Endocrine System PDF

Lecturer at Faculty of Nursing, October 6 University  Objectives: At the end of this lecture the students will be able to: 1. Identify patients at risk for T2DM and select an appropriate screening strategy. 2. Diagnose DM using current criteria. 3. Discuss with patients...

Lecturer at Faculty of Nursing, October 6 University  Objectives: At the end of this lecture the students will be able to: 1. Identify patients at risk for T2DM and select an appropriate screening strategy. 2. Diagnose DM using current criteria. 3. Discuss with patients the importance of lifestyle in the management of diabetes and the prevention of complications, especially the role of exercise, nutrition and avoidance of tobacco. 4. Propose an initial therapeutic plan for patients with T2DM and identify major drug side effects. 5. Describe recommended targets (glycemic control, lipids, blood pressure) for specific diabetic patients. 6. Propose a surveillance plan for patients with T2DM.  Endocrine System  Endocrine system is made up of several organs called glands. These glands, located all over your body, create and secrete (release) hormones.  Hormones are chemicals that coordinate different functions in the body by carrying messages through blood to organs, skin, muscles and other tissues.  Diabetes Mellitus  A metabolic disorder in which there is deficiency of insulin production or resistance of organs to the effect of insulin  A multisystem disease related to: Abnormal insulin production, or Impaired insulin utilization, or Both of the above.  Diabetes is a chronic disease, which occurs when the pancreas does not produce enough insulin, or when the body cannot effectively use the insulin it produces.  Leading cause of heart disease, stroke, adult blindness, and non-traumatic lower limb amputations  Normal physiology: Food digested, sugar converted to glucose, absorbed via portal system to liver. Converted to glycogen. Excess glucose goes to muscles, converted to glycogen.  Pancreas  The pancreas functions as both an exocrine and an endocrine gland  Exocrine function is associated with the digestive system because it produces and secretes digestive enzymes  Endocrine Function: produces two important hormones in Islets of Langerhans, insulin and glucagon  They work together to maintain a steady level of glucose, or sugar, in the blood and to keep the body supplied with fuel to produce and maintain stores of energy.  Pancreatic Hormones  Insulin (beta cells)  stimulates the uptake of glucose by body cells thereby decreasing blood levels of glucose  Glucagon (alpha cells)  stimulates the breakdown of glycogen and the release of glucose, thereby increasing blood levels of glucose  Glucagon and insulin work together to regulate & maintain blood sugar levels  Insulin Functions Stimulates storage of glucose in the liver and muscle (in the form of glycogen). Enhances storage of dietary fat in adipose tissue. Accelerates transport of amino acids (derived from dietary protein) into the cells. Insulin also inhibits the breakdown of stored glucose, protein, and fat. ALTERED CHO METABOLISM  Insulin   Glucose Utilization +  Glycogenolysis  Hyperglycemia  Glucosuria (osmotic diuresis)  Polyuria* (and electrolyte imbalance)  Polydipsia* * Hallmark symptoms of diabetes ALTERED PROTEIN METABOLISM  Insulin   Protein Catabolism   Gluconeogenesis (amino acids glucose)  Hyperglycemia  Weight Loss and Fatigue Who are at risk of diabetes?  Types of Diabetes Mellitus  Types Of Diabetes  Type 1 Diabetes Insulin dependent (IDDM or type I)  Type 2 Diabetes Non-insulin dependent (NIDDM or type II)  Gestational Diabetes  Secondary Diabetes  Type 1 Diabetes Mellitus Formerly known as “juvenile onset” or “insulin dependent” diabetes Most often occurs in people under 30 years of age Peak onset between ages 11 and 13  Type 1 Diabetes Mellitus Etiology and Pathophysiology Progressive destruction of pancreatic  cells Autoantibodies cause a reduction of 80% to 90% of normal  cell function before manifestations occur Causes: Genetic predisposition Exposure to a virus  Type 1 Diabetes Mellitus Etiology and Pathophysiology  Type 1 Diabetes Mellitus Clinical Manifestations Weight loss Polydipsia (excessive thirst) Polyuria (frequent urination) Polyphagia (excessive hunger) Weakness and fatigue Ketoacidosis  Type 2 Diabetes Mellitus Accounts for 90% of patients with diabetes Usually occurs in people over 40 years old 80-90% of patients are overweight  Type 2 Diabetes Mellitus Etiology and Pathophysiology Insulin resistance – Body tissues do not respond to insulin – Results in hyperglycemia Decreased (but not absent) production of insulin  Gestational Diabetes Develops during pregnancy Detected at 24 to 28 weeks of gestation Associated with risk for cesarean delivery, perinatal death, and neonatal complications  Secondary Diabetes Results from another medical condition or due to the treatment of a medical condition that causes abnormal blood glucose levels – Cushing syndrome (e.g. steroid administration) – Hyperthyroidism – Parenteral nutrition  Diagnosis On at least two occasions: 1. Random plasma glucose > 200 mg/dl 2. Fasting plasma glucose > 126 mg/dl 3. Urine analysis 4. HGB A1C normal range for the hemoglobin A1c test is between 4% and 5.6%. Hemoglobin A1c levels between 5.7% and 6.4% indicate increased risk of diabetes. levels of 6.5% or higher indicate diabetes  Management Prevention Research shows that you can lower your risk for type 2 diabetes by 58% by: Losing 7% of your body weight Exercising moderately (such as brisk walking) 30 minutes a day, five days a week  Management of Diabetes Type One: Insulin + Healthy Eating + Exercise Type Two: Healthy eating + exercise then Healthy eating + exercise + tablets then Healthy eating + exercise + tablets + insulin  Pharmacological Therapy  Insulin Therapy Newly Diagnosed Type 1 The Type 2 diabetic on maximum tablets The Type 2 diabetic with contraindications to OHA e.g. renal failure, poor tolerance Pregnancy Post acute MI Acute illness/ infection  Pharmacological Therapy cont., Insulin preparation vary according to four main characteristics: time course of action, concentration, species (source), and manufacturer. Time course – Insulin may be grouped into 3 main categories based on onset, peak, duration of action. Concentration – Most common concentration of insulin is U-100. Means that there are 100 units of insulin per 1 cubic centimeter. 100 units of U-100 is 1 ml, 50 units of U-100 is 1/2ml. Species – Derived from pancreas of cows and pigs and conversion of this insulin to human insulin. Manufacturer – Lilly human insulin – “Humulin” and Novo Nordisk human insulin – “Novolin”  Biphasic Insulin  Mixture of isophane and soluble or analogue insulins  Offer dual insulin release profiles from one injection  Depending on proportion of soluble, or analogue, component to isophane  Examples  Humalog Mix 25 or Mix 50 (Lilly)  Human Mixtard 10/20/30/40/50 (Novo Nordisk)  Novomix 30 (Novo Nordisk) Administration sites  Diabetes Mellitus Mixing insulin  Adverse Effects  Hypoglycemia  Allergic reactions  usually local site & usually diminish  less likely with human insulin  Insulin lipodystrophy  Atrophy or hypertrophy of subcutaneous fat at injection sites  Rotate within sites to prevent  Insulin insensitivity or resistance  Requires higher doses of insulin  Oral Hypoglycemic drugs  Type 2 diabetes generally results from either a decrease in Insulin secretion  increase resistance (activity)  The use of oral medications with diet & exercise can manage the problem but oral hypoglycaemics are NOT insulin & therefore cannot replace insulin  Complications of Diabetes Acute Complications: result from an imbalance in the treatment regimen. Hypoglycemia (low blood sugar), which is also called insulin reaction or insulin shock. Hyperglycemia (high blood sugar), which, if uncontrolled, may lead to diabetic ketoacidosis (DKA) in type 1 diabetes or hyperosmolar nonketotic syndrome (HNKS) in type 2 diabetes.  Comparison Hypoglycemia Hyperglycemia  Onset Sudden  Slower onset  Skin cold, pale, moist  Skin warm, red, dry  Normal Breath  Acidic Breath  Weak, rapid pulse  Kussmaul Respiration's  Weakness/  Rapid Pulse uncoordination  Polyuria, polydypsia,  Headache polyphagia  Irritable/Nervous  Nausea/Vomiting Behavior  Falling Blood Pressure  Insulin Shock (Hypoglycemia) Occurs when insulin levels are too high It is an Urgent medical emergency Prolonged hypoglycemia can result in serious brain damage Can occur if a pt. accidentally or intentionally takes too much insulin  Signs and Symptoms  Weak, Rapid Pulse  Cold, clammy skin  Weakness/uncoordination  Headache  Irritable, nervous behavior  Coma (severe cases)  Diabetic Ketoacidosis (DKA) Causes Signs and Symptoms Pt has not taken Polyuria (frequent urination) his/her insulin Polydypsia (excessive thirst) Polyphagia (excessive hunger) Pt has overeaten, Nausea/Vomiting flooding the body Kussmaul’s Respiration's (Deep with carbohydrates and Rapid) Warm, Dry Skin Pt has infection that Fruity Odor on Breath disrupts Abdominal Pain glucose/insulin Falling Blood Pressure balance Fever Decreased LOC  Hyperosmolar hyperglycemic nonketotic syndrome BG > 600 mg/dl Occurs in Type II diabetics (often elderly) Causes: similar to DKA Pathophysiology Similar to DKA, except there is enough insulin to prevent ketosis (fat breakdown), but not enough to prevent hyperglycemia  HHNS  Clinical manifestation dehydration, weakness, polyuria, polydipsia, somnolence, seizures, coma  Treatment  Re-hydrate  Insulin IV  Monitor closely  Complications of Diabetes Chronic Complications of type 1 and type 2 diabetes generally occur 10 to 15 years after the onset of diabetes. Macrovascular (large vessel) disease – affecting coronary peripheral vascular, and cerebrovascular circulations. Microvascular (small vessel) disease – affecting the eyes (retinopathy) and kidneys (nephropathy). Neuropathic diseases – affecting sensorimotor and autonomic nerves and contributing to such problems as impotence and foot ulcers.  Diabetes: Complications Macrovascular Microvascular Stroke Diabetic eye disease (retinopathy and cataracts) Heart disease and hypertension 2-4 X increased risk Renal disease Peripheral vascular disease Erectile Dysfunction Peripheral Neuropathy Foot problems  Complications of Diabetes Diabetic Foot  Macrovascular disease → PVD (↓ supply of oxygen, WBCs, nutrients)  Sensory neuropathy → injury  Teach prevention of ulceration/injury Infection – Immune deficiencies – Delayed detection d/t sensory neuropathy – Decreased circulation – delays or prevents immune response A Gangrene Foot…. Diabetes Complications Foot/Leg/Heel Ulcers  Nursing Care A. Assessment, planning, implementation with client according to type and stage of diabetes B. Prevention, assessment and treatment of complications through client self-management and keeping appointments for medical care C. Client and family teaching for diabetes management D. Health promotion includes education of healthy life style, lowering risks for developing diabetes for all clients E. Blood glucose screening at 3 year intervals starting at age 45 for persons in high risk groups  Nursing Care Common Nursing Diagnoses and Specific Teaching Interventions A. Risk for impaired skin integrity: Proper foot care 1. Daily inspection of feet 2. Checking temperature of any water before washing feet 3. Need for lubricating cream after drying but not between toes 4. Patients should be followed by a podiatrist 5. Early reporting of any wounds or blisters B. Risk for infection 1. Frequent hand washing 2. Early recognition of signs of infection and seeking treatment 3. Meticulous skin care 4. Regular dental examinations and consistent oral hygiene care  Nursing Care C. Risk for injury: Prevention of accidents, falls and bur D. Ineffective coping 1. Assisting clients with problem-solving strategies for specific concerns 2. Providing information about diabetic resources, community education programs, and support groups 3. Utilizing any client contact as opportunity to review coping status and reinforce proper diabetes management and complication prevention  Nursing Care Nursing Intervention Advice patient about the importance of an individualized meal plan in meeting weekly weight loss goals and assist with compliance. Assess patients for cognitive or sensory impairments, which may interfere with the ability to accurately administer insulin. Demonstrate and explain thoroughly the procedure for insulin self-injection. Help patient to achieve mastery of technique by taking step by step approach. Review dosage and time of injections in relation to meals, activity, and bedtime based on patients individualized insulin regimen.  Nursing Care Nursing Intervention Explain the importance of exercise in maintaining or reducing weight. Advise patient to assess blood glucose level before strenuous activity and to eat carbohydrate snack before exercising to avoid hypoglycemia. Assess feet and legs for skin temperature, sensation, soft tissues injuries, corns, calluses, dryness, hair distribution, pulses and deep tendon reflexes. Maintain skin integrity by protecting feet from breakdown. Advice patient who smokes to stop smoking or reduce if possible, to reduce vasoconstriction and enhance peripheral flow. Lecturer at Faculty of Nursing, October 6 University  Objective At the end of this lecture the students will be able to:  Explain the regulation of thyroid hormone secretion.  Recognize the symptoms of hypothyroidism and list possible causes of this disorder.  Know the treatment of hypothyroidism.  Recognize the symptoms of hyperthyroidism and understand what diagnostic tests are used to identify the cause.  Identify the unique presentation Grave’s Disease and its pathologic mechanism.  List the management options for hyperthyroidism and complications of each.  Compare and contrast the various types of thyroiditis.  Understand the affects that hypo- and hyperthyroidism can have on a developing fetus.  Apply nursing care plan for thyroid disorder patient.  Thyroid Hormones The thyroid gland produces thyroid hormones : Tetraiodothyronine (thyroxine or T4) and Triiodothyronine (T3). These hormones are essential for life and have many effects on body metabolism, growth, and development Iodine plays an important role in the function of the thyroid gland.  Hypothalamic - Pituitary - Thyroid Axis The thyroid gland is influenced by hormones produced by two other organs: The pituitary gland, located at the base of the brain, produces thyroid stimulating hormone (TSH) The hypothalamus, a small part of the brain above the pituitary, produces thyrotropin releasing hormone (TRH).  Hyperthyroidism  Hyperthyroidism is a hyperthyroid state resulting from hypersecretion of thyroid hormones (T3 and T4).  Hyperthyroidism is characterized by an increased rate of body metabolism.  A common cause is Graves’ disease, also known as toxic diffuse goiter.  Clinical manifestations are referred to as thyrotoxicosis.  Causes of Hyperthyroidism Causes Graves’ disease has an autoimmune derivation and is caused by circulating anti-TSH autoantibodies that displace TSH from the thyroid receptors and mimic TSH by activating the TSH receptor to release additional thyroid hormones. Thyrotoxicosis has several different pathophysiological causes, including autoimmune disease, functioning thyroid adenoma, and infection.  Hyperthyroidism Assessment and manifestation 1. Enlarged thyroid gland (goiter) 10. Nervousness and fine 2. Tachycardia or atrial fibrillation tremors of hands 3. Protruding eyeballs (exophthalmos) 11. Personality changes 4. Hypertension 12. Irritability and agitation 5. Heat intolerance 13. Mood swings 6. Diaphoresis 14. Oligomenorrhea (Irregular 7. Weight loss menstrual periods in 8. Diarrhea women) 9. Smooth, soft skin and hair  Thyroid crisis (storm) Thyroid crisis (storm), also called thyrotoxicosis, is a sudden worsening of hyperthyroidism symptoms that may occur with infection or stress. Fever, decreased mental alertness, and abdominal pain may occur. Immediate hospitalization is needed.  Diagnostic Evaluation  Decrease Thyroid-stimulating hormone (TSH) (normal TSH: 0.5–1.5 mU/L).  Elevated Thyroxine (T4) (normal values: 5.0–12.0 μg/dL).  Elevated Tri-iodothyronine (T3) (normal values: 80–230 ng/dL). Other Tests: 24-hr radioactive iodine uptake; thyroid autoantibodies; antithyroglobulin; electrocardiogram (ECG)  Medical Management  Treatment is directed toward reducing thyroid hyperactivity for symptomatic relief and removing the cause of complications. Three forms of treatment are available:  Irradiation involving the administration of 131I or 123I for destructive effects on the thyroid gland  Pharmacotherapy with antithyroid medications  Surgery with the removal of most of the thyroid gland  Medical Management Pharmacotherapy  Propylthiouracil (PTU) an antithyroid agent is given to return the patient to the euthyroid (normal) state. PTU inhibits use of iodine by thyroid gland; blocks oxidation of iodine and inhibitis thyroid hormone synthesis  Methimazole (Tapazole) an antithyroid agent is given to return the patient to the euthyroid (normal) state by inhibiting use of iodine by thyroid gland.  Other Drugs: Beta-adrenergic blockers, corticosteroids, radioactive iodine  Medical Management Pharmacotherapy  Maintenance dose is establish, followed by gradual withdrawal of the medication over the next several months.  Antithyroid drugs are contraindicated in late pregnancy because of a risk for goiter and cretinism in the fetus.  Nursing Care Plan  Primary Nursing Diagnosis Activity intolerance related to exhaustion and fatigue  Nursing Interventions 1. Provide adequate rest. 2. Administer sedatives as prescribed. 3. Provide a cool and quiet environment. 4. Obtain weight daily. 5. Provide a high-calorie diet. 6. Avoid the administration of stimulants. 7. Administer antithyroid medications 8. Administer iodine preparations that inhibit the release of thyroid hormone as prescribed. 9. Administer propranolol (INderal) for tachycardia as prescribed. 10. Prepare the client for radioactive iodine therapy, as prescribed, to destroy thyroid cells. 11. Prepare the client for thyroidectomy if prescribed.  Hypothyroidism  Hypothyroidism is a hypothyroid state resulting from a hyposecretion of the thyroid hormones T4 and T3.  Hypothyroidism is characterized by decreased rate of body metabolism.  The term myxedema refers to the accumulation of mucopolysaccharides in subcutaneous and other interstitial tissues.  Causes of Hypothyroidism Causes and classification The types of hypothyroidism are classified according to their causes:  Central hypothyroidism. There is a failure of the pituitary gland, the hypothalamus, or both to stimulate production of thyroid hormones.  Secondary or pituitary hypothyroidism. The cause is entirely a pituitary disorder in secondary hypothyroidism.  Tertiary or hypothalamic hypothyroidism. This refers to the cause as a disorder of the hypothalamus resulting in inadequate secretion of TSH due to decreased stimulation of TRH.  The thyroid disorder is already present at birth in cretinism.  Causes of Hypothyroidism Causes  Inflammation of the thyroid gland.  Autoimmune diseases. The most common cause of hypothyroidism in adults is autoimmune thyroiditis or Hashimoto’s disease.  Atrophy of the thyroid gland. The thyroid gland shrinks in size as a result of aging.  Therapy for hyperthyroidism. Therapies such as radioactive iodine and thyroidectomy could also cause hypothyroidism.  Medications such as lithium, iodine compounds, and antithyroid medications could decrease the production of TSH.  Iodine deficiency or excess. The imbalance in the iodine levels in the body also affects the thyroid gland.  Some women develop hypothyroidism after pregnancy (often referred to as “postpartum thyroiditis”).  Hyperthyroidism Assessment and manifestation 1. Lethargy and fatigue 9. Generalized puffiness and edema 2. Weakness, muscle aches, around the eyes and face. paresthesias 10. Forgetfulness and loss of memory 3. Intolerance to cold 11. Menstrual disturbances 4. Weight gain 12. Cardiac enlargement, tendency to 5. Dry skin and hair develop congestive heart failure. 6. Loss of body hair 7. Bradycardia 8. Constipation Assessment and manifestation  Myxedema coma  Myxedema coma, the most severe form of hypothyroidism, is rare. It may be caused by an infection, illness, exposure to cold, or certain medications in people with untreated hypothyroidism. Symptoms and signs :  Below normal temperature  Decreased breathing  Low blood pressure  Low blood sugar  Unresponsiveness  Diagnostic Evaluation  Elevated Thyroid-stimulating hormone (TSH) assay result is >4.0 mU/L ( normal values: 0.5–1.5 mU/L).  Thyroxine (T4) radioimmunoassay decreased (normal values: 5.0–12.0 μg/dL).  Tri-iodothyronine (T3) decreased (normal values: 80–230 ng/dL).  Electrocardiogram (ECG) reveals low voltage, T wave abnormalities.  Other Tests: 24-hr radioactive iodine uptake; thyroid autoantibodies; antithyroglobulin  Medical Management Pharmacotherapy  Treatment consists of replacing the deficient hormone with synthetic thyroid hormone; low doses are initially used, and the dose is increased every 1 to 2 months based on the clinical response and serial laboratory measurements that show normalization of thyroid-stimulating hormone (TSH) levels in primary hypothyroidism.  Levothyroxine sodium a synthetic thyroid hormone replacement is used to returns the patient to the euthyroid (normal) state. Dosage is 1.5–2.5 mcg/kg PO daily; (use lowest dose possible because over-replacement of thyroid can cause bone loss or cardiovascular complications).  Nursing Care Plan Nursing Assessment  Assessment of the patient with hypothyroidism should include:  Assessment of the thyroid from an anterior or posterior position.  Auscultation of the lobes of the thyroid gland using the diaphragm of the stethoscope if there are abnormalities palpated.  Assess thyroid gland for firmness (Hashimoto’s) or tenderness (thyroiditis).  Nursing Care Plan Diagnosis  Activity intolerance related to fatigue and depressed cognitive process.  Risk for imbalanced body temperature related to cold intolerance.  Constipation related to depressed gastrointestinal function.  Ineffective breathing pattern related to depressed ventilation.  Disturbed thought processes related to depressed metabolism and altered cardiovascular and respiratory status.  Nursing Care Plan Planning & Goals To achieve a successful nursing care plan, the following goals should be realized:  Increase in participation in activities.  Increase in independence.  Maintenance of normal body temperature.  Return of normal bowel function.  Improve respiratory status.  Maintenance of normal breathing pattern.  Improve thought processes.  Nursing Care Plan Nursing Interventions Promote rest. Space activities to promote rest and exercise as tolerated.  Protect against coldness. Provide extra layer of clothing or extra blanket.  Avoid external heat exposure. Discourage and avoid the use of external heat source.  Mind the temperature. Monitor patient’s body temperature.  Increase fluid intake. Encourage increased fluid intake within the limits of fluid restriction.  Provide foods high in fiber.  Manage respiratory symptoms. Monitor respiratory depth, rate, pattern, pulse oximetry, and ABG.  Pulmonary exercises. Encourage deep breathing, coughing, and use of incentive spirometry.  Orient to present surroundings. Orient patient to time, place, date, and events around him or her.  Nursing Care Plan  Primary Nursing Diagnosis Activity intolerance related to weakness and apathy  Nursing Interventions 1. Monitor vital signs, including heart rate and rhythm. 2. Administer thyroid replacement, levothyroxine sodium (Synthroid) is most commonly prescribed. 3. Instruct the client about thyroid replacement therapy. 4. Instruct the client in low-calorie, low-cholesterol, low-saturated-fate diet. 5. Assess the client for constipation; provide roughage and fluids to prevent constipation. 6. Provide a warm environment for the client. 7. Avoid sedatives and narcotics because of increase sensitivity to these medications. 8. Monitor for overdose of thyroid medications, characterized by tachycardia, restlessness,, nervousness, and insomnia. 9. Instruct the client to report episodes of chest pain immediately.