endocrine 1.ppt

By
Dr./ Mona Nadr
Assessment and
Management of Patients with
Endocrine Disorders
ADVANCED ADULT CARE NURSING
Third year / bachelor

Figure 42-2 The pituitary gland, the relationship of the brain to pituitary action,
and the hormones secreted by the anterior pituitary and the posterior pituitary.

Glands of the Endocrine System
 Hypothalamus
 Posterior Pituitary
 Anterior Pituitary
 Thyroid
 Parathyroids
 Adrenals
 Pancreatic islets
 Ovaries and testes

Hypothalamus
 Releasing and inhibiting hormones
 Corticotropin-releasing hormone
 Thyrotropin-releasing hormone
 Growth hormone-releasing hormone
 Gonadotropin-releasing hormone
 Somatostatin-=-inhibits GH and TSH

Anterior Pituitary
 Growth Hormone--
 Adrenocorticotropic hormone
 Thyroid stimulating hormone
 Follicle stimulating hormone—ovary in
female, sperm in males
 Luteinizing hormone—corpus luteum in
females, secretion of testosterone in males
 Prolactin—prepares female breasts for
lactation

Posterior Pituitary
 Antidiuretic Hormone
 Oxytocin—contraction of uterus, milk ejection
from breasts

Adrenal Cortex
 Mineralocorticoid—aldosterone. Affects
sodium absorption, loss of potassium by
kidney
 Glucocorticoids—cortisol. Affects metabolism,
regulates blood sugar levels, affects growth,
anti-inflammatory action, decreases effects of
stress
 Adrenal androgens—dehydroepiandrosterone
and androstenedione. Converted to
testosterone in the periphery.

Adrenal Medulla
 Epinephrine and norepinephrine
serve as neurotransmitters for sympathetic
system

Thyroid
 Follicular cells—excretion of triiodothyronine
(T3) and thyroxine (T4)—Increase BMR,
increase bone and calcium turnover, increase
response to catecholamines, need for fetal
G&D
 Thyroid C cells—calcitonin. Lowers blood
calcium and phosphate levels

Parathyroid
 Parathyroid hormone—regulates serum
calcium

Pancreatic Islet cells
 Insulin
 Glucagon—stimulates glycogenolysis and
glyconeogenesis
 Somatostatin—decreases intestinal
absorption of glucose

Kidney
 1, 25 dihydroxyvitamin D—stimulates calcium
absorption from the intestine
 Renin—activates the RAAS
 Erythropoietin—Increases red blood cell
production

Ovaries
 Estrogen
 Progesterone—inportant in menstrual
cycle,*maintains pregnancy,

Testes
 Androgens, testosterone—secondary sexual
characteristics, sperm production

Assessment
 Health history—energy level, hand and foot
size changes, headaches, urinary changes,
heat and cold intolerance, changes in sexual
characteristics, personality changes, others
 Physical assessment—appearance including
hair distribution, fat distribution, quality of
skin, appearance of eyes, size of feet and
hands, peripheral edema, facial puffiness,
vital signs

Diagnostic Evaluation
 Serum levels of hormones
 Detection of antibodies against certain
hormones
 Urinary tests to measure by-products
(norepinephrine, metanephrines, dopamine)
 Stimulation tests—determine how an
endocrine gland responds to stimulating
hormone. If the hormone responds, then the
problem lies w/hypothalmus or pituitary
 Suppression tests—tests negative feedback
systems that control secretion of hormones

Diabetes Insipidus
 Diabetes Insipidus is a disorder of water metabolism
caused by deficiency of ADH (Antidiuretic hormone),
also called vasopressin, secreted by the posterior
pituitary or by inability of the kidneys to respond to
ADH (nephrogenic DI).
Causes
 1. Secondary to head trauma, brain tumor, or surgical
ablation or irradiation of the pituitary gland.
 2. Infections of the central nervous system (meningitis,
encephalitis, tuberculosis) or with tumors
(metastatic disease, lymphoma of the breast or lung)
 3. Failure of the renal tubules to respond to ADH.

 Clinical Manifestations
1. Polyuria – daily output of 5 to 20L of dilute urine
2. Polydipsia (intense thirst) – drinks 4 to 40L of fluids
daily, has craving for cold water.
3. High serum osmolality and high serum sodium level.
 Diagnostic Evaluation
 1. Serum osmolality
 2. Water deprivation test: test—withhold
fluids for 8-12 hours. Weigh patient frequently.
Inability to slow down the urinary output and fail
to concentrate urine are diagnostic. Stop test if
patient is tachycardic or hypotensive

Pharmacologic Tx and Nursing
Management
 DDAVP—intranasal bid
 Can be given IM if necessary. Every 24-96h. Can
cause lipodystrophy.
 Can also use Diabenese and thiazide diuretics in
mild disease as they potentiate the action of ADH
 If renal in origin—thiazide diuretics, NSAIDs
(prostaglandin inhibition) and salt depletion may
help

Nursing Interventions
1. Polyuria
- Measure intake and output accurately.
- Measure specific gravity of urine (normal specific
gravity is 1.003 to 1.030.
- Observe patient for signs of circulatory shock due
to dehydration.
2. Severe dehydration
- Administer fluids orally and intravenously to
replace fluid lost.
- Administer appropriate electrolytes to replace
those lost through excessive urination.
- Monitor laboratory test results.
- Obtain daily weights and record.

Complications of diabetes
mellitus :
1.Acute complications:

Diabetic ketoacidosis.

Hyperglycemic Hyperosmolar Non-Ketotic Syndrome

Hypoglycemia.
2.Chronic complications
-Microvascular

retinopathy

nephropathy

neuropathy
- Macrovascular

cerbrovascular, cardiovascular, peripheral vascular disease

Hypoglycemia
Hypoglycemia: Usually present with insulin treated patients.
Causes of hypoglycemia

Due to too much insulin/oral medication is used or too little glucose

Delayed ingestion of meal and increased physical activity.
Symptoms of hypoglycemia include:

Confusion

Nausea

Hunger

Tiredness

Perspiration

Headache

Heart palpitation

numbness around the mouth

Tingling in the fingers, tremors

Muscle weakness, blurred vision

Cold temperature

Irritability, and loss of consciousness
Treatment of hypoglycemia

50 % glucose I.V

Glucagon IM

Diabetic ketoacidosis:

This more common in type I diabetes

Is caused by the breakdown of fatty acids into ketones when there is not
enough glucose stored in the cells for energy.
Predisposing factors for diabetic ketoacidosis

Acute infection.

Injuries.

Emotional stress.
Clinical features for diabetic ketoacidosis

Acetone smell.

Marked dehydration.

Orthostatic hypotension.

Clouding of consciousness which can lead to coma.
Investigations for diabetic ketoacidosis

Increased ketone bodies in blood and urine
Treatment for diabetic ketoacidosis

Fluid and electrolyte replacement

Insulin replacement


1. Rehydration – important for maintaining tissue perfusion.
Fluid replacement enhances the excretion of excessive
glucose by the kidneys. The patient may need as much as 6
to 10 L of I.V. fluid to replace fluid losses caused by
polyuria, hyperventilation, diarrhea, and vomiting.

Initially, 0.9% Normal Saline Solution is administered at a
rapid rate, usually 0.5 to 1 L/hour for 2 to 3 hours. Half-
strength normal saline (0.45%) solution (also known as
hypotonic saline solution) may be used for patients with
hypertension or Hypernatremia and those at risk for heart
failure.

After the first few hours, half-strength normal saline
solution is the fluid of choice for continued rehydration,
provided the blood pressure is stable and the sodium level
is not low.

Moderate to high rates of infusion (200 to 500 ml/hour)
may continue for several more hours.

When blood glucose level reaches 300 mg/dL or less, the
IV solution may be changed to dextrose 5% in water (D5W)

Hyperglycemic hyperosmolar
non-ketotic syndrome
(HHNS):

Hyperglycemia predominate, with alterations of
the sensorium (sense of awareness). At the
same time, ketosis is minimal or absent.

Predisposing factors are same as ketoacidotic
coma.

Clinical features of diabetic ketoacidosis

Marked dehydration - hyperglycemia – seizures-
stupor-coma.

Treatment: same as ketoacedotic coma.

Chronic complications of
diabetes (macrovascular):

Diabetic macrovascular complications
result from changes in the medium to large
blood vessels.

Blood vessel walls thicken, sclerose, and
become occluded by plaque that adheres to the
vessel walls. Eventually, blood flow is blocked.

Coronary artery disease, cerebrovascular
disease, and peripheral vascular disease are the
three main types of macrovascular
complications that occur more frequently in the
diabetic population.

Chronic complications of
diabetes (microvascular):

Diabetic retinopathy is caused by a blockage of blood
vessels within the eye that leads to the blood vessels
leaking into the retina. This eventually leads to
blindness.

Diabetic nephropathy or Kidney Failure. Diabetes
Mellitus is the number one cause of kidney failure and
develops in 40 to 50% of all diabetics. It is also the most
common cause of death in type I diabetics.

Diabetic neuropathy :Diabetes can also cause
damage the peripheral nervous system (arms and legs)
causing diabetic neuropathy. This leads to loss of nerve
function that either results in: Constant pain or loss of
feeling. Erectile Dysfunction

Nutritional therapy

Diet is the corner stone of diabetes treatment.

Weight loss is a goal for most patients with type II diabetes.

The individual diet is based on:

The patients' types of diabetes.

Height to weight ratio.

Usual dietary intake.

Cultural and personnel preference.

Life style component: eating pattern.

For diabetic patient diet must contain:

50 % to 55 % of carbohydrate.

12 % to 20 % protein.

And 30 % of fat (unsaturated fat).

Fiber diet: This type of diet plays a role in lowering total
cholesterol and low-density lipoprotein cholesterol in the blood,
may also improve blood glucose levels and decrease the need
for exogenous insulin.

Exercise therapy

Exercise is an important part of managing diabetes.

The exercise program should be designed for the individual patient.

All exercise programs should begin with milder forms of exercise and gradually increase.

Program should not be stated until the blood glucose is under control.

Exercises are performed at the some time everyday.

Blood glucose should lie checked before beginning to exercise.

Every diabetic patient should have emergency supplies for treatment for hypoglycemia
available when exercising.

Benefits of exercises for person with diabetes:

Improve glucose utilization for energy and also improves circulation.

Improve insulin sensitivity.

Improve lipid profile.

May improve hypertension.

Increase energy expenditure to assist with weight loss and preserve lean body mass.

Promotes cardiovascular fitness.

Increases strength and flexibility.

Improve sense of well being

General precautions for exercise in people with diabetes:

Use proper footwear and, if appropriate, other protective equipment.

Avoid exercise in extreme heat or cold.

Inspect feet daily after exercise.

Avoid exercise during periods of poor metabolic control.

Insulin Action
Action Name Colour Onset Peak Duration
Short Humulog Clear Immediate 0.5-1.5 hr 2-4 hr
Interm
ediate
NPH Cloudy 2-4 hr 4-10 hr 10-16 hr
Long Ultralente Cloudy 6-10 hr None 18-20 hr

Side effects of insulin

Hypoglycemia is the most common side effect
that may occur during insulin therapy or oral
hypoglycemic agents.

Insulin resistance: this is the result of antibodies
binding to insulin molecules and rendering them
inactive this response is seem with patients who
require 100 – 200 units a day.

Insulin hypersensitivity: (allergic reaction)

Local reaction (itching and erythema at the
injection site).

Systemic response (anaphylactic reaction)

4.Lipodystrophy: Atrophy or hypertrophy of the
subcutaneous tissue at the injection site.

Patient education for diabetes
mellitus 
Education for diabetic patient:

Basic definition of diabetes (having a high blood glucose level)

Normal blood glucose ranges

Effect of insulin and exercise (decrease glucose)

Effect of food and stress, including illness and infections (increase glucose)

Treatment modalities

Administration of insulin and oral antidiabetes medications

Meal planning (food groups, timing of meals)

Monitoring of blood glucose and urine ketones

Where to buy and store insulin, syringes, and glucose monitoring supplies

When and how to contact the physician

Recognition, treatment, and prevention of acute complications
If hypoglycemia occurs at home:

If the patient is able to swallow give:

½ cup of juice ( apple or orange )

½ cup of 2% or skim milk.

½ cup of regular soda ( not sugar free)

6-7 hand candies.

3 glucose tablets.

1 table spoon of honey.

1 table spoon of sugar.

If the patient is unable to swallow (unconscious):

Turn the patient on the side.

Administer 1 mg of glycogen by injection.

Feed the patient as soon as he or she is awake and able to swallow.

Give a fast acting source of sugar and a longer acting source such as crackers and cheese or a meat
sandwich.

If the patient does not awaken within 15 min give another dose of glycogen and inform physician
immediately or call an emergency service.

Patient education for diabetes
mellitus Skin and foot care:

Inspect feet daily for temperature, cuts blisters, abrasions or discoloration of the toes.

Tell any abnormalities to the health care provider.

Use a mirror if unable to bend to see the bottom of the foot.

Be certain to check between the toes.

Wash the feet in warm water (not hot) using mild soap; do not soak the feet to avoid cracking
of the skin.

Thoroughly dry the feet after washing.

Pay attention to dry between the toes.

on medicated cream if the skin is dry, do not put the cream between toes.

Cut the nails straight a cross.

Wear properly fitted shoes, never walk barefoot.

Bread in new shoes gradually.

Never wear open sandals or sandals with straps between the toes.

Use socks and blankets to warm the feet, do not use a heating bad or hot water bottle near
them.

Test the temperature of bath water before stepping into tub or shower.

Elevate the feet wherever possible to improve circulation.
Pointers for traveling:

Carry extra medication or insulin in a case bottle gets lost or broken.

Wear Medic- Alert tag.

Carry an emergency supply of fast, acting sugar at all times.

Obtain sufficient rest and avoid stressful situations as much as possible to prevent stress
included hypoglycemia.

Drink a glass of water every 2 hrs to

CUSHING’S SYNDROME
Definition: is a condition in which the plasma cortisol levels
are elevated, causing signs and symptoms of
hypercortisolism.
Pathophysiology

The normal feedback mechanisms that control
adrenocortical function are ineffective resulting in excessive
secretion of adrenal cortical hormones.
Clinical Manifestations

Manifestations caused by Excess Glucocorticoids

1. Weight gain or obesity

2. Heavy trunk; thin extremities

3. “Buffalo hump” (fat pad) in neck and
supraclavicular area

4. Rounded face (moon face); plethoric, oily

5. Fragile and thin skin, striae and ecchymosis,
acne

6. Muscles wasted because of excessive catabolism

7. Osteoporosis – kyphosis, backache

8. Mental disturbances – mood changes, psychosis

9. Increased susceptibility to infections


Manifestations caused by Excess Mineralocorticoids

1. Hypertension

2. Hypernatremia, hypokalemia

3. Weight gain

4. Expanded blood volume

5. Edema

Manifestations caused by Excess Androgens

1. Women experience virilism
(masculinization)

a. Hirsutism – excessive growth of hair
on
the face and midline of trunk

b. Breasts – atrophy

c. Clitoris – enlargement

d. Voice – masculine

e. Loss of Libido


Diagnostic Evaluation:
1. Dexamethasone suppression test – Dexamethasone (1mg)
is administered orally at 11 PM, and a blood sample is taken
to measure the plasma cortisol level, obtained at 8AM the
next morning.

Nursing intervention

1. Mild, moderate, or severe weakness and muscle wasting.

- Help patient to perform active and passive range-of-motion
exercises to maintain muscle tone.

- Alternate periods of rest and exercise to avoid fatigue.

- Encourage patient to ambulate.

2. Susceptibility to develop fractures due to osteoporosis.

- Handle patient gently while moving.

- Assist with ambulation.

- Provide walker or cane to increase stability.

- Provide firm mattress and bed board.

- Keep side rails in raised position.

- Put bed in lowered position.

- Keep call bell within easy reach of patient at all times.

3. Decreased ability to fight infection due to immunosuppressive and
anti- inflammatory effects of excessive cortisol.

- Avoid exposing patient to unnecessary risks by protecting
patient from other patients visitors, and staff who have
respiratory infections
- Observe patient for signs and symptoms of infections.

- Avoid catheterizations.

4. Fragile and thin skin; prone to breakdown, easy bruising, and infection.

- Avoid use of harsh, drying soaps.

- Avoid use of adhesive tapes.

- Institute nursing measures to prevent skin breakdown.

- Use air mattress, sheepskins, heel and elbow protectors.

- Turn patient every hour.

- Apply direct pressure over all injection and venipuncture sites.

- Avoid repeated venipuncture.

5. Susceptibility to development of hyperglycemia and glucosuria.
- Check urine for sugar and acetone before meals and at bed time.
- Monitor blood glucose levels.
- Institute diabetic diet and diabetic teaching if necessary.
- Reassure patient that diabetic condition will probably disappear when condition is
controlled.
6. Susceptibility to ulcer formation.
- Give small, frequent feedings.
- Administer antacids, as ordered.
- Monitor stools for occult blood.
- Report immediately any vomiting of blood or passing of black, tarry stools.
7. Susceptibility to development of hypokalemia, with subsequent changes in cardiac
function.
- Monitor serum K+ levels.
- Offer high-potassium diet (oranges, bananas, tomatoes).
- Monitor apical pulse for regularity.
8. Susceptibility to development of hypertension and edema due to sodium and water
retention.
- Weigh patient daily, early in the morning.
- Monitor blood pressure at least four times daily.
- Restrict sodium intake.
- If patient is on diuretic therapy, monitor potassium level and supplement diet with
potassium.
9. Altered body image due to physical changes.
- Reassure patient that physical changes may be reversible with treatment.
10. Mood swings, with periods of euphoria, irritability, and depression.
- Allow patient to express feelings.
- Do not reprimand patient for inappropriate behavior.
- Explain to family and encourage acceptance on the part of family and staff.

PHEOCHROMOCYTOMA

Pheochromocytoma is a catecholamine-
secreting neoplasm associated with
hyper-function of the adrenal medulla.
Tumors located in the adrenal medulla
produce both increased epinephrine
and norepinephrine; those located
outside the adrenal gland tend to
produce epinephrine only.

Clinical Manifestations

Variation in signs and symptoms depends on the
predominance of norepinephrine or epinephrine secretion
and on whether secretion is continuous or intermittent.

1. Hypertension

2. Orthostatic hypotension, dizziness, and syncope

3. Palpitations; chest pain

4. Hypermetabolism manifested by tremor,
nervousness, weight loss, heat intolerance,

diaphoresis, and exhaustion.

5. Fasting hyperglycemia and glycosuria

6. Diarrhea, nausea, abdominal pains, possible
symptoms of bowel obstruction

7. Headaches and migraines

Diagnostic Evaluation
1. VMA (vanillylmandelic acid) and metanephrine
(metabolites of epinephrine and
norepinephrine) are elevated in 24-hour urine
sample.
2. Epinephrine and norepinephrine in urine and
blood are elevated while patient is
symptomatic.
3. CT scan and magnetic resonance imaging
(MRI) of the adrenal glands or of the
entire abdomen are done to identify tumor.


1.Withhold coffee, tea, bananas, chocolate, citrus fruits, aspirin,
foods containing vanilla, and antihypertensive medications
for three days prior to and during urine specimen
collection.
2. Help patient avoid excessive physical and emotional stress
3. Collect 24-hour urine specimen in a bottle that contains a
preservative.

1. Hypertension

- Monitor and record vital signs.

- Administer antihypertensive medications, as ordered, and
observe for therapeutic effectiveness.

- Watch for signs and symptoms of cardiovascular accident or
congestive heart failure.

2. Orthostatic hypotension, dizziness, and syncope.

- Instruct patient to change positions slowly, especially when
getting out of bed.

- Take safety precautions; for example, raise side rails to prevent
injury.

3. Palpitations; chest pain

- Check apical and radial pulse for 1 full minute.


4. Hypermetabolic state manifested by tremor, nervousness, weight loss,
heat intolerance, diaphoresis, and exhaustion.

- Provide a quiet, nonstimulating, nonstressful environment.

- Offer diet high in calories, vitamins, and minerals.

- Omit coffee, tea, and cola from the diet to prevent their
stimulating effects.

- Weigh patient daily and record weight.

- Promote rest and assess patient for need of sedation.

- Keep room cool.

- Offer frequent bathing and hygienic measures.

5. Fasting hyperglycemia and glycosuria

- Monitor blood glucose levels.

- Check urine for glycosuria before meals and at bedtime.

- Record results and report abnormal findings to physician.

6. Diarrhea, nausea, abdominal pains

- Check bowel sounds daily.

- Check and keep an accurate record of bowel movements.

- Administer antidiarrherial medication, as ordered.

7. Pounding headaches and migraines

- Assess blood pressure during pain episodes.

- Assure patient that headaches will cease once hypertension is
controlled

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