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  1. 1. Disorders of the Endocrine system
  2. 2. Review Of Anatomy/Physiology Of The Endocrine Glands  The endocrine system is made up of glands and the hormones they secrete.  Although the endocrine glands are the primary hormone producers, the brain, heart, lungs, liver, skin, thymus, gastrointestinal mucosa, and placenta also produce and release hormones.
  3. 3.  The primary endocrine glands are the pituitary (the master gland), pineal, thyroid, parathyroid, islets of Langerhans, adrenals, ovaries in the female and testes in the male.  The function of the endocrine system is the production and regulation of chemical substances called hormones.  A hormone is a chemical transmitter. It is released in small amounts from glands, and is transported in the bloodstream to target organs or other cells.  Hormones are chemical messengers, transferring information and instructions from one set of cells to another.
  4. 4.  Hormones regulate growth, development, mood, tissue function, metabolism, and sexual function.  Hyposecretion or hypersecretion of any hormone can be harmful to the body.  Controlling the production of hormones can treat many hormonal disorders in the body.
  5. 5. The endocrine system and nervous system work together to help maintain homeostasis… balance. The hypothalamus is a collection of specialized cells located in the brain, and is the primary link between the two systems. It produces chemicals that either stimulate or suppress hormone secretions of the pituitary gland.
  6. 6. Anterior Pituitary Gland ● Growth Hormone (GH)- affects growth of skeletal muscles and bones ● Prolactin (PRL)- stimulates milk production after pregnancy ● Gonadotropic- regulates hormone activity of sex organs ● Also effects adrenal cortex and thyroid hormone release
  7. 7. Posterior Pituitary ● Oxytocin- helps during pregnancy ● Antidiuretic hormone (ADH)- inhibits urine production ● Alcohol inhibits ADH causing increased output of urine
  8. 8. Growth Hormone (GH):Essential for the growth and development of bones, muscles, and other organs. It also enhances protein synthesis, decreases the use of glucose, and promotes fat destruction. Over secretion of growth hormone: Giantism in childhood Acromegaly in adults (with large bones of face, hands and feet ). Under secretion of growth hormone: Dwarfism in childhood
  9. 9. Adrenocorticotropin (ACTH): Essential for the growth of the adrenal cortex. Thyroid-Stimulating Hormone (TSH):Essential for the growth and development of the thyroid gland.
  10. 10. Follicle-Stimulating Hormone (FSH):is a gonadotropic hormone. It stimulates the growth ovarian follicles in the female and the production of sperm in the male.
  11. 11. Luteinizing Hormone(LH):is a gonadotropic hormone stimulating the development of corpus luteum in the female ovarian follicles and the production of testosterone in the male. Prolactin (PRL):stimulates the development and growth of the mammary glands and milk production during pregnancy.
  12. 12. Melanocyte-stimulating hormone (MSH): regulates skin pigmentation and promotes the deposit of melanine in the skin after exposure to sunlight.
  13. 13. Antidiuretic Hormone (ADH): stimulates the reabsorption of water by the renal tubules. Hyposecretion of this hormone can result in diabetes insipidus. Oxytocin: stimulates the uterus to contract during labor, delivery, and parturition. A synthetic version of this hormone, used to induce labor, is called Pitocin. It also stimulates the mammary glands to release milk.
  14. 14. The islets of Langerhans are small clusters of cells located in the pancreas. Langerhans. Alpha cells facilitate the breakdown of glycogen to glucose. This elevates the blood sugar. Beta cells secrete the hormone insulin, which is essential for the maintenance of normal blood sugar levels. Inadequate levels result in diabetes mellitus.
  15. 15. Assessment 24 History Changes in energy level T olerance to heat or cold Weight Fat and fluid distribution, Secondary sexual characteristics Sexual dysfunction Memory Concentration Sleep patterns Mood
  16. 16. History… The healthhistoryinformation should include: 1. The severityofthesechanges 2. The lengthoftimethepatienthas experienced thesechanges 3. The wayinwhichthesechangeshave affectedthepatient’ s abilityto carryout ALD 4. The effectofthechangeson thepatient’ s self-perception 25
  17. 17. Physical Exam • Vitalsigns • Visualhead-to-toeassessment • T actileexamination • Appearanceoffacialhairinwomen • “moonface,” • “buffalohump,” • Exophthalmos 26
  18. 18. Physical Exam … • Edema • Thinning of theskin • Obesity of the trunk • Thinness of theextremities • Increasedsize of the feet and hands • Elevated/Decaresed blood pressure • Behavioral changes such as agitation, nervousness, a flat affect, or a lack of concern about personal appearance
  19. 19. Endocrine-related Problems 28 1. Overproduction of ahormone 2. Underproduction of ahormone 3. Nonfunctional receptors that cause target cells to become insensitiveto hormones
  20. 20. Disorders of the islets of Langerhans The pancreatic islets also called “islets of Langerhans” or island of Langerhans are the regions of the pancreas that contain its endocrine (i.e., hormone producing) cells. The most common islet cell the Beta cell. Insulin is the major hormone in the regulation of carbohydrates, fat, and protein metabolism.
  21. 21. Cont.… There are three main types of cells in the pancreatic islets.  (alpha) 20 % cells that secrete “glucagon”.  (beta) 75% cells that secrete “insulin”.  (delta) 5% cells that secrete “somatostatin”.
  22. 22. INSULIN A hormone produced in the pancreas by the islets of Langerhans, which regulates the amount of glucose in the blood.  The lack of insulin causes a form of diabetes mellitus. The main function of insulin is to lower blood levels of absorbed nutrients when they rise above normal.
  23. 23. GLUCAGON A hormone formed in the pancreas which promotes the breakdown of glycogen to glucose in the liver and assist insulin in regulating blood glucose in the normal range. 1.Gluconeogenesis:The synthesis of glucose from noncarbohydrate source ( such as amino acids & glycerol) 2.Glycogenolysis:Glycogen breakdown releases glucose when it is needed.
  24. 24. SOMATOSTATIN SOMATOSTATIN (GHRIH) Also known as growth inhibiting hormone. The effect of this hormone, also produced by the hypothalamus, is to inhibit the secretion of both insulin and glucagon.
  25. 25. Diabetes mellitus Diabetes mellitus is characterized by chronic hyperglycemia due to inadequate insulin secretion and/or the effectiveness of endogenous insulin (insulin resistance). Diabetes mellitus is a contributing factor to development of cardiovascular disease, hypertension, kidney disease, neuropathy, retinopathy, peripheral vascular disease and stroke as individuals age.
  26. 26. Cont.… Type 1 diabetes mellitus is an autoimmune dysfunction involving the destruction of beta cells, which produce insulin in the islets of Langerhans of the pancreas. Immune system cells and antibodies are present in circulation and may also be started by certain genetic tissue types or viral infections.
  27. 27. Cont… Type 1 diabetes mellitus usually occurs at a young age, and there are no successful interventions to prevent the disease. Type 2 diabetes mellitus is a progressive condition due to increasing inability of cells to respond to insulin (insulin resistance) and decreased production of insulin by the beta cells. It often occurs later in a client’s life due to obesity, inactivity, and heredity.
  28. 28. Risk Factors  Family history of diabetes  Obesity (BMI > 27 k/m2)  Race  Age ≥ 45 years  Previously identifiedimpaired fasting glucose or impaired glucose tolerance  Hypertension (≥ 140/90mmhg)  HDL cholesterol level≤ 35 mg/dL(0.9mmol/l) and /ortriglyceride levelof ≥ 250mg/dL (2.8 mmol/L)  History of gestational diabetes or delivery ofbabies over 9lbs (4 Kg)
  29. 29. DM Classification 1. Type1 diabetes(previouslyreferredto as insulindependent diabetes(IDD) 2. Type2 diabetes (previouslyreferredto as non-insulindependent diabetes(NIDD) 3. Gestationaldiabetes 4. Diabetes mellitusassociatedwith other conditions or syndrome
  30. 30. Type 1 Diabetes (T1D) T1Discharacterizedbydestructionofthe pancreaticbetascells Factorscontributingtobetacelldestruction:  Genetic(common)  Immunologic  Environmental(e.g.,viral)
  31. 31. Type 2 Diabetes (T2D)  Accountsforapproximately90to95%ofcases  Results from decreased sensitivity of tissues to insulin (called insulin resistance) & impairedβ-cellfunctioningresultingindecreasedinsulinproduction  MostpeoplewithT2Dareobeseadults>40yrsofage  Obesity appears to play a major role in T2Dby down regulating insulinreceptors in skeletal muscleandfat cells  Peripheralinsulinresistance  Stimulatesincreasedinsulinproductionasacompensatory response,whichmay alsopredisposethepatienttoweight gain.
  32. 32. Cont.…  The exact mechanisms that lead to insulin resistance and impaired insulin secretion in T2Dareunknown,althoughgeneticfactorsarethoughttoplayarole  Prevalenceofdiabetesincreaseswithage, withabout half ofcasesinpeopleolderthan55  Despite the impaired insulin secretion that is characteristic of T2D, there is enough endogenousinsulinpresent, topreventlipolysisandproductionof ketenebodies Therefore,diabeticketoacidosis(DKA)doesnottypicallyoccurinT2D
  33. 33. SIGNS AND SYMPTOM ⚫ Hallmarksymptomsof all typesof DMarethe3Ps: • Polyuria • Polydipsia • Polyphagia
  34. 34. SIGNS AND SYMPTOM Type I: • Fast onset because no insulin is being produced • Increased appetite (polyphagia) because cells are starved for energy • Increased thirst (polydipsia) from the body attempting to rid itself of glucose • Increased urination (polyuria) from the body attempting to rid itself of glucose • Weight loss since glucose is unable to enter cells • Frequent infections as bacteria feeds on the excess glucose • Delayed healing because elevated glucose levels in the blood hinders healing process
  35. 35. Cont.… Type II: Slow onset because some insulin is being produced Increased thirst (polydipsia) from the body attempting to rid itself of glucose Increased urination (polyuria) from the body attempting to rid itself of glucose infection as bacteria feeds on the excess glucose Delayed healing because elevated glucose levels in the blood hinder the healing process
  36. 36. Diagnosis 47 • History- personal,family,symptoms • Physicalexamination • Neurology examination • Lab tests
  37. 37. cont.… 52 ⚫ Serumglucose ⚫ Serumacetone(ketones) ⚫ Electrolytes ⚫ Arterialbloodgases(ABGs) ⚫ CBC ⚫ RFT
  38. 38. Dx … BloodT ests A.FastingBloodglucose(IBG)test ⚫ Mostaccuratewhenthetestisperformedonbloodobtainedinthemorningbyvein-puncture ⚫ Theclientshouldbefastingforatleast8hours(W aterispermitted) BGL (mg/dL) Indication ≤99 Normal 100 to 120 Pre-diabetic (impaired fasting glucose) 126 and above Diabetes * Confirmed by repeating the test on a different day
  39. 39. Dx … B.OralglucoseT oleranceT est(OGTT) ◦ Most sensitive test for the of diabetes ◦ Lessconvenient thanFBGtest ◦ Performedinthemorningafter 10-12hourfast BGL (mg/dL): After 2hrs Indication 139 and below Normal 140 to 199 Pre-diabetic (impaired glucose tolerance) 200 and above Diabetes* * Confirmed by repeating the test on a different day
  40. 40. Dx … C.RandomplasmaGlucoseT est(RPG) ⚫ RPGlevelof200mg/dLplusthe3Psandunexplainedweightlossindicatesdiabetes D.GlycosylatedHemoglobinassays(HbAsc) ⚫ HbAscisthebestindicatoroftheaverageBGLinthelast 120days ⚫ NormalrangeofHbA1cinadultsis4%-6% ⚫ Levelsover8%indicatespoordiabeticcontrol E.Electrolytes,BUNandserumcreatinine
  41. 41. Criteria for the of DM (especiallyT2D) I. Symptomsofdiabetespluscasual BGL≥200mg/dL Theclassicsymptomsofdiabetesincludethe3Ps II. Fasting plasmaglucose≥126mg/dL(7.0mmol/L) Fastingisdefinedasnocaloricintakeforatleast 8 hours III. 2-hourpostloadglucose≥200mg/dL(11.1mmol)duringanoral glucosetolerancetest.Thetestshouldbeperformedusinga glucoseloadcontainingtheequivalent of75gglucosedissolvedin water
  42. 42. Diabetes Management The main goal of diabetes treatment is to normalize insulin activity and blood glucose levels to reduce the development of vascular and neuropathic complications. There are five components of diabetes management which are equally important
  43. 43. Objective of treatment  Relieve symptoms  Prevent acute hyperglycemic complications  Prevent chronic complications of diabetes  Prevent treatment-related hypoglycemia  Achieve and maintain appropriate glycemic targets Ensure weight reduction in overweight and obese individuals
  44. 44. 1. Nutritional therapy
  45. 45. 1. Nutritional therapy 57  Nutrition, meal planning, and weight control are the foundation of diabetes management  Thegoals of nutritional managementinclude: • Providingall theessentialfoodconstituents necessary for optimal nutrition • Meeting energy needs • Achieving and maintaining reasonable weight • Preventingwidedailyfluctuations inbloodglucose levels • Decreasing serum lipid levels, if elevated
  46. 46.  For obese diabetic patients (especially with T2D) weight loss is the key to treatment  Ingeneral - overweight is considered to be a BMI of 25-29  Obesity is defined as 20%above a BMI equalto or greater than 30  Theuse of fiber diets:  Soluble (legumes, fruits)  Insoluble (whole grain breads and serials) plays a role in lowering total cholesterol and low density lipoprotein cholesterol in the blood 58
  47. 47. 2.Exercises Exercise is extremely important in managing diabetes because it lowers the BGL by: Increasing the up take of glucose by body mussels and Improving insulin utilization
  48. 48. Cont.… Exerciserecommendations  People with diabetes should exercise at the same time (preferably whenbloodglucoselevelsareat their peak) andinthesameamount eachday  Aslow,gradualincreasein theexerciseperiodis encouraged  Formanypatients, walking isasafeand beneficial formof exercise.
  49. 49. Whocanexercise(ADARecommendations)Thosewith; A.Bloodglucose lessthan250 mg/dl B. Nosymptomsof retinopathy C. Noneuropathy D.NoNephropathy E. Nocardiovascular problemssuchasangina, embolism,or aneurysm F. Noother condition that makesexercise inadvisable
  50. 50. Generalprecautionsforexercisein Diabetes Avoid exercise during periods of poor metabolic control Inspect feet daily after exercise Avoid exercise in extreme cold or heat Use proper foot wear and if appropriate, other protective equipment
  51. 51. 3. Monitoring Glucose levels and ketones Blood glucose monitoring is a cornerstone of diabetes management, and self-monitoring of blood glucose (SMBG) levels has dramatically altered diabetes care.
  52. 52. 4. Pharmacologic Therapy  Includestreatmentwithinsulinor oral anti-diabeticagents  Decisions in drug treatment should be based primarily on the typeof diabetes andthegoals for glycoliccontrol.
  53. 53. InsulinTherapyandPreparations ⚫ Because the body losses the ability to produce insulin in T1D, exogenous insulin must be administeredforlife. ⚫ InT2D,insulinmaybenecessary:  Onalongtermbasistocontrolglucoselevelsifdiet andoralagentsfail  ForsomepatientsinwhomT2Disusuallycontrolled bydietaloneorbydietandoral agentspatientsmay requireinsulintemporaryduring:  Infection  Pregnancy  Surgery, or  Someotherstress-full events.
  54. 54. Cont.… Insulinaction The main action of insulin is to stimulate carbohydrate metabolism by increasing the movement of glucose and other monosaccharide in to the cells of muscle, fat, andliver. Once insulin binds with receptors on the cell membrane, glucose can move intothecell,promotingcellularmetabolismandenergyproduction.
  55. 55. Cont.… Anumberof insulinpreparationsareavailableTheyvaryaccordingtothree (3)main characteristics: 1. Timecourseofaction, 2. Species(source)and 3. Manufacturer
  56. 56. Suggested insulin injection site
  57. 57.  Insulin regimen in type 1 Diabetes Mellitus  1. Conventional insulin therapy-describes simpler non- physiologic insulin regimens, such as single daily injections, or two injections per day (including a combination of regular or short-acting and NPH insulin)  2. Intensive insulin therapy-describes treatment with three or more injections per day or with continuous insulin infusion with an insulin pump.
  58. 58.  Intensive insulin therapy requires: - Monitoring blood sugar before breakfast (fasting), before lunch, before dinner & before bed.  Counting and recording carbohydrates.  Adjusting insulin doses in response to given glucose patterns. - Coordinating diet, exercise, and insulin therapy.  Responding appropriately to hypoglycemia
  59. 59.  Designing insulin therapy Total insulin dose per day Initiation, 0.2 to 0.4 units/kg/day Maintenance – highly variable roughly 0.6 to 0.7 units/kg/day Regimen options-with NPH and regular insulin (commonly available in Ethiopian setting) 1. NPH twice daily injection – before breakfast and at bed time and Regular Insulin twice daily injection-before breakfast and before dinner 2. 70/30 (70% NPH & 30% regular) twice daily injection-before breakfast and before dinner 3. NPH twice daily injections – before breakfast and before bedtime
  60. 60. ADVERSE REACTIONS Of INSULIN Thetwomajoradversereactionsseenwithinsulinadministrationare: 1.Hypoglycemia, occurswhen:  Thepatient eatstoolittlefood  Theinsulindoseisincorrectlymeasuredandisgreaterthanthatprescribed  Thepatient drasticallyincreasesphysical activity 2.Hyperglycemia, occurswhen:  Thepatient eatstoomuchfood  T oolittleor noinsulinisgiven  Thepatientexperiencesemotionalstressinfection,surgery, pregnancy , or anacuteillness
  61. 61. Complications of InsulinTherapy 77 1. Local allergicreactions Rx- antihistamine1hourbeforetheinjection 2. Systemicallergicreactions Rx- desensitization 3. Insulinlipdystrophy LipoatrophyandLipohypertrophy Mgt-Rotationof injectionsites
  62. 62. Complications of InsulinTherapy… 4. InsulinResistance • Mostcommonlyoccursbecauseof obesity , whichcanbeovercomebyweight loss • Clinicallydefinedasadailyinsulin requirementof200unitsor more Rx • Moreconcentratedinsulinpreparation, suchas U500 • Occasionally , prednisonetoblocktheproduction of antibodies
  63. 63. OralAnti-diabeticAgents  May be effective for patients who have T2D that cannot be treated by diet and exercise alone  Cannot be used during pregnancy  May also be used with insulin in the management of some patients withT2D  Use with insulin may decrease the insulin dosage in some individuals
  64. 64. Cont.… Metformin – the first line medicine for initiation of therapy if intolerant to metformin or have a contraindication to it, sulfonylureas can be the initial treatment medicine.  Metformin, 500mg, P.O.daily with meals. Titrate dose slowly depending on blood glucose
  65. 65. Cont.… Glibenclamide, 2.5mg-5mg, P.O.daily 30 minutes before breakfast. Titrate dose slowly depending on HbA1c and/or fasting blood glucose levels to 15mg daily.  When 7.5mg per day is needed, divide the total daily dose into 2, with the larger dose in the morning.  Avoid in the elderly and patients with renal impairment.
  66. 66. 5.Patient Education 🢅 Nutrition 🢅 Medication effects and side effects 🢅 Exercise 🢅 Disease progression 🢅 Prevention strategies:blood glucose monitoring techniques,and medication adjustment 🢅 T eaching survival skills Basic definitions of insulin T reatment modalities Recognition,treatment,and prevention of acute complications 🢅 Preventive measures of long term complications
  67. 67. Pt educationCont’d… Teaching patients to self administer insulin 🢅Storing insulin 🢅Selecting syringes 🢅Preparing the injection mixing insulins 🢅With drawing insulin 🢅Selecting and rotating the injection site 🢅Preparing the skin.Alcohol is not recommended for cleansing 🢅Inserting the needle 🢅Aspiration is generally not recommended
  68. 68. Acute Complications of Diabetes There are three major acute complications of diabetes related to short-term imbalances in bloodglucose levels: a. Hypoglycemia b. Diabeticketoacidosis/ DKA, and c. Hyperglycemichyperosmolarnon-ketotic syndrome/HHNS, which is also called hyperglycemic hyperosmolar syndrome or state
  69. 69. 1.Hypoglycemia (Insulin Reactions) ⚫ OccurswhentheBGLsfallsto<50to60mg/dL(2.7to 3.3mmol/L) Causes ⚫ T oo much insulin or OHAs ⚫ T oo little food ⚫ Excessive physical activity Often occurs before meals, especially if meals are delayed or snacks are omitted
  70. 70. Hypoglycemia Clinical manifestations i. Mildhypoglycemia Stimulationof sympathetic nervous systemresultingina surgeof epinephrine and norepinephrine  Inturnresultsin: Sweating Tremor Tachycardia Palpitation Nervousness Hunger TheC/Msarebecause of: 1. Adrenergic stimulation 2. Effect of hypoglycemiaon CNS
  71. 71. Hypoglycemia C/Ms Cont’d ii. Moderatehypoglycemia • DropinBGLdeprives thebraincellsof neededfuel for functioning • Signsof impairedfunctionof theCNSmayinclude:  Inability toconcentrate  Headache,Light headiness,  Confusion, Memoryloses,  Slurredspeech,  Double vision  Drowsiness,  Numbnessof thelips anN do v e tm ob ne r g1 6 u,2 e0 1 5 Adrenergic symptom: Sweating Tremor Tachycardia Palpitation Nervousness +
  72. 72. Hypoglycemia C/Ms Cont’d iii. Sever hypoglycemia Resultsin: ImpairedCNSfunctions Disorientedbehavior Seizures, Difficultyarousingfromsleep, and Lossof consciousness
  73. 73. Management By:Fikadu B.JU 95 A.Immediatetreatmentwithcarbohydrate  Theusual recommendation isfor 15gof afast-acting concentratedsourceofcarbohydratesuchasthe following, givenorally: A. Threeor four commercially prepared glucosetablets B. 100-150ml of fruit juiceor regular soda C. 6to10hardcandies D. 2to3teaspoons of sugar or honey NursingAlert: To prevent sharp increase in BGL, it is not necessary to add sugar to juice, even if it is labeled as unsweetened juice: the fruit sugarin juicecontainsenough carbohydrateto raisethe BGL
  74. 74. Management Immediatetreatmentwithcarbohydrate… • TheBGLshouldberetested in 15minutesandretreatedif it isless than70to75mg/dL(3.8 to4mmol/L) • If thesymptomspersistforlongerthan10to15minutesafterinitial treatment, thetreatmentis repeated • Oncethesymptomsresolve,asnackcontainingproteinandstarch (eg,milk orcheeseandbananas/crackers) isrecommendedunless thepatientplanstoeataregular meal or snackwithin30to60 minutes
  75. 75. Management Immediatetreatment withcarbohydrate… B.InitiatingEmergencyMeasures Glucagoninjection: Hasanonsetof 8to 10minutes, andits action lasts12to27minutes Foradults whoareunconsciousandcannotswallow,aninjectionof glucagon1mgcanbeadministered either subcutaneouslyor intramuscularly Afterinjection of glucagon,thepatient maytakeaslongas20 minutesto regainconsciousness
  76. 76. Management Immediatetreatmentwithcarbohydrate… Aconcentratedsourceof carbohydrate: • Shouldbegiventothepatientonawakeningto preventrecurrenceof hypoglycemiafollowedbyasnack • 50%/40%Dextroseinwater (D50W/D40W) • 🗸 Forpatientswhoareunconsciousorcannot swallow • 🗸 25to50mLof 50%/40%dextroseinwater may beadministeredIV • 🗸Theeffectisusuallyseenwithinminutes
  77. 77. C.ProvidingPatientEducation  Consistentpatternofeating,administeringinsulin,and exercising  Between-mealandbedtimesnacksmaybeneededtocounteractthemaximuminsulineffect  Thepatient should cover the time of peakactivity of insulin byeating asnackandbytaking additionalfoodwhenphysical activityisincreased  Routinebloodglucosetests to anticipate change insulinrequirementsandtoadjust the dosage
  78. 78.  T oprevent unexpected hypoglycemia all patients treated with insulin should wearanidentification braceletortagstatingthat theyhavediabetes  Symptomsofhypoglycemia  Patientswithdiabetes,especially thosereceiving insulin,learntocarrysomeformof simplesugarwith themat all times  Advisingtorefrainfromeatinghigh-calorie,high-fat dessert foods(eg,cookies, cakes, icecream)totreat hypoglycemiabecausetheirhighfatcontentmayslow theabsorptionoftheglucoseandresolutionofthe hypoglycemicsymptoms
  79. 79. Diabetic Ketoacidosis (DKA) Definition • DKA is a metabolic derangement in T1D that is caused by an absence or markedly inadequate amount of insulin • Insulin deficiency results in disorders in the metabolism of carbohydrate,protein, and fat
  80. 80. DKA Causes: 84 Threemaincauses: 1. Decreased or misseddoseor deficiencyof insulin causedby: An insufficient dosageof insulin prescribed An insufficient insulin being administered bythepatient Patient error in drawing upor injecting insulin Intentional skipping of insulin doses Equipment problems 2.Illnessor infection 3. Undiagnosedanduntreateddiabetes
  81. 81. DKA Causes …  Illnessesandinfections areassociatedwith insulin resistance  Inresponsetophysical(andemotional)stressors, thereis anincrease in thelevel of “stress”hormones:  Glucagon,  Epinephrine, norepinephrine,  Cortisol, and  Growthhormone Thesehormonespromoteglucose productionbytheliver and interferewith glucoseutilizationby muscleandfat tissue
  82. 82. DKA: Pathophysiology Thethreemainclinical featuresofDKAare: 1. Hyperglycemia 2. Dehydrationandelectrolyteloss 3. Acidosis
  83. 83. DKA: Diagnosis  BGLs may vary from 250 to 800mg /dL  Serum Bicarbonate 0-15mq/L  PH 6.8-7.3  PaCO2 10-30mmHg – Respiratory compensation  Increased creatinine  Increased BUN  Increased hematocrite
  84. 84. DKA: Prevention  If DKA is related to illness,teach the patient about “Sick day” rules for managing their diabetes when ill  Assess diabetic self management skills including blood glucose testing and insulin administration  If insulin dose is intentionally altered, psychological counseling is recommended for patients and family members
  85. 85. DKA: Medical Management T reatment Goals: 1. T reating hyperglycemia 2.Correcting dehydration 3. Maintaining electrolyte balance 4.Reversing acidosis
  86. 86. HHNS Is ametabolic disorderofT2Dresulting fromarelativeeffective insulin deficiency (i.e., Insulin resistance) initiatedbyaninter- currentillness that raises the demandfor insulin,associated with polyuria andseverdehydration.  Occurs most often in older people (50 to 70 years of age) who havenoknownhistoryof diabetesor who havetype2diabetes
  87. 87. Hyperosmolalityandhyperglycemiaarepredominant The patient’s persistent hyperglycemia causes osmotic diuresis, resulting in losses of waterandelectrolytes.  BecauseofwatershiftsfromICFspacetoECFspace thepatientmay presentwithneurologicabnormalities suchas: Somnolence, coma, Seizures, Hemiparesis, and Aphasia
  88. 88. HHNS: Precipitating factors i. Acute illness (e.g.pneumonia,stroke) ii. Medications that exacerbate BGL (e.g. thiazides) iii. T reatments such as dialysis
  89. 89. H HNS: Diagnosis History Physical Examination Lab test BGL 600 to 1200mg/dL Electrolytes BUN CBC- RBCs Serum osmolality >350 mosm/kg ABG analysis – PH normal
  90. 90. HHNS: Medical Management TheoverallapproachtothetreatmentofHHNSis similartothat of DKA: Fluidreplacement, Correctionof electrolyteimbalances, and Insulinadministration
  91. 91. Comparison of DKA and HHNS Characteristics DKA HHNS Patients most commonly Can occur in type 1 or type 2 diabetes; more common in type 1 diabetes Can occur in type 1 or type 2 diabetes; more common in type 2 diabetes, especially elderly patients with type 2 diabetes Precipitating event Omission of insulin; physiologic stress (infection, surgery, CVA, MI) Physiologic stress (infection, surgery, CVA, MI) Onset Rapid (<24 h) Slower (over several days) Blood glucose levels Usually >250 mg/dL (>13.9 mmol/L) Usually >600 mg/dL (>33.3 mmol/L) Arterial pH level <7.3 Normal Serum and urine ketones Present Absent Serum osmolality 300–350 mOsm/L >350 mOsm/L Plasma bicarbonate level <15 mEq/L Normal BUN and creatinine levels Elevated Elevated Mortality rate <5% 10–40%
  92. 92. Long term of dm complication  assigment
  93. 93. Disorders of the thyroid gland  It is a butterfly-shaped organ  Located in the lower neck, anterior to the trachea  Consists of two lateral lobes connected by an isthmus  Is about 5 cmlong and 3 cmwide and weighs about 30 g  Hasvery high blood flow:  About 5 mL/min per gram of thyroid tissue (150ml/min) Approximately five times the blood flow to the liver Highmetabolic activity of thethyroidgland
  94. 94. Synthesis of thyroid hormones (T3 &T4)  T3+T4= Iodine molecule + tyrosine (amino acid) The major use of iodine in the body is by the thyroid gland, and the major derangement in iodinedeficiencyis alteration of thyroid function.
  95. 95. Function ofThyroid Hormone A.Theprimary functionof thyroid hormoneisto control cellular metabolicactivity  T4 Relativelyweak hormone Maintainsbody metabolisminasteadystate  T3 Is about fivetimes as potent asT4 Has amore rapid metabolicaction B.Influencecellreplicationandare important inbrain development. C. Necessary for normal growth.
  96. 96. Cont.…. Metabolism ⚫ The complex of physical and chemical processes occurring within a living cell or organism that are necessary for the maintenance of life. ⚫ Catabolism is the set of metabolic pathways that breaks down molecules into smaller units that are either oxidized to release energy , or used in other anabolic reactions ⚫ Anabolism is the set of metabolic pathways that construct molecules from smaller units
  97. 97. Definition of terms Euthyroid:state of normalthyroid hormoneproduction Thyroid storm: severe life-threatening hyperthyroidism precipitated by stress; characterized by high fever, extreme tachycardia, andalteredmental state Thyrotoxicosis: condition produced by excessive endogenous or exogenousthyroid hormone
  98. 98. SpecificDisorders of theThyroid Gland Goiter Hyperthyroidism Hypothyroidism
  99. 99. Goiter  A lack of iodine in the patient’s diet (endemic, simple goiter) causes the thyroid gland to become enlarged.  The thyroid gland can also become enlarged by ingesting large amounts of goitrogenic drugs or goitrogenic foods that decrease production of thyroxine, such as strawberries, cabbage, peanuts, peas, peaches, and spinach.  A simple goiter is not caused by inflammation or neoplasm.
  100. 100. SIGNS AND SYMPTOMS  Difficulty in swallowing (dysphagia) due to a large thyroid pressing on the esophagus  Enlarged thyroid gland  Respiratory distress from the large gland, causing pressure on the trachea  A tight feeling in the throat from a large gland  Coughing
  101. 101. TREATMENT  If increased TSH, administer hormone replacement with levothyroxine (T4), desiccated thyroid, or liothyronine (T3).  If the thyroid gland is overactive, then administer small doses of Lugol’s solution or potassium iodide solution.  If the simple goiter cannot be reduced through medication, then a thyroidectomy is performed during which all or part of the thyroid is removed.
  102. 102. NURSING INTERVENTION  Avoid goitrogenic foods or drugs in sporadic goiter since they make thyroid hormone production.  Use iodized salt to prevent and treat endemic goiter, since the thyroid needs iodine to make thyroid hormone.  Explain to patient:  The need for life-long thyroid replacement after thyroidectomy and radioactive iodine.  The need for intermittent lab work to monitor the thyroid.  Visits to the primary care practitioner to monitor size of thyroid gland.
  103. 103. Hyperthyroidism  There is an overproduction of T3 and T4 by the thyroid gland that can be caused by an autoimmune disease where the body’s immune system attacks the thyroid gland.  Other causes can be a benign tumor (adenomas) resulting in an enlarged thyroid gland (goiter) or an overproduction of TSH by the pituitary gland, caused by a pituitary tumor.
  104. 104.  The thyroid gland produces three hormones: thyroxine (T4), triiodothyronine (T3), and thyrocalcitonin (calcitonin). Secretion of T3 and T4 is regulated by the anterior pituitary gland through a negative feedback mechanism.  When serum T3 and T4 levels decrease, thyroid-stimulating hormone (TSH) is released by the anterior pituitary.  This stimulates the thyroid gland to secrete more hormones until normal levels are reached.
  105. 105. Cont.….  T3 and T4 affect all body systems by regulating overall body metabolism, energy production, and fluid and electrolyte balance, and controlling tissue use of fats, proteins, and carbohydrates.  Calcitonin inhibits mobilization of calcium from bone and reduces blood calcium levels.  Hyperthyroidism is a clinical syndrome caused by excessive circulating thyroid hormones.  Because thyroid activity affects all body systems, excessive thyroid hormone exaggerates normal body functions and produces a hypermetabolic state.
  106. 106. Risk Factors  Causes of hyperthyroidism ■ Graves’ disease is the most common cause. Autoimmune antibodies result in hypersecretion of thyroid hormones. ■ Toxic nodular goiter, a less common form of hyperthyroidism, is caused by overproduction of thyroid hormone due to the presence of thyroid nodules. ■ Exogenous hyperthyroidism is caused by excessive dosages of thyroid hormone.
  107. 107. SIGNS AND SYMPTOMS  Enlarged thyroid gland (goiter) caused by tumor  Protrusion of the eyeballs (exophthalmos) due to lymphocytic infiltration which pushes out the eyeball  Sweating (diaphoresis); excess thyroid hormone raises the metabolic rate  Increased appetite due to increased metabolism  Nervousness due to high levels of thyroid hormone  Weight loss due to increased metabolism  Menstrual changes due to elevated levels of thyroid hormone
  108. 108. Laboratory Tests Serum TSH test – Decreased in the presence of Graves’ disease (may be elevated in secondary or tertiary hyperthyroidism)  Free thyroxine index (FTI) and T3 – Elevated in the presence of disease  Thyrotropin-releasing hormone (TRH) stimulation test – Failure of expected rise in TSH
  109. 109. TREATMENT  For mild cases and for young patients, administer antithyroid medication such as propylthiouracil and methimazole to block synthesis of T3 and T4.  For Graves’ disease and for patients 50 years of age or older, radioactive iodine therapy is used to decrease production of thyroid hormones. Administer Lugo's solution, SSKI, or potassium iodide.  For severe cases where the size of the thyroid gland interferes with swallowing or breathing, the thyroid gland is surgically reduced in size or removed.
  110. 110. Cont.…  Administer beta blockers such as propranolol until hyperthyroidism diminishes to decrease sympathetic activity and control tachycardia, tremors, and anxiety.
  111. 111. NURSING INTERVENTION  Monitor vital signs.  Provide cool environment.  Protect the patient’s eyes with dark glasses and artificial tears if the patient has exophthalmos.  Provide a diet high in carbohydrates, protein, calories, vitamins, and minerals.  Monitor for laryngeal edema following surgery (hoarseness or inability to clearly speak).  Keep oxygen, suction, and a tracheotomy set near bed in case the neck swells and breathing is impaired.
  112. 112.  Keep calcium gluconate near the patient’s bed following surgery.  This is the treatment for tetany and is used to maintain the serum calcium level in normal range.  Place the patient in a semi-Fowler’s position to decrease tension on the neck following surgery.  Support the patient’s head and neck with pillows.  Monitor for muscle spasms and tremors (tetany) caused by manipulation of the parathyroid glands during surgery.  Check drainage and hemorrhage from incision line; red flags are frank hemorrhage and purulent, foul smelling drainage.  Monitor for signs of hypocalcemia (tingling of hands and fingers).  The treatment is IV calcium, administered quickly.
  113. 113.  Check for Trousseau’s sign (inflate blood pressure cuff on the arm and muscles contract).  Check for Chvostek’s sign (tapping of the facial nerve causes twitching of the facial muscles).  Both this sign and Trousseau’s sign are positive when the parathyroid glands have been manipulated during thyroid surgery, in which case they secrete too much phosphorus and not enough calcium.  Since muscles, i.e. the heart, need calcium for work, a low calcium level may cause muscle spasms which are easily detected by Chvostek’s sign and Trousseau’s sign.
  114. 114. Complication  Hemorrhage at the incision site due to a released surgical tie, excessive coughing, or movement.  Thyroid Storm/Crisis ;-Thyroid storm/crisis results from a sudden surge of large amounts of thyroid hormones into the bloodstream, causing an even greater increase in body metabolism.  Airway Obstruction;-Hemorrhage, tracheal collapse, tracheal mucus accumulation, laryngeal edema, and vocal cord paralysis can cause respiratory obstruction, with sudden stridor and restlessness.  Hypocalcemia and Tetany;-Damage to parathyroid gland causes hypocalcemia and tetany
  115. 115. Hypothyroidism Hypothyroidism is a condition in which there is an inadequate amount of circulating thyroid hormones triiodothyronine (T3 ) and thyroxine (T4 ), causing a decrease in metabolic rate that affects all body systems.
  116. 116. Classifications of hypothyroidism by etiology  Primary – Primary hypothyroidism stems from dysfunction of the thyroid gland. This is the most common type of hypothyroidism and is caused by disease (autoimmune thyroiditis – Hashimoto’s disease) or loss of the thyroid gland (iodine deficiency, radioactive iodine treatment, surgical removal of the gland).  Secondary – Secondary hypothyroidism is caused by failure of the anterior pituitary gland to stimulate the thyroid gland or failure of the target tissues to respond to the thyroid hormones (pituitary tumors).  Tertiary – Tertiary hypothyroidism is caused by failure of the hypothalamus to produce thyroid- releasing factor.
  117. 117. Hypothyroidism is also classified by age of onset  Cretinism – Cretinism is a state of severe hypothyroidism found in infants.  Juvenile hypothyroidism – Juvenile hypothyroidism is most often caused by chronic autoimmune thyroiditis and affects the growth and sexual maturation of the child.  Adult hypothyroidism;-Because older adult clients who have hypothyroidism may have manifestations that mimic the aging process, hypothyroidism is often undiagnosed in older adult clients, which can lead to potentially serious adverse effects from medications (sedatives, opiates, anesthetics).
  118. 118. Risk Factors  The disorder is most prevalent in women, with the incidence rising significantly in people who are 30 to 60 years of age.  Many individuals who have mild hypothyroidism are frequently undiagnosed, but(intraoperative hypotension, cardiac complications following surgery).  Use of medications (lithium [Lithobid], amiodarone [Cordarone])  Inadequate intake of iodine
  119. 119. SIGNS AND SYMPTOMS  Fatigue due to slow metabolism  Hypothermia due to slow metabolism  Brittle nails due to low levels of thyroid hormone, which helps growth and development  Thick dry hair from lack of thyroid hormone  Dry skin from lack of thyroid hormone  Menstruation changes due to diminished levels of thyroid hormone  Slow cognitive function due to slow metabolism  Weight gain, low levels of thyroid hormone causes fatigue, sluggishness
  120. 120. Diagnostic Procedures  Skull x-ray, computed tomography scan, and magnetic resonance imaging ☐ These procedures can locate pituitary or hypothalamic lesions that may be the underlying cause of hypothyroidism.  ECG ☐ Sinus bradycardia, flat or inverted T waves, and ST deviations
  121. 121. TREATMENT Replacement hormone; levothyroxine is the treatment of choice. Serum measurements of T3 and T4 will need to be performed after 6 to 8 weeks to determine if the patient is taking the correct dose. The patient needs to be aware that this is a lifetime replacement.
  122. 122. NURSING INTERVENTION  Monitor vital signs.  Provide a warm environment.  Low-calorie diet.  Increase fluids and fiber to prevent constipation.  Take thyroid replacement hormone each morning to avoid insomnia.  Monitor for signs of thyrotoxicosis (an increase in T3): nausea, vomiting, diarrhea, sweating, tachycardia.  Explain to the patient: Side effects of thyroid hormone replacement. Review the signs of hyperthyroidism and hypothyroidism. Have patient contact health care provider if signs change.
  123. 123. Complications Myxedema;-  Myxedema is a life-threatening condition that occurs when hypothyroidism is untreated or when a stressor (such as infection, heart failure, stroke, or surgery) affects an individual who has hypothyroidism.  Clients who have been taking levothyroxine and suddenly stop the medication are also at risk.
  124. 124. Clinical Manifestations  Significantly depressed respirations (hypoxia, hypercapnia)  Decreased cardiac output  Worsening cerebral hypoxia  Lethargy, stupor, coma  Hypothermia  Bradycardia, hypotension  Hyponatremia
  125. 125. Nursing Actions Maintain airway patency with ventilatory support if necessary. Provide continuous ECG monitoring. Monitor ABGs to detect hypoxia, hypercapnia, respiratory acidosis. Warm the client with blankets. Monitor the client’s body temperature until stable
  126. 126.  Replace thyroid hormone by administering large doses of levothyroxine (Synthroid) IV bolus.  Monitor vital signs because rapid correction of hypothyroidism can cause adverse cardiac effects.  Monitor intake and output, and daily weights. With treatment, urine output should increase, and body weight should decrease; failure to do so should be reported to the provider.  Treat hypoglycemia with glucose.  Administer corticosteroids.  Check for possible sources of infection (blood, sputum, urine) that may have precipitated the coma. Treat any underlying illness.
  127. 127. Disorders of the parathyroid glands
  128. 128. Hypoparathyroidism  Hypoparathyroidism is diminished functioning of the parathyroid glands leading to low levels of PTH, which causes hypocalcemia.  The primary cause of hypoparathyroidism is destruction of the glands by an autoimmune cause.  Occasionally the gland(s) may be accidentally removed during thyroidectomy
  129. 129. SIGNS AND SYMPTOMS Tetany (muscle irritability) due to abnormal levels of calcium Tingling of periorbital area, hands, and feet from abnormal calcium levels Lethargy due to low levels of parathyroid hormone Cataract development Convulsions due to acute low calcium levels
  130. 130. INTERPRETING TEST RESULTS  Decreased serum calcium due to low levels of PTH.  Increased serum phosphate due to low levels of PTH.  Decreased serum PTH from diminished secretion from the parathyroid glands.  Decreased urinary calcium from diminished PTH.  Positive Chvostek’s sign due to decreased calcium levels.  Positive Trousseau’s sign due to decreased calcium levels.
  131. 131. TREATMENT  Administer calcium gluconate by slow IV drip for acute hypocalcemia  Oral calcium—calcium gluconate, lactate, carbonate (Os-Cal).  Large doses of vitamin D (calciferol) to help absorption of calcium.  Aluminum hydroxide gel (Amphogel) or aluminum carbonate gel; basic (Basaljel) to decrease phosphate levels.  Keep tracheostomy set and injectable calcium gluconate at bedside for impaired respiration from swelling as well as for emergency administration of calcium.
  132. 132. NURSING INTERVENTION  Monitor patients condition  If the parathyroids were damaged during thyroid surgery: • Administer calcium to maintain the serum levels in a low normal range. • Testing should be done every 3 months.
  133. 133. Hyperparathyroidism Overactivity of the parathyroid glands caused by a tumor produces too much PTH, resulting in hypercalcemia and hypophosphatemia. Excess calcium is reabsorbed by the kidneys and may result in kidney stones; however, malfunction in the feedback mechanism prevents detection of excessive calcium levels in the blood, thereby failing to adjust the secretion of PTH. Parathyroid tumors are usually benign.
  134. 134. SIGNS AND SYMPTOMS Asymptomatic Increased serum calcium level Bone pain or fracture as a result of excreting calcium from bone  Kidney stones  Frequent urination as a result of increased calcium in the urine (hypercalciuria)
  135. 135. INTERPRETING TEST RESULTS Increased serum calcium. Increased serum PTH. Decreased serum phosphate. Increased urine calcium. Presence of parathyroid tumor shows on ultrasound. Fine needle biopsy of the parathyroid tumor.
  136. 136. TREATMENT Surgical removal of the parathyroid tumor. Administer bisphosphonates to lower serum calcium by increasing calcium absorption in the bone.  IV normal saline to dilute serum calcium. Diuretic such as furosemide to excrete excess calcium in the urine.
  137. 137. NURSING INTERVENTION  Monitor intake and output.  Monitor for fluid overload.  Monitor electrolyte balance.  Give the patient acid-ash juices such as cranberry juice.  Strain urine for kidney stones.  Place the patient on a low-calcium and high-phosphorus diet.  Explain to patient:  Avoid over-the-counter calcium supplements.  Maintain daily activities.
  138. 138. Disorders of the pituitary gland
  139. 139. HYPOPITUTARISM  Hypopituitarism is an underactive pituitary gland that results in deficiency of one or more pituitary hormones.  This may result from disorders involving the pituitary gland, hypothalamus or surrounding structures.  If there is decreased secretion of most pituitary hormones, the term panhypopituitarism is used.
  140. 140. ETIOLOGY  Disease of the pituitary gland itself, such as pituitary tumors (adenomas)  Destruction of the pituitary gland by trauma or vascular lesion or brain surgery.  Radiation therapy to the head and neck area.
  141. 141. Contd…  Infections: cerebral-bscess, meningitis, encephalitis,  Ischaemia and infarction  Autoimmune inflammation (hypophysitis)  Congenital malformations of the pituitary gland
  142. 142. CLINICAL FEATURES • The clinical features depends upon type of hormone deficiency. Type of hormone Symptoms LowACTH Decrease production of cortisol by the adrenal glands which causes symptoms related to adrenal insufficiency. Low growth hormone Failure of growth in children causing short height (dwarfism) and undue tiredness and weakness in adults.
  143. 143. Type of hormone Symptoms Low LH & FSH In Men: decrease in libido, impotence & impaired fertility due to a decreased ability to produce testosterone. In Female: irregular or absent menstrual periods leading to infertility. Low thyroid hormone Undue tiredness, weight gain, constipation, dry skin and feeling colder than usual.
  144. 144. Types of hormone Symptoms Lack ofADH From the posterior part of the pituitary gland results in the passing of uncontrolled large amounts of urine and causes severe thirst. Prolactin deficiency Low levels can lead to a woman inability to produce breast milk after childbirth.
  145. 145. DIAGNOSTIC EVALUATION  Health history and clinical manifestation  Change in physical appearance  Blood test  Radioimmunoassay
  146. 146. DEFICIENCY HORMONE THERAPY DOSE TRH L-thyroxine 0.1 – 0.15 mg /day LH In female: Cyclical estrogen therapy with Ethinyl oestradiol 20 – 30 μg for 3 weeks
  147. 147. DEFICIENCY HORMONE THERAPY DOSE LH &FSH Progesterone (medroxy progesteroneAcetate) In male: Teststerone 5mg/day from day 14-21 Of menstrual cycle 250-300mg IM every2-4 weeks GH Biosynthetic 24U/m2/week SC
  148. 148. SURGICAL MANAGEMENT Transsphenoidal surgery: • Removal of the tumor by an operation through the nose and the sphenoidal sinuses.
  149. 149. Contd …  Craniotomy: Tumor is removed by opening the skull.
  150. 150. DWARFISIM • Dwarfism is when an individual is short in stature resulting from a medical condition caused by problems that arise in the pituitary gland in which the growth of the individual is very slowed or delayed.
  151. 151. CAUSES  The most common causes are achondroplasia is a bone-growth disorder  Turner syndrome  Growth hormone deficiency and  Poor nutrition.
  152. 152. SIGN & SYMPTOMS  Short stature  Delayed puberty  Symptomatic hypoglycemia in 10% cases  Delayed eruption of secondary teeth in children
  153. 153. TREATMENT  Hormone therapy • Growth hormone deficiency is treated with injections of a synthetic version of the hormone.  Surgical treatment: • Inserting metal staples into ends of long bones where growth occurs (growth plates) in order to correct the direction in which bones are growing.
  154. 154. Disease conditions caused by hypopituitarism:  Dwarfism  Dibetes Insipidus  Addisson’s disease  Hypothyroidism
  155. 155. DIABETES INSIPIDUS  It is a disorder of the posterior lobe of the pituitary gland characterized by a deficiency of antidiuretic hormone (ADH), or vasopressin.  Great thirst (polydipsia) and large volumes of dilute urine characterize the disorder.
  156. 156. CAUSES  Head trauma  Brain tumor  Surgical ablation or irradiation of the pituitary gland  Infections of the central nervous system  Failure of the renal tubules to respond to ADH
  157. 157. CLINICAL FEATURES  Excessive thirst • May be intense or uncontrollable • Involves craving for water  Excessive urine volume
  158. 158. DIAGNOSIS  Urine analysis  Monitoring urine output  Water deprivation test  Hypertonic saline test  MRI
  159. 159. TREATMENT The objectives of therapy are:  To replace ADH (which is usually a long-term therapeutic program).  To ensure adequate fluid replacement.  To identify and correct the underlying intracranial pathology.
  160. 160. Contd… 1. Fluid replacement 2. Central diabetes insipidus may be controlled with vasopressin (desmopressin, DDAVP). It can be taken as either an injection, a nasal spray, or tablets.
  161. 161. COMPLICATIONS  Dehydration:  Electrolyte imbalance • Dry skin and mucus • Fatigue, lethargy • Fever & Rapid heart rate • Headache • Sunken eyes • Unintentional weight loss • Irritability • Muscles pain
  162. 162. Syndrome of inappropriate antidiuretic hormone (SIADH) SIADH is caused by too much ADH being secreted by the posterior pituitary gland. ADH is responsible for controlling the amount of water reabsorbed by the kidney; it prevents the loss of too much fluid.  When too much water is detected, ADH production or secretion is halted.
  163. 163. SIADH may be caused by damage to the hypothalamus or pituitary, inflammation of the brain, some medications such as selective serotonin receptor inhibitors (SSRIs), carbamazepine, cyclophosphamides, and chlorpropamide. Certain cancers, especially lung, may produce ADH.
  164. 164. SIGNS AND SYMPTOMS Headaches due to hyponatremia Nausea and vomiting due to hyponatremia Confusion due to hyponatremia Personality changes due to hyponatremia
  165. 165. INTERPRETING TEST RESULTS Hyponatremia (low serum sodium) due to the dilution Treatment Administer saline IV to replenish sodium. Treat underlying cause.
  166. 166. NURSING INTERVENTION Monitor electrolytes to determine sodium levels. Restrict fluid because excess fluid dilutes sodium levels. Weigh the patient daily using the same scale, at same time of day with similar clothing. Monitor intake and output.
  167. 167. HYPERPITUTARISM  Hyperpituitarism is the primary hypersecretion of pituitary hormones.  It typically results from a pituitary adenoma.  There are usually three hormones that are over secreted due to pituitary adenoma are prolactin, adrenocorticotropic hormone (ACTH) and growth hormone (GH).
  168. 168. Contd…  Some of the common disorders as a result of hypersecretion of piutitary glands are as follows:  Excess prolactin: Prolactinoma.  Excess ACTH: Cushing’s disease.  Excess GH: Gigantism and Acromegaly.
  169. 169. ETIOLOGY  Pituitary tumor  Inherited condition known as multiple endocrine neoplasia type 1
  170. 170. CLINICAL FEATURES  Headache  Visual field loss or Double vision  Excessive sweating  Hoarseness  Milk secretion from breast  Sleep apnea  Joint pain and limitation of motion  Muscle weakness
  171. 171. Difference between Gigantism & Acromegaly 179 Gigantism  Start in infancy and growth is continuous.  Onset before puberty.  Excessive growth 8- 9feet,enlargement of organs heart, liver, spleen. Acromegaly  Starts at age 20-50yrs and growth is slow.  Onset after puberty.  Increase in size of hands, feet, lower jaw, skin becomes thick and coarse.
  172. 172. DIAGNOSIS  Physical examination  Laboratory investigations  Radiological imaging studies
  173. 173. TREATMENT Medication: Drugs may be used to shrink large tumors before surgery or in cases where surgery is not an option. Medication to reduce prolactin levels is usually the preferred treatment for patients with a prolactinoma.
  174. 174. Cond… Bromocriptine and Cabergoline are dopamine agonists (drugs that behave like dopamine) and can shrink prolactinomas and return secretions of prolactin to normal levels. Acromegaly may be treated with Somastatin analogs (octreotide) to lower growth hormone levels and shrink tumors.
  175. 175. Contd… Radiation: Used to treat patients who cannot undergo after surgery or for residual tumor tissue surgery and do not respond to medication. There are two approaches to radiation:  Conventional  Stereotactic therapies
  176. 176. Contd… Conventional radiation therapy • It is administered in small doses over a period of 4 to 6 weeks. • One drawback is that radiation treatments can damage normal tissue surrounding the tumor.
  177. 177. Contd… Stereotactic therapy • It provides a high-dose beam of radiation targeted at the tumor. • It may be completed in one session, resulting in less damage to surrounding tissue.
  178. 178. Note • Most patients that undergo radiation treatment require hormone replacement therapy due to a gradual decline in the secretion of other pituitary hormones.
  179. 179. Contd… 3. Surgery:  Trans-sphenoidal Adenectomy  Hypophysectomy
  180. 180. Nursing Intervention  Help to accept altered body image that is irreversible.  Assist family to understand what client is experiencing.  Help to recognize that the need for medical supervision will be life- long.  Help to understand the basis for the change in sexual functioning.
  181. 181. Contd…  Provide psychological and emotional support.  Perform range of motion exercise to assure joint mobility.  Monitor for hyperglycemia and cardiovascular problems (hypertension, angina, CHF) and modify care accordingly
  182. 182. Contd…  Teach self-care after a hypophysectomy.  Encourage to follow the established medical regimen, particularly hormone replacement  Limit stressful situations.  Protect self from infection.