Endocrine system

Pancreas –   Endocrine and Exocrine gland

Hormones produced

Insulin     

• Decrease blood sugar by

1. Stimulating active transport of glucose into muscle and adipose tissue
2. Promoting the conversion of glucose to glycogen for storage
3. Promoting conversion of fatty acids into fat
4. Stimulating protein synthesis

          Glucagon

Increases blood sugar by promoting conversion of glycogen to glucose

• Beta cells of Islets of langerhans
• Insulin

1. Transcellular membrane transport of glucose
2. Inhibits breakdown of fats and protein
3. Requires Na for transport of glucose

Diabetes Mellitus – is a metabolic disease characterized by elevated levels of  glucose in the blood, resulting from defects in insulin secretion , insulin action or both

Manifestations

1)      Polyuria

2)      Polydypsia

3)      Polyphagia

4)      Weight loss

Diagnostic test

FBS ( Fasting Blood Sugar )  = or > than 126 mg/dl ( 7.0 mmol/L)  on two separate occasion

Normal –  < 100 mg/dl ( < 5.6 mmol/L)

Impaired Fasting Glucose – 100 –125 mg/dl (5.6-6.9 mmol/L)

2 Hours post prandial blood sugar  - Following ingestion of 75 gm of glucose  = or >  200mg/dl

                                                                                                                                        11.1mmol/L

Oral Glucose Tolerance test (OGTT/GTT)

• Initial urine and blood specimen are collected
• 150 – 300 g of CHO/p.o.

Series of blood specimen is collected

·        30 min

·        1 hour

·        2 hours – returns to Normal

·        3,4,5 as required

Done when results of FBS/ 2 hours PPBS are borderline ( High normal)

Glycosylated Hgb

• Most accurate
• Reflects sugar levels for the past 3 – 4 mos

Normal 4- 6 %

Cause – Unknown

Predisposing factors

• Stress – Stimulates secretion of epinephrine , norephineprine , glucocorticoids

                 

• Heredity
• Obesity
• Viral Infection
• Autoimmune disorders

 TYPES

 Type I  ( 5%-10 % )

• IDDM
• Onset any age ( < 30 yrs)
• Often have islet cells antibody
• Absolute Insulin deficiency
• Prone to DKA
• Often have antibodies to insulin even before insulin treatment

 Type II ( 90 %- 95%)

·        Onset usually over 30 years

·        Usually obese at diagnosis

·        Causes include obesity, heredity or environmental factors

·        No islet cell antibodies

·        Decrease in endogenous insulin, or increased with insulin resistance

·        Most patients can control blood glucose through weight loss if obese

·        Oral antidiabetic agents may improve blood glucose levels if dietary modification and exercise are unsuccessful

·        May need insulin on a short or long term basis to prevent hyperglycemia

·        Ketosis, rare, except in stress or infection

 ·        Gestational Diabetes

• Onset during pregnancy, usually in the second or third trimester
• Due to hormones secreted by the placenta, which inhibit the action of insulin
• Above-normal risk for perinatal complications, especially macrosomia (abnormally large babies)
• Treated with diet, if needed, insulin to strictly maintain normal blood glucose levels
• Occurs in about 2%-5% of all pregnancies
• Glucose intolerance transitory but may recur:

-         In subsequent pregnancies

-         30%-40% will develop overt diabetes (usually type 2) within 10 years (esp. if obese)

• Risk factors include obesity, age older than 30 years, family history of diabetes, previous large babies (over 9 lb.)
• Screening tests (glucose challenge test) should be performed on all pregnant women between 24 and 28 weeks gestation

Causes of Morning Hyperglycemia

1.      Dawn Phenomenon-  characterized by a relatively normal blood glucose level when blood glucose level begins to rise.  The phenomenon is thought to result from nocturnal surges in growth hormone secretion that create a greater need for insulin in the early morning hours in patient with Type 1

2.      Somogyi Effect-  normal or elevated blood glucose at bedtime, a decrease at 2-3 am to hypocglycemic levels and subsequent increase caused by the production of counter regulatory hormones

Medications

A.     OHA (Oral Hypoglycemic Agents)

  

          1.  Sulfonylureas

-   Directly stimulating the pancreas to secrete insulin.  These agents improve insulin action at the cellular level.  The common side effects are GI symptoms and dermatologic reactions

Ex.  1^st generation: Acetohexamide, chlorpropamide, tolazamide, tolbutamide

        2^nd generation:  glipizide, glyburide, glimeperide

           2.  Biguanides

        -  produces its antidiabetioc effects by facilitating insulin’s action on peripheral receptor sites.  Have no effect on pancreatic beta cells.  Biguamides used with sulfonylurea may enhance the glucose lowering effect more than either medication used alone.

         Ex.  Metformin, glucophage

       3. Apha Glucosidase Inhibitors

  they work by delaying the absorption of glucose in the intestinal system resulting in a lower postprandial blood glucose level. 

         Ex. Acarbose

4. Thiazolidineones

     -  they are indicated for patients with Type 2 diabetes who take insulin injections and whose blood glucose control is inadequate.  Enhance insulin action at the receptor sites without increasing insulin secretions from beta cells.  Women should be informed can cause resumption of ovulation in peri-menopausal, anovulatory women.

      Ex.  Pioglitazone

              Rosiglitazone

5. Meglitinides

     -  lowers the blood glucose level by stimulating insulin release from beta cells. 

      Ex.  Repaglinide

            Nateglinide

.  Insulin

     1.  Rapid-Acting: Clear Insulin

-         Regular

-         Humulin-R

-         Semilente

-         Crystalline zinc

-         Actrapid

-         Onset: 30 mins- 1 hr.

-         Peak: 2-4 hrs.

-         Duration: 6-8 hrs.

    2.  Intermediate-Acting: cloudy

-         NPH

-         Humulin-N

-         Lente

-         Monotard

-         Onset: 1-2 hrs

-         Peak: 6-8 hrs.

-         Duration: 18-24 hrs.

1. Long-Acting: cloudy

-         PZI

-         Ultralente

-         Onset: 3-4 hrs.

-         Peak: 16-20 hrs.

-         Duration: 30-36 hrs.

 Health Teaching

1.      Foot care:  daily cleanse feet in warm, soapy water; rinse and dry carefully; inspect, don’t break blisters; trim nails to follow natural curve of toe;  always wear breathable shoes such as leather; no crossing of the legs; no cream between toes; inspect visually daily  NCLEX

2.      Injection techniques (intra site rotation)

3.      Dietary management

4.      Quit smoking

Stress management (stress increases blood sugar)

PITUITARY GLAND: HORMONES PRODUCED AND FUNCTIONS

- controlled primarily by the hypothalamus; termed “master gland” as it directly affects the function of other endocrine glands

Anterior Lobe

1. Adrenocorticotropic hormone (ACTH)- concerned with growth and secretory activity of adrenal cortex, which produces steroids
2. Thyrotropic hormone (TSH) – for growth and secretory activity of thyroid; controls release rate of thyroxine, which controls rate of most chemical reaction in the body; target is thyroid gland
3. Somatotropic hormones (STH or GH)-  promote growth of body tissue
4. Gonadotropic hormones and estrogen secretion; follicle stimulating hormone (FSH)-  stimulate development of ovarian follicles; semeniferous tubules and sperm maturation
5. Luteinizing hormone (LH)- works with FSH in final maturation of follicles; promotes ovulation and progesterone secretion
6. Prolactin-  for milk production
7. Melanocyte stimulating hormone (MSH)- produces the characteristic skin darkening

Posterior Lobe

1. Vasopressin (ADH)- influnces water absorption by kidney
2. Oxytocin-influences the menstrual cycle, labor and lactation

Disorders of Anterior Pituitary

1.  Acromegaly-  hypersecretion of GH that occurs in adulthood; commonly associated with benign pituitary tumors

Manifestations:

a. Enlargement of external extremeties (e.g. nose, jaw, hands, feet)

    NCLEX  - assessment question “ are you buying larger size shoes”

                      One of the earliest manifestation is increase in shoe size

b. Protrusion of the jaw and orbital ridges

c.  Coarse features

d.  Visual problems, blindness

e.  Hyperglycemia, insulin resistance

f.   Hypercalcemia

Treatment

a.  Irradiation of pituitary

b.  Transphenoidal hypophysectomy:  removal of pituitary gland

   1. Assess for signs of increased cranial pressure- signs of adrenal insufficiency,   

        hypothyroidism and temporary diabetes insipidus

   2. Elevate head of bed 30 degrees

1.      Avoid coughing, sneezing, blowing nose

2.      Check for CSF in nasal packing

c.  Bromocriptine (Parlodel) with surgery or radiation

Nursing Interventions

a..  Provide emotional support

b.      Directed toward symptomatic care

2.  Gigantism- hypersecretion of GH that occurs in childhood

Manifestations:

a.  Proportional overgrowth in all body tissue

b.  Overgrowth of long bones: height in childhood may reach 8 or 9 feet

c.  Teaching and nursing responsibilities same with acromegaly

3.  Dwarfism-  hyposecretion of GH during childhood

Manifestations:

a.       Retarded symmetrical physical growth

b.      Premature body aging processes

c.       Slow intellectual development

Treatment

1.  Removal of the causative  factor (for ex. Tumors)

2.      Human growth hormone injections (HGH)

Nursing Responsibilities- same with acromegaly

Disorders of Posterior Pituitary

1.  Diabetes Insipidus-  hyposecretion of ADH, due to a tumor or damage of the posterior lobe of the pituitary; may be idiopathic; may be genetic; very common following neurosurgery or head trauma

Manifestations

a.  Polyuria

b.  Polydipsia

c.  Hypernatremia

d.  Weight loss

e.  Dehydration/dry skin

Treatment

a.  Desmopressin acetate (DDAVP) nasal spray

b.  Vasopressin tannate (Pitressin Tannate) in Oil (IM for chronic severe cases)

c.  Lypressin (diapid) nasal spray

Nursing Interventions

1.  Maintain adequate fluids

2.  Avoid foods with diuretic-type action

3.  Monitor intake and output: report any changes; can sometimes have 800mL output per hour

4.  Daily weights

5.  Specific gravity (should be greater that 1.004)

2.  Syndrome of Inappropriate Antidiuretic Hormone (SIADH)-  inappropriate, continued release of antidiuretic hormone resulting in water intoxication; caused by neoplastic tumors, respiratory disorders, drugs

Manifetstions

a.  Mental confusion/irritability

b.  Lethargy/seizures

c.  Dilutional hyponatremia

d.  Weight gain

e.  Anorexia, nausea and vomiting

f.  Weakness

Treatment

a.  Fluid restriction (less than 500 mL/24 hrs) with hypertonic solutions to treat the hyponatremia

2.  Strict intake and output

3.  Treat underlying cause (surgery, radiation, chemotherapy)

4.  diuretics

5.  Daily weight

Adrenal Gland

Disorders of Adrenal Cortex

1. Addison’s disease- hyposecretion of adrenal cortex hormones, (insufficiency of cortisol, aldosterone and androgen); discontinuing steroid medication abruptly without weaning off them

Causes

1)     Autoimmune or idiopathic atrophy of the adrenal glands

2)     Surgical removal of Adrenal glands

3)     Infection ( Tuberculosis , Histoplasmosis)

4)     Decreased ACTH

Manifestations

a.  Slow, insidious onset

b.  Malaise and generalized weakness from increased potassium restriction

c.  Hypotension, hypovolemia from increased sodium excretion

d.  Increase pigmentation of the skin- “eternal tan”

e.  Anorexia, nausea, vomiting

f.  Electrolyte imbalance (hyponatremia, hyperkalemia)

g. Weight loss

h. Loss of libido

i.  Hypoglycemia

j.  Personality changes

Treatment

a.  Lifelong steroid replacement; hydrocortisone (Florinef); complications of long-term steroid therapy include osteoporosis

b.  High protein, high carbohydrate diet may increase sodium intake ( low potassium intake)

c.  Monitor fluid and electrolytes routinely

d.      Decrease emotional and physical stress

Nursing Interventions

a.  Observe for Addisonian crisis (sudden extreme weakness; severe abdominal, back and leg pain; hyperpyrexia; coma; death)

b.  Observe for side effects of hormone replacement

c.   Provide emotional support

d.  Teaching (lifelong medications, prompt treatment of infection, illness, stress management)

e.  Monitor fluid and electrolyte balance regularly

NCLEX- Common Complication is Shock

CGFNS – Initial manifestation , Hypotension, Bronze skin.

2.  Cushing’s Syndrome-  hypersecretion of the glucocorticoids; overdose of steroid medications

Manifestations

a.  Central-type obesity, moon face, buffalo hump and obese trunk with thin extremities

b.  Mood swings

c.  Malaise and muscular weakness (increase preotein catabolism)

d.  Masculine characteristics in females (hirsutism)

e.  Hypokalemia (may cause arrythmias)

f.  Hyperglycemia (insulin resistant)

g.  Hypertension (edema; may lead to CHF or CVAs)

h.  Acne (striae on chest, abdomen, legs)

i.  Amenorrhea

j.  Osteoporosis; thin skin with ecchymosis

k.  Increased susceptibility to infections

l. Peptic ulcer

Treatment

a.  Adrenalectomy: unilateral or bilateral

b.  Chemotherapy:  bromocriptine (Parlodel) ; mitotane (Lysodren), or aminoglutethimide (Cytadren)

c.  High-protein, low-carbohydrate, low sodium diet with potassium supplement

Nursing Interventions

a.  Protect from infection

b.  Protect from accidents and falls due to osteoporosis

c.  Client education concerning lifelong self-administration of hormone suppression therapy

Steroid replacement (similar to Cushing’s syndrome but in lesser effect)

Purpose:

a.  anti-inflammatory and anti-allergic reaction

b.  Enables one to tolerate high degree of stress

Indications:

a.  Crisis (fro ex. Shock, bronchial obstruction)

b.  Long-term therapy (for ex. Post-adrenalectomy, arthritis, leukemia)

3.  Aldosteronism (Conn’s syndrome)- hypersecretion of aldosterone from adrenal cortex (usually due to tumor)

Manifestations:

a.  Hypokalemia and hypernatremia

b.  Hypertension from hypernatremia

c.  Muscle weakness and cardiac problems related to hypokalemia

Treatment

a.  Surgical removal of tumor/adrenal gland

b.  Potassium replacement

c.  Antihypertensive drugs: spinolactone (Aldactone)

Nursing Interventions

a.  Provide quiet environment

b.  Monitor BP and cardiac activity

c.  Monitor potassium level

Disorders of Adrenal Medulla

1.  Pheochromocytoma- hypersecretion of the hormones of adrenal medulla (exact cause unknown)

Manifestations (sudden onset): seen in young women and men

a.  Hypertension (principal manifestation): very high crisis

b.  Sudden attackes resemble manifestations of overstimulation of sympathetic nervous system

-         Sweating

-         Apprehension

-         Palpitations

-         Nausea

-         Vomiting

-         Orthostatic hypotension

-         Headache

-         Tachycardia

c.  Hyperglycemia

Treatment

a.  Surgical excision of tumor or adrenal gland

b. Symptomatic if surgery not feasible

Nursing Interventions:

a.  Provide high-calorie, nutritious diet (avoid caffeine)

b.  Preoperative:  control hypertension

Thryroid Gland

Disorders of Thyroid Gland

1.  Myxedema: hyposecretion of throid hormone in adulthood; highest incidence between ages 50 & 60; more often in women

Manifestations

a.  Slow rate of metabolism

b.  Personality changes (depression)

c.  “Dull” appearance

d.  Anorexia and constipation

e.  Intolerance to cold

f.  Decreased sweating

g.  Hypersensitivity to barbiturates and narcotics

h.  Generalized interstitial edema

i.  Husky voice from swelling of vocal cords

j.  Coarse, dry skin

k.  Thin hair

l.  Generalized weakness

m.  Goiter

n.  Weight gain

o. puffy appearance (nonpitting)

p. Anemia

q.  Increased cholesterol and lipids

r.  Menstrual disorders in women

Treatment: drug therapy:  Levothyroxine (Synthroid)

a.  Thyroid replacement hormones should be taken on an empty stomach

b.  Monitor heart rate: fewer than 100 beats per minute is desirable; monitor for cardiac symptoms of angina at initiation of therapy

Nursing Interventions

a.  Directed toward manifestations of decreased metabolism

-         provide warm environment

-         Low-calorie, low cholesterol, low saturated fat diet

-         Increase roughage

-         Moderate fluids

-         Avoid sedatives

-         Plan rest periods

-         Weigh client

b.  Observe for overdosage manifestations of thyroid preparations

2.  Cretinism- hyposecretion of thyroid hormones in the fetus or neonate

-         diagnosed shortly after birth thru newborn screening

-         can lead to severe, irreversible mental retardation, if not treated

-         requires lifelong hormone replacement therapy

3.  Hyperthyroidism (Grave’s disease, diffuse toxic goiter)-  hypersecretion of thyroid hormone; over treatment of hypothyroidism

Manifestations

a.  Increased rate of body metabolism

b.  Personality changes

c.  Enlargement of the thyroid gland

d.  Exopthalmos (never goes away)

e.  Cardiac dysrhytmia and hypertension

f.  Increased appetite (but weight loss)

g.  Diaerrhea

h.  Diaphoresis and heat intolerance

i.  Easy fatigability

j.  Anxiety/insomnia

k.  Nervous appearance

l.  Amenorrhea

Treatment

a.  Drug therapy

1.      Methimazole (Tapazole): blocks thyroid hormone production

2.      Propylthiouracil (Propyl-Thyracil): blocks thyroid hormone production

-         can cause agranulocytosis

-         client must have frequent CBCs performed

3.      Iodides: decrease vascularity; inhibit release of thyroid hormones

-         Lugol’s solution ( use is decreasing because this medication is expensive and inactivates thyroid medications in the bowel)

-         Saturated solution of potassium iodide (SSKI); use prior to thyroidectomy

4.      Propanolol (inderal); relief of tachycardia

b.  Radioiodinetherapy: slowly destroys hyperfunctioning thyroid tissue

c.  Thyroidectomy: subtotal or total

Nursing Interventions:

a.  Provide adequate rest

b.  Provide cool, quiet environment

c.  Provide high calorie (4000-5000 cal.day), high protein, carbohydrate, vitamin diet without stimulants, extra fluids

d.  Weigh client daily

e.  Provide emotional support; activities

f.  Provide eye protection: ophthalmic medicine; tape eyes at night; decrease sodium and water

g.  elevate head of bed

h.  Be alert for complications

-         corneal abrasion

-         heart disease

-         Thyroid Storm (usually occurs after thyroid surgery)

Thyroidectomy- removal of the thyroid gland, either total or partial

Nursing Interventions

a.  Semi-Fowler’s position

b.  Check dressing esp. back of neck

c.  Observe for repiratory distress; tracheostomy tray, oxygen and suction apparatus at bedside

d.  Be alert for signs of hemorrhage

e.  Talking limited, note any hoarseness; may indicate injury to laryngeal nerve

f.  Observe for signs of tetany: Chvostek’s sign and Trousseau’s sigh (parathyroid glands may accidentally be removed)

g.  Calcium gluconate IV at bedside

h.  Observe for Thryoid Storm (life threatening)

-         Fever

-         Tachycardia

-         Delirium

-         Irritability

-         Important to assess temperature routinely

-     gradually increase range of motion to neck; support when sitting up

Parathyroid Gland

Disorders of Parathyroid Gland

1.      Hypoparathyroidism- hyposecretion of the parathyroid hormone; accidental removal during thyroid surgery

Manifestations

a.  Hypocalcemia

b.  Acute: increased neuromuscular irritability tetany (positive Chvostek and positive Trousseau)

c.  Chronic:

-         Poor development of tooth enamel

-         Lethargic

-         Thin hair; brittle nails

-         Mental retardation

-         Circumoral paresthesia with numbness and tingling of fingers

Treatment

a.  Acute:  IV Calcium Gluconate

b.  Chronic:

-         oral calcium salts

-         Vitamin D and aluminum hydroxide gel (Amphojel)

-         High calcium, low phosphorous diet

Nursing Interventions

a.  Provide quiet room, no stimulus

b.      Assess for increased signs of neuromuscular irritability

2. Hyperparathyroidism (causes are tumor or renal disease)- hypersecretion of parathyroid hormone

Manifestations (causes loss of calcium from the bones to the serum)

a.  Bone deformities (susceptible to fractures

b.  Calcium deposits in various body organs

c.  Hypercalcemia

d.  Gastric ulcers and GI disturbances

e.  Apathy, fatigue, weakness, depression

f.  Nausea, vomiting, anorexia

g.  Constipation, abdominal pain

h.  Joint and bone pain

i.  Polyuria

j.  Polydipsia

k.  Azotemia

l.  Hypertension

Treatment

a.  Subtotal surgical resection of parathyroid gland

b.  Hydration and diuretics- furosemide (Lasix) excretes excess calcium

c.  Plicamycin (Mithracin) or gallium nitrate (Ganite)

Nursing Interventions

a.  Force fluids

b.  Provide a low-calcium, low Vit. D diet

c.  Prevent constipation and fecal impaction

d.  Strain all urine

e.  Safety measures to prevent breaks

f.  Calcitonin; binds phosphate; in renal failure

PITUITARY GLAND: HORMONES PRODUCED AND FUNCTIONS

- controlled primarily by the hypothalamus; termed “master gland” as it directly affects the function of other endocrine glands

Anterior Lobe

1. Adrenocorticotropic hormone (ACTH)- concerned with growth and secretory activity of adrenal cortex, which produces steroids
2. Thyrotropic hormone (TSH) – for growth and secretory activity of thyroid; controls release rate of thyroxine, which controls rate of most chemical reaction in the body; target is thyroid gland
3. Somatotropic hormones (STH or GH)-  promote growth of body tissue
4. Gonadotropic hormones and estrogen secretion; follicle stimulating hormone (FSH)-  stimulate development of ovarian follicles; semeniferous tubules and sperm maturation
5. Luteinizing hormone (LH)- works with FSH in final maturation of follicles; promotes ovulation and progesterone secretion
6. Prolactin-  for milk production
7. Melanocyte stimulating hormone (MSH)- produces the characteristic skin darkening

Posterior Lobe

1. Vasopressin (ADH)- influnces water absorption by kidney
2. Oxytocin-influences the menstrual cycle, labor and lactation