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Endocrine Problems Allison Acerra RN, MSN With contributions from Mary Kate Sullivan RN,MSN Copyright © 2020 by Elsevier, Inc. All rights reserved. Endocrine Disorders  Dysfunction arises from imbalances in  production of hormones  in body’s ability to use hormone produced  alters function in ta...

Endocrine Problems Allison Acerra RN, MSN With contributions from Mary Kate Sullivan RN,MSN Copyright © 2020 by Elsevier, Inc. All rights reserved. Endocrine Disorders  Dysfunction arises from imbalances in  production of hormones  in body’s ability to use hormone produced  alters function in target organ or tissue  effects are experienced systemically  Primary Disorder  involves gland itself  Secondary Disorder  problem outside of gland Copyright © 2020 by Elsevier, Inc. All rights reserved. 2 Assessment of the Endocrine System  Subjective data  past medical history  Medications  Labs  Functional Health PAtterns  Health Perception  Nutrition  Metabolic  Elimination Copyright © 2020 by Elsevier, Inc. All rights reserved. 3 Assessment of the Endocrine System  Functional Health Patterns cont.  Activity and Exercise  Sleep-Rest  Cognitive-Perceptual  Self Perception- Self concept  Role relationships  Sexuality- Reproduction  Coping-stress  Values and beliefs Copyright © 2020 by Elsevier, Inc. All rights reserved. 4 Pituitary Gland  Pituitary gland: “Mastery Gland”  Secretes hormones that in turn control the secretion of hormones by other endocrine glands  Anterior Pituitary  FSH (follicle stimulating hormones), LH (luteinizing hormone), Prolactin, Adrenocorticotropic hormone (ACTH), Thyroid Stimulating hormone (TSH), Growth hormone (GH)  Posterior Pituitary  Antidiuretic hormone (ADH) or Vasopressin, Oxytocin Copyright © 2020 by Elsevier, Inc. All rights reserved. 5 Anterior Pituitary Copyright © 2020 by Elsevier, Inc. All rights reserved. 6 Tumors  Most common: Pituitary adenoma  Hypersecretory pituitary adenomas- secrete excess hormone  Growth hormone  Adrenocorticotropic hormone  Treatment: Surgery  Transsphenoidal microsurgery  Transfrontal craniotomy  Radiation Copyright © 2020 by Elsevier, Inc. All rights reserved. 7 Hypersecretion Disorders  Acromegaly/Gigantism  Most cases a benign GH secreting pituitary adenoma  Overgrowth of soft tissues and one  Hands, feet, and face Copyright © 2020 by Elsevier, Inc. All rights reserved. 8 Clinical Manifestations Overgrowth of the bones and soft tissue Enlargement of features Arthritic changes Cardiomegaly Hyperglycemia Copyright © 2020 by Elsevier, Inc. All rights reserved. 9 Diagnostic Studies  History and Physical examination  Labs: GH IGF-1  MRI or high resolution CT scan  Complete eye examination Copyright © 2020 by Elsevier, Inc. All rights reserved. 10 Interprofessional and Nursing Care  Surgery: Hypophysectomy  Radiation therapy  Drug therapy  Somatostatin analog (Octreotide)  Dopamine agonist (Bromocriptine, Cabergoline)  Growth hormone antagonist (Pegvisomant [Somavert])  Combination  Psychosocial support  Cardiac monitoring Copyright © 2020 by Elsevier, Inc. All rights reserved. 11 Posterior Pituitary  Oxytocin  Antidiuretic Hormone (ADH)  Over production of ADH  Under production of ADH  Usually result from trauma, infection or inflammation Copyright © 2020 by Elsevier, Inc. All rights reserved. 12 Syndrome of Inappropriate Antidiuretic Hormone Copyright © 2020 by Elsevier, Inc. All rights reserved. 13 Etiology and Pathophysiology  Overproduction of ADH  Reabsorption of water into the circulation  Increased intravascular fluid volume  Dilutional hyponatremia and decreased serum osmolality  More often in older adults  Most common causes: Cancer (esp. small cell CA) Copyright © 2020 by Elsevier, Inc. All rights reserved. 14 Clinical Manifestations & Diagnostic Studies  Low urine output  Weight gain  Thirst, dyspnea on exertion, and fatigue  Hyponatremia  120-135 mEq/L irritability, headache, muscle cramping  Below 120mEq/L vomiting, abdominal cramps, muscle twitching  Serum osmolality less than 280 mOsm/kg  Urine specific gravity greater than 1.030 Copyright © 2020 by Elsevier, Inc. All rights reserved. 15 Interprofessional Care  Monitor I&Os (fluid restrictions)  Vital sigs  Daily weights  Neuro assessment  Monitor electrolytes  Seizure and fall precautions  Assess S/S of Hyponatremia  Medications: Lasix, Demeclocycline, hypertonic saline solution, Vasopressor receptor antagonists Copyright © 2020 by Elsevier, Inc. All rights reserved. 16 Diabetes Insipidus Copyright © 2020 by Elsevier, Inc. All rights reserved. 17 Etiology and Pathophysiology  Deficient production or secretion of ADH  Increased ADH increases the urine output  Causes electrolyte imbalances  DI may be transient or chronic  Central DI, Nephrogenic DI, Primary DI Copyright © 2020 by Elsevier, Inc. All rights reserved. 18 Clinical Manifestations  Serum osmolality increased (usually greater than 295 mOsm/kg)  Hypernatremia: greater than 145 mg/dL  Polyuria (UO 2-20L per day)  Polydipsia  Tired/weakness Copyright © 2020 by Elsevier, Inc. All rights reserved. 19 Diagnostic Studies  Urine output  Urine specific gravity  Water deprivation test  Desmopressin (DDAVP) stimulation test Copyright © 2020 by Elsevier, Inc. All rights reserved. 20 Interprofessional Care  Maintaining adequate hydration  Hypotonic IV solutions (0.45% saline) or D5W  Vital Signs (BP, HR)  Urine output  Level of consciousness  Electrolytes, specific gravity  Monitor for signs of dehydration  Assess fluid volume status  Limiting sodium intake (Only for Nephrogenic DI) Copyright © 2020 by Elsevier, Inc. All rights reserved. 21 Drug Therapy  Desmopressin (DDAVP)  ADH replacement drug  Chlorpropamide and Carbamazepine (Tegrtol)  Thiazide diuretics (hydrochlorothiazide, Cholorothiazide [Diuril])  Indomethacin (Indocin) Copyright © 2020 by Elsevier, Inc. All rights reserved. 22 Disorders of Adrenal Cortex Copyright © 2020 by Elsevier, Inc. All rights reserved. 23 Addison’s Disease Copyright © 2020 by Elsevier, Inc. All rights reserved. 24 Etiology and Pathophysiology  Primary Addison’s disease  Secondary Lack of pituitary ACTH  80% of cases caused by an autoimmune response  Autoimmune polyglandular syndrome  Most common in white females  Iatrogenic Addison’s disease Copyright © 2020 by Elsevier, Inc. All rights reserved. 25 Clinical Manifestations  Anorexia  Nausea  Progressive weakness  Fatigue  Weight loss  Abdominal pain  Diarrhea  Headache  Orthostatic hypotension  Salt craving  Joint pain Copyright © 2020 by Elsevier, Inc. All rights reserved. 26 Hyperpigmentation (Fig. 49-13) Copyright © 2020 by Elsevier, Inc. All rights reserved. 27 Copyright © 2020 by Elsevier, Inc. All rights reserved. 28 Complications  Addisonian crisis  Hypotension, tachycardia  Dehydration  Decreased sodium, increased potassium, decreased glucose  Fever, weakness, confusion  Severe vomiting, diarrhea, pain  Shock may cause circulatory collapse Copyright © 2020 by Elsevier, Inc. All rights reserved. 29 Diagnostic Studies  History and physical assessment  ACTH stimulation test  CRH stimulation test  Serum cortisol and ACTH  Urine cortisol and aldosterone  Serum electrolytes  CT scan, MRI Copyright © 2020 by Elsevier, Inc. All rights reserved. 30 Interprofessional Care  Manage underlying cause  Lifelong hormone therapy  Glucocorticoid (prednisone, hydrocortisone)  Mineralocorticoid (fludrocortisone)  Androgen: women require (Dehydroepiandrosterone [DHEA])  Increase dietary salt intake  Increase steroids at times of stress Copyright © 2020 by Elsevier, Inc. All rights reserved. 31 Nursing Implementation  Frequent monitoring necessary  Correct fluid and electrolyte imbalance  Obtain complete medication history  Watch for signs of Cushing syndrome  Patient teaching  Monitor for signs and symptoms of infection Copyright © 2020 by Elsevier, Inc. All rights reserved. 32 Addisonian crisis  Symptoms  Weakness  Confusion  Abdominal pain  Hypotension  Treatment  Shock management  High-dose hydrocortisone replacement  0.9% saline solution and 5% dextrose Copyright © 2020 by Elsevier, Inc. All rights reserved. 33 Audience Response Question The nurse gives corticosteroids to a patient with acute adrenal insufficiency. The nurse determines that treatment is effective if what is observed? a. The patient is alert and oriented. b. The patient’s lung sounds are clear. c. The patient’s urinary output decreases. d. The patient’s potassium level is 5.7 mEq/L. Copyright © 2020 by Elsevier, Inc. All rights reserved. 34 Audience Response Question An IV hydrocortisone infusion is started before a patient is taken to surgery for a bilateral adrenalectomy. Which explanation, if given by the nurse, is most appropriate? a. “The medication prevents sodium and water retention after surgery.” b. “This drug stimulates your immune system and promotes wound healing.” c. “The drug prevent clots from forming in the legs during your recovery from surgery.” d. “This medicine is given to help your body respond to stress after removal of the adrenal glands.” Copyright © 2020 by Elsevier, Inc. All rights reserved. 35 Cushing Syndrome and Hyperaldosteronism Copyright © 2020 by Elsevier, Inc. All rights reserved. 36 Etiology and Pathophysiology  Caused by excess of corticosteroids  Prolonged administration of high dose corticosteroids  ACTH-secreting pituitary adenoma  Adrenal tumors  Ectopic ACTH production by tumors Copyright © 2020 by Elsevier, Inc. All rights reserved. 37 Cushing Syndrome (2 of 3) (Fig. 49-11) Copyright © 2020 by Elsevier, Inc. All rights reserved. 38 Cushing Syndrome (3 of 3) Fig. 49-12 Copyright © 2020 by Elsevier, Inc. All rights reserved. 39 Clinical Manifestations  Excess glucocorticoids  Hyperglycemia related to glucose intolerance and increased gluconeogenesis  Muscle wasting causes weakness  Loss of bone matrix causes osteoporosis and back pain  Loss of collagen causes thin skin, easily bruises  Delay in wound healing Copyright © 2020 by Elsevier, Inc. All rights reserved. 40 Clinical Manifestations  Mineralocorticoid excess may cause:  Hypokalemia  Hypertension  Adrenal androgen excess may cause:  Severe acne  Male characteristics in women  Feminization in men Copyright © 2020 by Elsevier, Inc. All rights reserved. 41 Copyright © 2020 by Elsevier, Inc. All rights reserved. 42 Diagnostic Studies  Confirmation of increased plasma cortisol levels  Midnight or late night salivary cortisol  Low-dose dexamethasone suppression test  24-hour urine cortisol Levels greater than 100 mcg/24 hr  Urine levels of 17-ketosteroids may be high Copyright © 2020 by Elsevier, Inc. All rights reserved. 43 Diagnostic Studies  Plasma ACTH levels  High or normal with Cushing disease (pituitary etiology)  Low or normal with Cushing syndrome  Hypokalemia and alkalosis  With ectopic ACTH syndrome and adrenal cancer Copyright © 2020 by Elsevier, Inc. All rights reserved. 44 Interprofessional Care  Normalize hormone secretion  Treatment depends on cause  Surgical removal or irradiation of pituitary adenoma  Adrenalectomy for adrenal tumors or hyperplasia  Removal of ACTH-secreting tumors  If cause is prolonged, use of corticosteroids  Gradually taper the steroids off Copyright © 2020 by Elsevier, Inc. All rights reserved. 45 Cushing Syndrome Nursing Diagnoses  Risk for infection  Impaired nutrition status  Disturbed body image  Impaired tissue integrity  Lack of knowledge Copyright © 2020 by Elsevier, Inc. All rights reserved. 46 Cushing Syndrome Planning  Patient goals  Have relief of symptoms  Avoid serious complications  Maintain a positive self-image  Actively take part in therapeutic plan  Prevent infection  Low NA diet  I&Os Copyright © 2020 by Elsevier, Inc. All rights reserved. 47 Cushing Syndrome Nursing Implementation  Monitor  Vital signs  Daily weight  Glucose  Assess for signs and symptoms of  Inflammation/infection  VTE  Emotional support Copyright © 2020 by Elsevier, Inc. All rights reserved. 48 Cushing Syndrome Nursing Implementation  Preoperative care  Optimize physical condition  Control hypertension and hyperglycemia  Correct hypokalemia  High-protein diet to correct protein depletion  Depends on planned surgical approach Copyright © 2020 by Elsevier, Inc. All rights reserved. 49 Cushing Syndrome Nursing Implementation  Postoperative care  Increased risk of hemorrhage  Large release of hormones into circulation causes instabilities in BP, fluid balance, and electrolyte levels Copyright © 2020 by Elsevier, Inc. All rights reserved. 50 Cushing Syndrome Nursing Implementation  Postoperative care  High doses of corticosteroids are given IV during and for several days after surgery  Increased risk for: infection, problems controlling glucose, delayed wound healing  Report any significant changes in vital signs  Monitor fluid intake and output  Give corticosteroids as ordered  Obtain morning urine samples for cortisol measurement Copyright © 2020 by Elsevier, Inc. All rights reserved. 51 Cushing Syndrome Nursing Implementation  Postoperative care  Monitor for acute adrenal insufficiency Vomiting, increased weakness Dehydration, hypotension Painful joints Pruritus Peeling skin Severe emotional problems Copyright © 2020 by Elsevier, Inc. All rights reserved. 52 Cushing Syndrome Nursing Implementation  Postoperative care  Bed rest until BP is stabilized after surgery  Monitoring for subtle signs of infection  Meticulous care to prevent infection Copyright © 2020 by Elsevier, Inc. All rights reserved. 53 Cushing Syndrome Nursing Implementation  Ambulatory care  Home health nurse  Always wear Medic Alert bracelet  Avoid exposure to extremes temperatures, infection, and stress  Teach how to adjust medication and when to call HCP  Lifetime replacement therapy Copyright © 2020 by Elsevier, Inc. All rights reserved. 54 Hyperaldosteronism Etiology and Pathophysiology  Conn's syndrome  Excess aldosterone secretion  Sodium retention  Potassium and hydrogen ion excretion  Hypertension with hypokalemic alkalosis Copyright © 2020 by Elsevier, Inc. All rights reserved. 55 Hyperaldosteronism Etiology and Pathophysiology  Primary hyperaldosteronism  Solitary adrenocortical adenoma  Genetic link  Secondary hyperaldosteronism  Nonadrenal cause Renal artery stenosis Renin-secreting tumors Chronic kidney disease Copyright © 2020 by Elsevier, Inc. All rights reserved. 56 Hyperaldosteronism Clinical Manifestations  Increased aldosterone  Sodium retention  Potassium excretion  Sodium retention  Hypernatremia, hypertension, headache  No edema Copyright © 2020 by Elsevier, Inc. All rights reserved. 57 Hyperaldosteronism Clinical Manifestations  Hypokalemia  Muscle weakness  Fatigue  Dysrhythmias  Glucose intolerance  Metabolic alkalosis → tetany Copyright © 2020 by Elsevier, Inc. All rights reserved. 58 Hyperaldosteronism Diagnostic Studies  Primary aldosteronism  Increased plasma aldosterone levels  Increased sodium levels  Decreased potassium levels  Decreased plasma renin activity  CT scan or MRI  Plasma 18-hydroxycorticosterone level Copyright © 2020 by Elsevier, Inc. All rights reserved. 59 Hyperaldosteronism Treatment  Adrenalectomy to remove adenoma  Preoperative  Potassium-sparing diuretics  Antihypertensives  Oral potassium supplements  Sodium restrictions Copyright © 2020 by Elsevier, Inc. All rights reserved. 60 Hyperaldosteronism Treatment  Bilateral adrenal hyperplasia  Potassium-sparing diuretic  Calcium channel blockers to control BP  Dexamethasone to decrease adrenal hyperplasia Copyright © 2020 by Elsevier, Inc. All rights reserved. 61 Hyperaldosteronism Nursing Management  Careful assessment  Fluid and electrolyte balance  Cardiovascular status  Patient teaching  Medications and side effects  Signs and symptoms of hypokalemia and hyperkalemia  Frequent monitoring Copyright © 2020 by Elsevier, Inc. All rights reserved. 62 Adrenal Medulla Copyright © 2020 by Elsevier, Inc. All rights reserved. 63 Pheochromocytoma  Hypersecretion disorder of Adrenal Medulla  Rare condition caused by tumor in adrenal medulla  Secretes catecholamines norepinephrine and epinephrine Copyright © 2020 by Elsevier, Inc. All rights reserved. 64 Etiology and Pathophysiology  Actions of catecholamines:  Norepinephrine- works on alpha receptors  Epinephrine- works on both alpha and beta receptors  Increase with family history  Occurs in male and female equally  Ages 40-60 Copyright © 2020 by Elsevier, Inc. All rights reserved. 65 Clinical Manifestation  Severe episodic hypertension  Accompanied by severe ponding headache  Tachycardia with palpitations  Profuse sweating  Unexplained abdominal and chest pain Copyright © 2020 by Elsevier, Inc. All rights reserved. 66 Diagnostic Studies  24 hour urine measuring urinary fractionated metanephrines  Fractionated catecholamines  Creatine  CT scan  MRI Copyright © 2020 by Elsevier, Inc. All rights reserved. 67 Interprofessional Care  Surgery- Adrenalectomy  Demser Alpha adrenergic receptor blocker  Beta adrenergic receptor blocker  Calm environment  Reporting symptoms  Nourishing foods Copyright © 2020 by Elsevier, Inc. All rights reserved. 68