Endocrine Disorders Part 1 of 2(3).ppt

Endocrine Disorders Part 1 (Concept: Metabolism) Pituitary and Copyright © 2016 by Saunders, an imprint of Adrenal Disorders Elsevier In...

Endocrine Disorders Part 1 (Concept: Metabolism) Pituitary and Copyright © 2016 by Saunders, an imprint of Adrenal Disorders Elsevier Inc.  2 Hormone Functions and Regulation  Released in response to body’s needs  Responsible for reproduction, fluid and electrolyte balance, host defenses, responses to stress and injury, energy metabolism, and growth and development  Endocrine system: maintain homeostasis  Maintenance of physiologic stability despite environmental changes Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  3 Hormone Functions and Regulation (cont.)  Feedback mechanisms:  Controls regulation of endocrine activity by either stimulating or inhibiting hormone synthesis and secretion  Triggered by blood levels of specific substances  May be positive or negative Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  4 Age-Related Changes  IncreasedADH secretion impairs ability to concentrate urine, increasing risk of dehydration Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  5 Diagnostic Tests and Procedures  Radiographic studies:  Conventional radiographs  Computed tomographic (CT) scans  MRI  Cerebral angiography  Laboratory studies:  Radioimmunoassay  Enzyme-linked immunosorbent assay (ELISA)  Hormone reserve activity also can be measured using a number of “suppression” or “stimulation” tests Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  6 Pituitary  “Master gland” inside the brain  Monitors and regulates bodily functions:  Growth and development  Sexual/Reproductive development  Communication with other glands Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  7 Hyperpituitarism  Cause:  Pathologic state caused by excess production of one or more of the anterior pituitary hormones (GH, prolactin, FSH, LH, ACTH)  Common factor is presence of a pituitary adenoma (tumor)  Tend to occur in young women during teens, early 30s  Growth hormone and prolactin often in excess (produces S/S:)  Overproduction leads to gigantism or acromegaly (see next slides)  Overproduction of prolactin (stimulates milk production at birth) causing prolactemia (abnormal lactation) Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  8 Hyperpituitarism(cont.)  Signs and symptoms (variable):  Visual deficits and headaches may be first symptoms; often a result of pressure on optic nerves  Enlarged hands, feet, sinuses, deformities of spine and mandible  Enlarged tongue, skin, liver and spleen  Excessive perspiration, oily skin, peripheral neuropathies, joint degeneration, muscle weakness  Excess growth hormone impedes the activity of insulin; may have symptoms of DM  Increased strength, leading to c/o weakness, fatigue Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  Organomegaly  9 Hyperpituitarism(cont.)  Acromegaly  Most patients with acromegaly have pituitary macroadenomas that secrete excess growth hormone.  S/S may occur in the 4th-5th decade of life.  Prevents longitudinal growth of bones, so they grow in thickness & width.  Also affects the cardiovascular, digestive, nervous, and genitourinary systems.  Enlarged hands, feet, organs Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  10 Hyperpituitarism(cont.)  Gigantism  Less common than acromegaly.  Occurs in early childhood or puberty.  Normally towards the end of puberty, the bone plates seal. With this, before closure, there is an excess of GH, which allows them to grow in length. They grow very tall.  Affects multiple systems, resulting in fatality at a very early age. Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  11 Hyperpituitarism(cont.)  Assessment  Gigantism/acromegaly: energy level, height/weight, vital signs, contours of the face and skull, visual acuity, speech, voice quality, abdominal distention  Nursing Diagnoses  Disturbed body image  Activity intolerance  Chronic pain  Ineffective self-health management Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  12 Hyperpituitarism Treatment  Surgery (to removal a tumor)  Radiation therapy  Sometimes used in combination with surgery, can to shrink tumors  Gamma knife radiotherapy: uses radiation delivered to the site from multiple angles to treat acromegaly  Hormone replacement for life usually required after radiotherapy Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  13 Hypopituitarism  Dwarfism  Inadequate secretion of growth hormone during preadolescence  Maximum height reached about 40% below normal  Causes hereditary or related to damage (hemorrhage, trauma, infection, autoimmune disorders, etc.) to the anterior portion of the pituitary gland  Panhypopituitarism  Growth has been completed and some pathologic process impairs the function of the pituitary (Sheehan syndrome-post partum shock, tumors, infection, removal/destruction of pituitary) Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  14 Hypopituitarism  Signs and symptoms  Depends on the stage of life which hormones are deficient  Generally-fatigue, weakness, malaise, lethargy  Dwarfism  Occurs early; person as short as 36 inches but with proportional physical characteristics  Often have delayed or absent sexual maturation  Accelerated pattern of aging, thus shorter life span  Panhypopituitarism  Simmonds cachexia (muscle organ waste, disrupting digestion & metabolism)  Decreased muscle & organ size  Poor coping d/t absence of ACTH  Inability to regulate temp efficiently (d/t hypothyroid) Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  15 Hypopituitarism (cont.)  Medical diagnosis  Health history, physical examination, diagnostic tests  Conventional radiographs and CT scans  Cerebral angiography to detect malformed blood vessels  Serum levels of pituitary hormones  Medical and surgical treatment  Deficient hormones are replaced as needed  If caused by tumor, surgery, or radiation Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  16 Diabetes Insipidus (DI)  Cause  Excessive output of dilute urine  Classifications:  Nephrogenic DI  Inherited defect: renal tubules do not respond to ADH, resulting in inadequate water reabsorption  Neurogenic DI (central or hypothalamic)  A defect in either the production or secretion of ADH exists  Dipsogenic DI (primary polydipsia)  A disorder of thirst stimulation  When patient ingests water, serum osmolality decreases, which causes reduced vasopressin secretion Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  17 Diabetes Insipidus (cont.)  Pathophysiology  Antidiuretic hormone (ADH) deficiency or inability of kidneys to respond to ADH results in the excretion of large volumes of very dilute urine  Signs and symptoms  Massive diuresis, dehydration could lead to hypotension & circulatory collapse, and thirst  Malaise, lethargy, and irritability  If untreated, will lead to cardiac arrest & death  Medical diagnosis  Health history, physical examination, and laboratory findings  24-hour urine output of greater than 4 L of fluid without food or fluid restriction (osmolality + specific gravity very low) Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  18 Diabetes Insipidus (cont.)  Medical treatment  Intravenous fluid volume replacement and vasopressors often required to maintain adequate blood pressure  Neurogenic DI  DDAVP (desmopressin acetate, anti-diuretic & clotting promoter) given PO, IV or nasal inhalation. Sub-Q injections can be given when the cause is reversible (infection). Some require it for life.  Sodium intake restricted and thiazide diuretics prescribed, which decreases Na , helping to increase the reabsorption of water. Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  19 Diabetes Insipidus (cont.)  Teach the patient to:  Monitor wt daily  Monior I & O  S/S water intoxication: drowsiness, headache  Test urine for specific gravity  Continue taking drugs, as prescribed. Prolonged use of nasal spray can cause ulcers, chest tightness, respiratory problems and infection  Schedule activities with regular rest periods Copyright © 2016 by Saunders, an imprint of Elsevier Inc. 20 Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  21 Syndrome of Inappropriate Antidiuretic Hormone (SIADH)  Cause  Water imbalance related to an increase in ADH production or secretion, or both  Factors which may cause/contribute: brain trauma, surgery, tumors, infection; drugs: vasopressin, general anesthesia, oral hypoglycemic agents, tricyclic antidepressants  Pathophysiology  When ADH is elevated despite normal or low serum osmolality, kidneys retain excessive water  Plasma volume expands, causing the blood pressure to rise. Body sodium is diluted (hyponatremia), and water intoxication develops. Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  22 Syndrome of Inappropriate Antidiuretic Hormone (cont.)  Signs and symptoms  Weakness, muscle cramps or twitching, nausea, diarrhea, irritability, headache, and weight gain without edema  When the central nervous system is affected by water intoxication, the level of consciousness deteriorates  Patient may have seizures or lapse into a coma Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  23 Syndrome of Inappropriate Antidiuretic Hormone (cont.)  Medical diagnosis  Laboratory tests of serum and urine electrolytes and osmolality  Simultaneous measurements of urine & serum osmolality (urine high and serum low)-indicative of SIADH  Radiographic studies can detect causative factors Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  24 Syndrome of Inappropriate Antidiuretic Hormone (cont.)  Medical treatment  Acutely ill: hypertonic saline, very slowly over 4- to 6-hour period (drives fluid from interstitial space into intravascular space)  Restrict fluids to 800 to 1000 mL/day with high intake of dietary sodium to help pull Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  25 Adrenal Gland  Metabolism  Immune system  BP  Stress response Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  26 Adrenal Hypofunction  Cause  Primary adrenal insufficiency  Also called Addison disease  Destructive disease resulting in deficiencies of cortisol and aldosterone (steroid hormones used to help balance water and salts)  Secondary adrenal insufficiency  A result of dysfunction of the hypothalamus or pituitary that leads to decreased androgen and cortisol production  Aldosterone may be affected Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  27 Adrenal Hypofunction (cont.)  Pathophysiology  Impaired secretion of cortisol: decreased gluconeogenesis and decreased liver and muscle glycogen, depleting glucose supply hypoglycemia  Signs and symptoms  Progressive weakness, lethargy, unexplained abdominal pain, and malaise  Skin hyperpigmentation Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  28 Adrenal Hypofunction (cont.)  Acute adrenal crisis (Addisonian Crisis)  A life-threatening emergency  From sudden marked decrease in available adrenal hormones  Precipitating factors are adrenal surgery, pituitary destruction, abrupt withdrawal of steroid therapy, and stress (infection, illness, trauma, etc.) Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  29 Adrenal Hypofunction (cont.)  Acute Adrenal Crisis (Addisonian Crisis)  Manifestations include symptoms: hypotension, tachycardia, dehydration, confusion, hyponatremia, hyperkalemia, hypercalcemia, and hypoglycemia  If untreated, fluid and electrolyte imbalances can lead to circulatory collapse, cardiac arrhythmias, cardiac arrest, coma, and death Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  30 Adrenal Hypofunction (cont.)  Medical diagnosis  Laboratory studies that help to support:  Low serum and urinary cortisol level, decreased fasting glucose, hyponatremia, hyperkalemia, and increased BUN  Plasma cortisol levels  EKG (alterations such as peaked T waves, widened QRS, increased PR interval, all d/t electrolyte abnormalities)  Radiographic studies  Arteriograms,CT scans, and MRI (revealing lesions, aneurysms, or defects) Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  31 Adrenal Hypofunction (cont.)  Medical treatment  Replacement therapy with glucocorticoids and mineralocorticoids Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  32 Adrenal Hypersecretion (Cushing Syndrome)  Cause  Production of excess amounts of corticosteroids  Causes:  pituitary tumors  prolonged administration of high doses of corticosteroids Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  33 Adrenal Hypersecretion (Cushing Syndrome): Pathophysiology  Excess levels of circulating corticosteroids  Physical Assessment: obesity, facial redness, hirsutism (excessive hair growth on unexpected areas of the body), menstrual disorders, hypertension, muscle wasting of extremities  Additionally delayed wound healing, insomnia, irrational behavior, and mood disturbances such as irritability and anxiety Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  34 Adrenal Hypersecretion (Cushing Syndrome): Pathophysiology(cont.)  Findings that lead to diagnosis  Truncal obesity  Protein wasting  Facial fullness, often called a “moon face”  Purple striae on the abdomen, breasts, buttocks, or thighs  Osteoporosis (low glucocorticoids effect on bone metabolism)  Hypokalemia of uncertain cause Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  35 Adrenal Hypersecretion (Cushing Syndrome)  Medical diagnosis  Laboratory studies:  24-hour urine collection for free cortisol (cortisol in excessive causes wt gain)  Low-dose dexamethasone suppression test  Abnormal laboratory findings: polycythemia, hypokalemia, hypernatremia, hyperglycemia, leukocytosis, glycosuria, hypocalcemia, and elevated plasma cortisol  Radiographic studies:  CTscan and MRI (to identify a potential tumor or osteoporosis) Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  36 Adrenal Hypersecretion (Cushing Syndrome) (cont.)  Medical treatment  Drug therapy (interfere with ACTH production):  Mitotane (Lysodren), ketoconazole (Nizoral), aminoglutethimide (Cytadren), and metyrapone (Metopirone)  Radiation:  Administered externally or internally  Surgical management; removal of adrenal tumors, pituitary tumor Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  37 Adrenal Hypersecretion (Cushing Syndrome) (cont.)  Assessment  Detailed history and physical examination  Onset of symptoms, prior treatments, drug allergies, and current medications  Interventions  Risk for infection  Disturbed thought processes  Risk for impaired skin integrity  Risk for injury-broken bones (d/t osteoporosis)  Disturbed body image  Ineffective self-health management Copyright © 2016 by Saunders, an imprint of Elsevier Inc. Thyroid and Parathyroid Disorders Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  39 The Thyroid Gland  Anatomy and physiology:  Located in lower portion of the anterior neck  Two lobes, one on each side of trachea  Lobes connected in front of trachea by a narrow bridge of tissue called the isthmus  Plays a major role in regulating the body’s rate of metabolism and growth and development Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  40 Age-Related Changes in Thyroid Function  Increased incidence of thyroid nodules  Serum levels of T4 remain approximately the same in a healthy older person, but levels of T3 often decline  Incidenceof hypothyroidism increases with age, especially among women Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  41 Assessment of the Thyroid Gland (cont.)  Diagnostic tests and procedures  Serum T3, free T4, T4, and TSH  Thyroid-releasing hormone (TRH) stimulation test  Radioactive iodine (RAI) uptake test  Thyroid ultrasonography  MRI or CT Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  42 Characteristics of Hyperthyroidism  Abnormal increase of thyroid hormones  Graves disease:  Most common type of hyperthyroidism  Autoimmune disorder  Antibodies activate thyroid-stimulating hormone (TSH) receptors, which in turn stimulate thyroid enlargement and hormone secretion  Most often develops in young women Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  43 Signs and Symptoms  Associated with increased metabolic rate!  Weight loss and nervousness  In more severe cases:  Restlessness, irritable behavior, sleep disturbances, emotional lability, personality changes, hair loss, and fatigue  Weight loss, even when the patient is eating well, is common  Poor tolerance of heat and excessive perspiration  Changes in menstrual and bowel patterns  Warm, moist, velvety skin; fine hand tremors; swelling of the neck; and ophthalmopathy including exophthalmos  Tearing, light sensitivity, decreased visual acuity, and swelling around orbit of the eye  Tachycardia, increased systolic blood pressure, sometimes atrial fibrillation Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  44 Complications  Thyrotoxicosis (thyroid storm or crisis)  Excessive stimulation caused by elevated thyroid hormone levels that produce dangerous tachycardia and hyperthermia  S/S: restless, agitation, coma.  Medical emergency! Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  45 Medical Diagnosis  Decreased TSH and elevated serum T4  Measurement of thyroid-stimulating antibodies and results of a radioactive iodine uptake test to diagnose Graves disease  Treatment:  Radiation  Drugs  Surgery Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  46 Multinodular Goiter  Caused by small thyroid nodules that secrete excess thyroid hormone  Nodules can be benign or malignant  Usually need surgical removal Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  47 Care of the Patient Having a Thyroidectomy (cont.)  Complications:  Ineffective airway clearance  Laryngeal nerve damage  Damage to the parathyroid glands  Tetany,leg cramps, spasms (may be a sign of hypocalcemia) Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  48 Signs and Symptoms of Hypothyroid  Swelling of the lips and eyelids  Dry, thick skin  Bruising  Thin, coarse hair  Hoarseness  Generalized nonpitting edema  Facial edema  May seem slow, depressed, or apathetic Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  49 Medical Diagnosis  Based on laboratory determination of free T4 and TSH  Complications  Myxedema coma  Medical treatment  Hormone replacement therapy  Levothyroxine (Synthroid) or liothyronine (Cytomel) Copyright © 2016 by Saunders, an imprint of Elsevier Inc. Hypothyroidism 50 Conditions  Inadequate secretion of thyroid hormones  Cretinism   Low thyroid hormone levels in fetal or early life. If not treated early, hypothyroidism during infancy causes permanent physical and mental retardation  Is usually reversible with treatment (eat iodine rich foods)  Myxedema   Caused from underactive thyroid gland.  Facial edema  Usually can be treated by treating hypothyroid Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  51 Simple Goiter  Thyroid enlargement with normal hormone production  Causes:  Iodine deficiency and long-term exposure to goitrogens (foods rich in goitrogens are mustard, kale, broccoli, peanuts, red wine, tea, etc.)  The gland may enlarge to compensate for hypothyroidism  Sometimes the enlarged gland produces excess hormones, making the patient hyperthyroid Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  52 Simple Goiter (cont.)  Treatment  If mild enlargement and normal hormones, no intervention  Some patients need hormone replacement therapy  Surgery indicated if pressure on the trachea or esophagus or if the condition is disfiguring Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  53 Goiter  Nodules  Can be benign or malignant  Nodular goiters usually surgically removed Copyright © 2016 by Saunders, an imprint of Elsevier Inc.  54 Any questions Copyright © 2016 by Saunders, an imprint of Elsevier Inc.