closure is called “acromegaly” ► Typically, several facial features undergo overgrowth ► Head ► Lips, tongue, jaw, nose ► Paranasal, mastoid sinuses ► Separation and malocclusion of the teeth All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  12 Diagnostic Evaluation of Pituitary Hyperfunction ► History of excessive growth during childhood ► Evidence of increased levels of GH ► Radiographic studies ► May reveal a tumor ► Endocrine studies All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  13 Therapeutic Management of Pituitary Hyperfunction ► Surgical treatment to remove tumor ► Radiation and radioactive implants ► Hormone replacement therapy after surgery in some cases ► Thyroid extract ► Cortisone ► Sex hormones All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  14 Care Management of Pituitary Hyperfunction ► Early identification of children with excessive growth rates ► Early treatment for improved outcomes ► Observation for signs of tumor ► Emotional support ► Addressing body image concerns All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  15 Precocious Puberty ► Defined as sexual development before age 9 years in boys or before age 8 years in girls ► Evaluation for pathologic cause: required in white girls younger than 7 years and African American girls younger than 6 years ► Potential causes: ► Disorder of gonads, adrenal glands, or hypothalamic-pituitary gonadal axis ► 95% are idiopathic All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  16 Types of Precocious Puberty ► Central precocious puberty (CPP) ► 80% of cases of precocious puberty ► Early maturation and development of gonads and secondary sex characteristics ► Peripheral precocious puberty ► Premature development of breasts, pubic and axillary hair, and menses All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  17 Therapeutic Management of Precocious Puberty ► Treatment of specific cause if known ► May be treated with leuprolide (Lupron) ► Slows prepubertal growth to normal rates ► Treatment is discontinued at age when normal pubertal changes are expected to resume ► Psychologic support for child and family All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  18 Diabetes Insipidus All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  19 Diabetes Insipidus ► The principal disorder of the posterior pituitary gland ► Results from hyposecretion of antidiuretic hormone (ADH) ► Produces uncontrolled diuresis ► Primary causes: familial or idiopathic ► Secondary causes: trauma, tumors, central nervous system infection, aneurysm All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  20 Clinical Manifestations of Diabetes Insipidus ► Cardinal signs: polyuria and polydipsia ► First sign is often enuresis (involuntary urination: wetting self) ► Infants: irritability relieved with feedings of water but not milk; dehydration often occurs ► Diagnosed by reducing fluid intake with little or no effect on urine output All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  21 Therapeutic Management of Diabetes Insipidus ► Instruct parents in difference between diabetes insipidus and diabetes mellitus ► Daily hormone replacement ► Drug of choice: vasopressin (DDAVP) ► Nasal spray or intravenous administration ► Subcutaneous or intramuscular injection ► Treatment required for life All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  22 Syndrome of Inappropriate Antidiuretic Hormone (SIADH) All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  23 Syndrome of Inappropriate Antidiuretic Hormone (SIADH) All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  24 Syndrome of Inappropriate Antidiuretic Hormone (SIADH) ► Results from oversecretion by the posterior pituitary gland (increased ADH) ► Fluid retention and hypotonicity ► Kidneys unable to reabsorb water ► Manifestations ► Anorexia, nausea/vomiting, irritability, personality changes ► Fluid retention and hypotonicity ► Symptoms alleviated when ADH is decreased All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  25 Care Management of SIADH ► Accurate measurements of intake and output ► Observation for signs of fluid overload ► Seizure precautions ► ADH-antagonizing medications ► Child and family education All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  26 Disorders of Thyroid Function ► Thyroid hormone regulates basal metabolic rate ► Thyroid secretes two types of hormones ► Thyroid hormone, which is made up of ► Thyroxin (T4) ► Triiodothyronine (T3) ► Calcitonin ► Patients may have hypothyroidism or hyperthyroidism ► Patients may have disturbance in secretion of TSH (anterior pituitary) All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  27 Goiter ► Hypertrophy of the thyroid gland ► Congenital ► Usually results from maternal ingestion of antithyroid drugs during pregnancy ► Acquired ► Result of neoplasm, inflammatory disease, dietary deficiency (but rarely in children), or increased secretion of pituitary thyrotropic hormone All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  28 Care Management of Goiter ► Goiters may become noticeable during periods of rapid growth ► Large goiters may be obvious; smaller nodules may be evident only on palpation ► Thyroid hormone replacement is necessary for treatment of hypothyroidism ► Immediate surgery may be life-saving in infants born with goiter All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  29 Lymphocytic Thyroiditis ► Also known as “Hashimoto disease” or “autoimmune thyroiditis” ► Most common cause of thyroid disease in children and teenagers ► Accounts for largest percentage of juvenile hypothyroidism ► Occurs most frequently after age 6 years, peaks during adolescence All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  30 Clinical Manifestations of Lymphocytic Thyroiditis ► Enlarged thyroid gland ► Usually symmetric ► Firm, nontender ► Freely moveable ► Tracheal compression ► Sense of fullness ► Hoarseness, dysphagia ► Hyperthyroidism possible All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  31 Diagnostics & Management of Lymphocytic Thyroiditis ► Diagnostics ► Thyroid function tests usually normal ► TSH may be mildly elevated ► Antithyroid antibodies are present ► Goiter may be transient, asymptomatic ► Goiter may resolve spontaneously within 1-2 years ► Oral thyroid hormone administration often decreases the goiter significantly ► Surgery is contraindicated in this disorder All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  32 Hyperthyroidism (Graves Disease) ► Graves disease constitutes largest percentage of cases of childhood hyperthyroidism ► It is believed to be caused by autoimmune response to TSH receptors ► Signs include enlarged thyroid gland and exophthalmos ► Incidence peaks between ages of 12 to 14 years, but condition may be present at birth ► Familial association exists All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  33 Management of Graves’ Disease ► Therapy: controversial ► Goal of therapy: to retard rate of hormone secretion ► Treatments ► Antithyroid drugs (propylthiouracil and methimazole) ► Subtotal thyroidectomy ► Ablation with radioiodine All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  Care Management of Hyperthyroidism ► Identify children with hyperthyroidism ► Be alert for signs and symptoms ► Child needs quiet environment, rest periods ► Help family cope with emotional lability ► Dietary requirements are higher to meet child’s increased metabolic rate ► Medications have side effects  35 Disorders of Parathyroid Function ► Parathyroid glands secrete parathormone (PTH) ► Function of PTH: to maintain serum calcium level by ► Increasing release of calcium and phosphate from bone demineralization ► Increasing absorption of calcium and excretion of phosphate by the kidneys ► Promote calcium absorption in GI tract All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  36 Clinical Manifestations of Hypoparathyroidism ► Dry, scaly skin with eruptions ► Brittle hair, thin nails with transverse grooves ► Tetany, paresthesias, tingling, laryngeal stridor, spasms, or a combination of these ► Headache, seizures, emotional lability, depression, confusion, memory loss ► Diagnosis based on clinical symptoms ► Low plasma PTH All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  37 Clinical Manifestations of Hypoparathyroidism All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. Clinical Manifestations 38 Chvostek’s Sign Trousseau’s Sign Both due to hypocalcemia  Therapeutic Management Hypoparathyroidism ► Goal is to maintain calcium and phosphate levels ► Tetany immediately corrected (with Ca, Vit D, and Mg) ► Monitor renal function, blood pressure, serum vitamin D levels ► Maintain seizure and safety precautions ► Monitor for laryngospasm  40 Disorders of Adrenal Function ► Adrenal cortex secretes three groups of “steroids” ► Glucocorticoids (cortisol, corticosterone) ► Mineralocorticoids (aldosterone) ► Sex steroids (androgens, estrogens, and progestins) ► Altered levels of these produce significant dysfunction ► Adrenal medulla secretes catecholamines: epinephrine and norepinephrine ► Catecholamine-secreting tumors are the primary cause of adrenal medullary hyperfunction All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  41 Acute Adrenocortical Insufficiency ► Adrenal crisis: LIFE THREATENING! ► Without Tx, 20% will DIE! (Cleveland Clinic, 2022) -Compare this to risk of death from anaphylaxis = 0.7-2% (Up To Date, 2021) ► Etiologic factors: hemorrhage into the gland from trauma, fulminating infections, abrupt withdrawal of exogenous cortisone, failure to increase cortisone during times of stress ► Diagnosis generally based on clinical symptoms ► Child in Adrenal Crisis Video, before and after injection: https://www.youtube.com/watch?v=ecJdXDG-6XY All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  42 Acute Adrenocortical Insufficiency (Cont.) All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  43 Acute Adrenocortical Insufficiency (Cont.) ► Clinical symptoms ► Increased irritability, headache ► Abdominal pain, nausea, vomiting ► Hyperpyrexia, cyanosis, seizures ► Diagnosis based on clinical presentation ► Therapeutic management ► Replace cortisol ► IVFs ► Nursing- monitor electrolytes, s/s of dec K+ All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  44 Chronic Adrenocortical Insufficiency (Addison Disease) ► Rare in children ► Causes: ► Infections, neoplasms, autoimmune processes, or idiopathic ► Symptoms: appear gradually after 90% of adrenal tissue is nonfunctional ► Diagnosis ► Measurement of functional cortisol reserve ► Therapeutic management ► Replacement of cortisol and aldosterone ► Should be taken qd-qod (AM) with food ► Care management ► Parental guidance and education All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  45 Cushing Syndrome ► TOO MUCH CORTISOL: ► A characteristic group of manifestations caused by excessive circulating free cortisol ► May be caused by excessive or prolonged steroid therapy ► Condition: reversible once steroids are discontinued ► Abrupt withdrawal of steroids: may precipitate acute adrenal insufficiency All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  46 Cushingoid Appearance (Cont.) All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  47 Diagnostic Evaluation of Cushing Disease ► Measurement of serum cortisol levels ► Imaging of pituitary and treatment glands ► Skull films to examine the sella turcica ► Measurement of bone density (brittle) ► Laboratory tests ► Fasting blood glucose level ► Serum electrolyte levels ► 24-hour urine collection All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  48 Therapeutic Management of Cushing Disease ► Dependent upon the cause ► Surgical intervention ► Replacement of GH, ADH, thyroid hormone, gonadotropins, and steroids ► Care management ► Steroid administration early morning ► Alternate-day schedule ► Postoperative complications All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  49 Congenital Adrenal Hyperplasia ► Occurs in 1 per 12,000-15,000 births ► Overproduction of adrenal androgens ► Results in virilization of the female fetus ► Varying degrees of ambiguous genitalia ► Salt-wasting crisis frequently occurs All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 50  51 Therapeutic Management of Congenital Adrenal Hyperplasia ► Many different types: Vary in severity ► Administer glucocorticoids (prednisone or hydrocortisone) ► Diagnose and assign sex to the child according to genotype (Karyotyping) ► Reconstructive surgery may be required; but may be hindered by state legislation….. ► **Not all cases are diagnosed at birth ► Family Planning: Genetics referral ► Family experience: https://www.youtube.com/watch?v=Dq33NSLcWUg&t=1s ► Late onset: https://www.youtube.com/watch?v=gv6lVfJ_lPQ All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  52 Disorders of Pancreatic Hormone Secretion ► Diabetes mellitus ► Characterized by a total or partial deficiency of the hormone insulin ► The most common endocrine disorder of childhood ► Peak incidence between 10 and 15 years of age ► Increased risk for African American and Hispanic children ► Types: Table 47.2 page 1435 All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  53 Type 1 Diabetes Mellitus ► Characterized by destruction of beta cells, usually leading to absolute insulin deficiency ► Onset typically from autoimmune process (such as a virus) in childhood and adolescence but can occur at any age ► Most childhood cases of diabetes mellitus are type 1 ► More prominent in caucasian people All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 54  55 Type 2 Diabetes Mellitus ► Arises because of insulin resistance ► Onset usually after age 45 ► Native American, Hispanic, and African American children: at increased risk for type 2 diabetes mellitus ► Affected people may require insulin injections All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 56  57 Pathophysiology of Diabetes Mellitus ► With a deficiency of insulin, glucose is unable to enter the cell and remains in blood, causing hyperglycemia ► When serum glucose exceeds renal threshold, glucose spills into urine (glycosuria) ► Cells break down protein for conversion to glucose by the liver (glucogenesis) All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc. 58  59 Ketoacidosis ► When glucose is unavailable for cellular metabolism, the body breaks down alternative sources of energy; ketones are released, and excess ketones are eliminated in urine (ketonuria) or by the lungs (acetone breath) ► Ketones in the blood are strong acids that lower serum pH and produce ketoacidosis All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  60 Diabetic Ketoacidosis ► Pediatric emergency ► Results from progressive deterioration with dehydration, electrolyte imbalance, acidosis, coma; may cause death ► Therapy: should be instituted in an intensive care unit setting All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  61 Manifestations and Diagnosis ► Manifestations ► Polydipsia ► Polyphagia ► Polyuria ► Labs ► Random BG >200 mg/dL with s/s ► Fasting BG > 120 mg/dL All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  62 Long-Term Complications of Diabetes Mellitus ► Microvascular complications, especially nephropathy and retinopathy ► Macrovascular disease, neuropathy ► With poor control, vascular changes as early as 2.5-3 years after diagnosis ► With excellent control, can be delayed 20 years All Elsevier items and derived items © 2014, 2010, 2006, 2002, Mosby, Inc., an imprint of Elsevier Inc.  63 Therapeutic Management of Type 1 Diabetes Mellitus ► Multidisciplinary approach ► Insulin therapy ► Glucose monitoring; goal, near normal levels of