ENDOCRINE NURSING By : JOHN MARK B. POCSIDIO, RN, MSN

Functions of endocrine system

Response to stress and injury.

Growth and development.

Reproduction.

Homeostasis

Energy metabolism.

Endocrine glands Endocrine glands are specialized cluster of cells that secrete hormones.

o Secreted hormones go directly into the blood stream (ductless gland ) in respond to the nervous system stimulation.

HORMONES Hormones are chemical messengers secreted by endocrine organs and transported

throughout the body where they exert their action on specific cells called target cells. Hormones do not cause reactions but rather they are regulator of tissue responses.

Mechanisms of Hormones Hormones interact with high-affinity receptors

o These are linked to one or more effector system in the cell Some receptors are located on the surface of the cell

o These act through second messenger mechanisms Others are located in the cell

o They modulate the synthesis of enzymes, transport proteins, or structural proteins Binding to Target Cells

Hormones Maintain homeostatic balance utilizing a feedback mechanism that involves other

hormones, blood or chemicals, and the nervous system.“The Sequence”

Hypothalamus↓

Pituitary Gland or HypophysisAnterior or AdenohypophysisPosterior or Neurohypophysis

↓Target Glands

HYPOTHALAMUS

The hypothalamus is the site of the hunger center and is involved in appetite control. It contains centers that regulate the sleep–wake cycle, blood pressure, aggressive and sexual behavior, and emotional responses (ie, blushing, rage, depression, panic, and fear). The hypothalamus also controls and regulates the autonomic nervous system.

The ANATOMY of the Endocrine SystemPituitary Gland

Is a gland located below the hypothalamus at the base of the brain The optic chiasm passes over this structure

Is divided into two parts- the anterior or adenohypophysis and the posterior or the neurohypophysis

ANTERIORSecretes the following hormones:1. Growth hormone2. Prolactin3. Gonadotrophins- LH and FSH4. Stimulating hormones and trophic hormones

ACTHTSHMSH

The PHYSIOLOGY of the Endocrine System: Posterior PituitaryStores and releases1. OXYTOCIN2. ADH/Vasopressin

Radioactive iodine uptake test (raiu) Administration of I 123 or I 131 orally; measurement by a counter of the amount of radioactive

iodine taken up by the gland after 24 hours.

Increased uptake may indicate HYPERfunctioning gland Decreased uptake my indicate HYPOfunctioning gland Normal values: 5-30% in 24 hours

COMMON BOARD QUESTIONREMEMBER:

Not radioactive after procedure----CGFNS/ NCLEX Avoid cough syrup before test.(7-10 days prior) Temporarily discontinue contraceptive pills

THYRIOD SCANAdministration of radioactive isotope ( oral / IV) & visualization by a scanner of the distribution of radioactivity in the gland. (scintillation detector, gamma camera)Performed to determine location, size, shape, & anatomic function of thyroid gland; identifies areas of increased or decreased uptake; valuable in evaluating thyroid nodules.

COMMON LABORATORY PROCEDURES Thyroid Scan Pretest- Check for pregnancy, Thyroid medication may be withheld temporarily, advise

NPO Post-test- Ensure proper disposal of body wastes Nursing care usually the same as RAIU

Prohibited during thyroid studies1. TOPICAL ANTISEPTICS2. MULTIVITAMIN PREPARATIONS3. FOOD SUPPLEMENTS

4. COUGH SYRUPS-------- LOCAL/ CGFNS5. AMIODARONE6. ANTIARRYTHMIC AGENTSCONT. ( may affect test results)7. ESTROGENS8. SALICYLATES9. AMPHETAMINES10. CHEMOTHERAPEUTIC AGENTS11. ANTIBIOTICS12. CORTICOSTERIODS13.MERCURIAL DIURETICS

BMR It measures the oxygen consumption under basal conditions of overnight fast and rest

from mental and physical exertion. it can be estimated from the oxygen consumed over a timed interval by analysis of

samples of expired air

Points to remember BMR BMR- measures oxygen consumption at the lowest cellular activity. PREPARATION NPO 10-12 hours Night sleep 8-10 hours Do not get up from bed the following morning until the test is done. A device with a nose clip & a mouthpiece is used, the client performs deep breathing

exercises. NORMAL: +20% ( EUTHYRIOD)

FASTING BLOOD GLUCOSE Aids in the diagnosis of Diabetes Pre-test: NPO for 8 hours( midnight before the test) Normal FBS- 80-109 mg/dL DM- 126 mg/dL and above QUESTION? Patient can drink water or not???????

GLUCOSE tolerance test Aids in the diagnosis of DM Pre-test: Provide high-carbohydrate foods x 3 days, instruct to avoid caffeine, alcohol and

smoking for 36 hours before the test. Fast for 10 to 16 hours before the test. Withhold morning insulin or oral hypoglycemic medication ( client with diabetes mellitus)---

NCLEX The test will take 3 to 5 hours, requires intravenous or oral administration of glucose, and multiple

blood samples.Post-test:

avoid strenuous activity for 8 hours Normal OGTT- 1 and 2 hours post-prandial- glucose is less than 200 mg/Dl

Glycosylated Hemoglobin A 1-C Blood glucose bound to RBC hemoglobin Reflects how well blood glucose is controlled for the past 3 months FASTING is NOT required!

Glycosylated Hemoglobin A 1-CNormal level- expressed as percentage of total hemoglobinN- 4-7%Good control- 7.5%or lessFair control- 7.5 % to 8.9%Poor control- 9% and above

ENDOCRINE DISORDERSBy: JOHN MARK B. POCSIDIO, RN, USRN, MSNDisorders of the pituitary gland

HYPERPITIUTARISM Hyperfunctioning of the pituitary gland Over secretion of one or more of the anterior pituitary hormones Can lead to acromegaly/ gigantism

COMMON CAUSE: Benign pituitary adenoma Hyperplasia of the pituitary tissue

.

.SIGNS & SYMPTOMS:

Enlarged hands and extremities-CBQ Prominent supraorbital ridge Spade shape hands & feet Large nose and jaw, teeth are separated Cardiomegaly, enlarged liver- CBQ Abnormal glucose level Hypertrophy of the sweat and sebaceous gland Galactorrhoea ( prolactin) Peripheral neuropathy Arthrosis Sexual dysfunction

DIAGNOSTIC TEST: Skull X-ray, CT scan, MRI

NURSING INTERVENTIONS Provide emotional support to clients and family Provide frequent skin care Prepare patient for surgery- removal of pituitary gland( transphenoidal hypophysectomy) CBQ? LOCATION? Between the upper lip & gum

Post-operative care Monitor VS, LOC and neurologic status ( monitor packing & reinforce as needed) Place patient on Semi-Fowler’s Monitor for Increased ICP, bleeding, CSF leakage Instruct patient to AVOID sneezing, coughing and nose-blowing CBA- deep breathing is good just avoid coughing CBA- provide mouth care with saline or toothettes ( avoid toothbrush) Monitor development of DI/ SIADH measure I and O

Administer prescribed medications- antibiotics, analgesics and steroidsMEDICAL THERAPY:OCTREOTIDE ACETATE SC 3x/ week( analog of somatostatin)– produces feedback inhibition on GHSANDOSTATIN (IM 20-30mg) ---Effectively inhibits GH secretion for 30 days with just one IM injection of 20-30mg.- CBQBROMOCRIPTINE( long acting dopamine agonist)– can reduce growth hormone levels.

HYPOPITUITARISM Hyposecretion of the anterior pituitary gland

CAUSES: Congenital Post-partal necrosis( Sheehan's syndrome) Infection Surgery Radiation therapy

ASSESSMENT Findings Retarded physical growth due to decreased GH dwarfism Low intellectual development poor development of secondary sexual characteristics

Dwarfism, Cretenism, Achondroplasia

Diagnostics Physical examination and history CT scan MRI Hormone levels determination

NURSING INTERVENTIONS Provide emotional support to the family Encourage client and family to express feelings Administer prescribed hormonal replacement therapy (GH)

GROWTH HORMONESSERMORELIN (GEREF)-----IVSOMATREM (PROTROPIN)----IM/SCSOMATROPIN (HUMATROPE) ---IM/ SC( ORAL ROUTE IS INACTIVATED BY ENZYMES)---use cautiously to diabetic patientsSideEffect?Peripheral edema, arthralgias, myalgias, carpal tunnel syndrome, paresthisias, decrease glucose tolerance.

DIABETES INSIPIDUS Hypo functioning of the posterior pituitary gland A hypo-secretion of ADH

Most common cause???? Neurosurgery, trauma-CBQ

SIGNS AND SYMPTOMS: Polyuria- CBQ Dehydration-CBQ Polydipsia

Muscle pain and weakness ( hypo K) Postural hypotension and tachycardia

Diagnostic test Fluid deprivation test – 8-12 hrs or 3-5% wt loss. Inability to increase specific gravity and

osmolality CGFNS: WATCH OUT FOR??????!!!!! Urinary Specific gravity very low, 1.006 or less Serum Sodium levels high

NURSING INTERVENTIONS Monitor VS, neurologic status and cardiovascular status Monitor Intake and Output/ Daily weights Monitor urine specific gravity Provide adequate fluids Avoid!!! Coffee, tea, alcohol

MEDS: VASOPRESSIN/ DESMOPRESSIN- CBQ

SIADH Hyperfunctioning of the posterior pituitary gland Hyper-secretion of ADH abnormally Most common cause??? Neurosurgery/ trauma- CBQ

SIGNS & SYMPTOMS Mental status changes ( confusion)- CBQ Abnormal weight gain Hypervolemia Hypertension Hyponatremia Anorexia/ N/V

DIAGNOSTIC TEST Urine specific gravity is increased (concentrated) Hyponatremia CBC shows hemodilution

NURSING INTERVENTIONS Monitor VS and neurologic status Provide safe environment Restrict fluid intake (less than 500cc/day) Monitor I and O and daily weight Administer Diuretics and IVF carefully Administer prescribed Demeclocycline QUESTION???? SALINE OR WATER??? (TUBE FEEDINGS, NGT IRRIGATION)

DISORDERS OF THYRIODBy: JOHN MARK B. POCSIDIO, RN, USRN, MSN

HYPERTHYROIDISM Called GRAVE’S DISEASE Hyperfunctioning of the thyroid gland A hyperthyroid state characterized by increased circulating T3 and T4, thyrocalcitonin

POSSIBLE CAUSES: Autoimmune Thyroiditis Infection Tumor Radiation

SIGNS & SYMPTOMS Weight loss HEAT intolerance Hypertension Tachycardia Exopthalmos diarrhea Warm skin Diaphoresis Smooth & soft skin Fine tremors

DIAGNOSTICS Thyroid gland enlarged T3, T4 elevated RAIU: Increased uptake

NURSING INTERVENTIONS Rest ( quiet room) Administer anti-thyroid Methimazole and PTU Provide a HIGH-calorie diet, HIGH protein Manage diarrhea Provide a cool and quiet environment Avoid giving stimulants Provide eye care Administer PROPANOLOL for tachycardia Administer IODIONE preparation- Lugol’s solution Prepare clients for Radioactive iodine therapy Prepare patient for thyroidectomy NO ASPIRIN!!!!- CBQ COMPLICATION? Thyroid storm Manage Seizures as required. Provide a quiet environment

THYROIDECTOMY Removal of the thyroid gland

PRE-OPERATIVE CARE - Thyroidectomy Obtain VS and weight Assess for Electrolyte levels, glucose levels and T3/T4 levels Teach to support neck while moving-CBQ

POST-OPERATIVE CARE - Thyroidectomy Position: semi-fowlers ( neck midline) What to bring?: tracheostomy set, O2 tank, suction machine, calcium gluconate Check for SIGNS bleeding QUESTION??? Frequent swallowing or nape????? Assess for hoarseness Monitor for signs of hypocalcemia

HYPOTHYROIDISM Hypo functioning of the thyroid gland Hypo secretion of thyroid hormones Decreased T3 and T4 decreased basal metabolism

SIGNS & SYMPTOMS Lethargy and fatigue Weakness and paresthesia COLD intolerance- CBQ Weight gain Bradycardia-CBQ Constipation-CBQ Dry hair and skin-CBQ Generalized puffiness and edema around the eyes and face Menstrual irregularities

Diagnostic Tests

SERUM T3 and T4 level low SERUM CHOLESTEROL level elevated RAIU DECREASED

NURSING INTERVENTIONS Monitor VS especially HR Administer meds: LEVOTHYROXINE Diet: low calories, low cholesterol, low fat Provide warm environment Manage constipation appropriately Avoid!!!!! Sedatives anesthetics Narcotics Stress Infection Exposure to extreme cold

Hypoparathyroidism Hypo functioning of the parathyroid gland Hypo secretion of the parathyroid gland

Most common cause? Accidental removal of the parathyroids Autoimmune Radiation

.SIGNS & SYMPTOMS:

Signs of HYPOCALCEMIA Numbness and tingling sensation on the face ( Trosseau’s, chvostek) Muscle cramps Bronchospasms, laryngospasms-CBQ Seizure-CBQ Cardiac dysrhythmias-CBQ Hypotension

NURSING INTERVENTIONS Monitor VS and signs of Hypocalcaemia Initiate seizure precautions Place a tracheostomy set. O2 tank and suction at the bedside Prepare CALCIUM gluconate Provide a HIGH-calcium and LOW phosphate diet -CBQ Eat VIT D rich foods AVOID!!! Carbonated beverage & digitalis- CBQ

Hyperparathyroidism Hyper functioning of the parathyroid gland Hyper secretion of the parathyroid hormones

Most common cause?: Renal failure Vit D deficiency Adenoma

SIGNS& SYMPTOMS: Fatigue and muscle weakness/pain Skeletal pain and tenderness Fractures Osteoporosis Cardiac Dysrhythmias Renal Stones Constipation Anorexia, N/V

NURSING INTERVENTIONS Monitor VS, Cardiac rhythm, I and O Handle body parts carefully REMEMBER: LIFT sheet Increase fluids- CBQ Administer diuretics as ordered-CBQ Administer calcitonin as ordered Administer FOSAMAX as ordered

Give calcium regulators as prescribed like ALENDRONATE (FOSAMAX) CBQ Should not be chewed Should be taken with water at least 30 minutes before breakfast and remain upright for at least 30

min.

CUSHING’S DISEASE Hypersecretion of adrenal cortex hormones (glucocorticoid, mineralocorticoid, androgen and

estrogen)

SIGNS & SYMPTOMS: Hypervolemia Hypo K Hypertension Edema Hyperglycemia Moon face, buffalo hump, truncal obesity

HirsutismDIAGNOSTIC TEST:

o Dexamethasone suppression test:o Overnight DEXA:

given in the evening 1 mg (oral, midnight), blood is withdrawn in the morning 8AM (next day) normal result is less than 140 nmol/L or 5 mcg/dl (plasma cortisol) High level of ACTH indicates Secondary Cushing’s

o 24 hour urine cortisol: greater than 275 nmol/L is suggestive of abnormal condition

INTERVENTIONS: Monitor VS, observe for hypertension-CBQ Measure Intake & Output & daily weights-CBQ Protect client from exposure to infection-CBQ Minimize stress in the environment-CBQ Prevent accidents & falls & provide adequate rest Monitor urine for glucose & acetone DIET: LOW SODIUM, HIGH K- CBQ Maintain muscle tone Maintain skin integrity Prepare for surgery( adrenalectomy/ hypophysectomy)

ADDISON’S DISEASE Hyposecretion of adrenal cortex hormones Hypo functioning of the adrenal cortex

SIGNS & SYMPTOMS: Hypotension Hypovolemia Weight loss Hyper K Hypoglycemia Decrease ability to combat stress and infection Bronze skin Sparse axillary hair/ pubic hair

NURSING INTERVENTION Provide rest Administer hormone replacement therapy as ordered.-CBQ Glucocorticoids ( cortisone , hydrocortisone) Mineralocorticoids Monitor vital signs Check I & O/ Daily weights-CBQ Decrease stress in the environment Prevent exposure of infection DIET: HIGH SODIUM, LOW K-CBQ

PHEOCHROMOCYTOMA Benign tumor of the chromaffin cells of the adrenal medulla Peak incidence is ages 20 to 50 years Stimulates hyper secretion of cathecholamines (epinephrine and norepinephrine)

SNS over-activity

“5 H’s”Hypertension

HeadacheHyperhidrosis

HypermetabolismHyperglycemia

Diagnostic tests:Vanillylmandelic Acid test (VMA test)

24 hour urine specimenInstruct the patient to avoid the following medications and foods which may alter the result

CoffeeTeaBananasChocolateVanilla- CBQAspirinNormal 0.7-6.8mg/24hrs

Cont.CT Scan, MRI, Ultrasound

To localize the pheochromocytoma

Nursing intervention: Monitor VS especially BP. POSITION? HOB elevated Administer meds as ordered to control BP.

Phentolamine (Regitine) Na Nitroprusside (Nipride)

Promote rest; decrease stimuli. Monitor urine test for glucose & acetone. Provide high calorie, well-balanced diet; avoid stimulants such as coffee or tea. Prepare for adrenalectomy QUESTION???? CAN YOU PALPATE ABS???

DIABETES MELLITUS

A chronic disorder of impaired glucose metabolism, protein and fat metabolismRISK FACTORS for Diabetes Mellitus

Family History of diabetes Obesity Race/Ethnicity Age of more than 45 Hypertension Hyperlipidemia History of Gestational Diabetes Mellitus

DRUG THERAPY( for DM type 1)

Insulin points to remember: Route? SC do not massage. Clear first before cloudy Inject air in the NPH insulin vial or regular????? Administer insulin at room temperature. Rotate the site of injection Store insulin at the refrigerator Gently roll vial in between palms do not shake.

Drug therapy ( for dm type 2)Oral hypoglycemic agents (oha)

Drug of choice for type 2 diabetes mellitus. Stimulate the pancreas to secrete insulin----CGFNS Oral hypoglycemic agents are contraindicated during pregnancy-----LOCAL

DIAGNOSTIC TESTS1. FBS- > 1262. RBS- >2003. OGTT- > 2004. HgbA1- above 7 %----NCLEX5. Urine glucose6. Urine ketones

NURSING MANAGEMENT OF DM The main goal is to NORMALIZE insulin activity and blood glucose level by:

NUTRITIONAL MODIFICATION NUTRITIONAL ASPECT: Balanced diet is the best diet for diabetes mellitus------NCLEX Carefully follow the exchange list of the diet. Do not skip meals

EXERCISE All exercise must be carefully planned, suggest 6-7 days a week, the same time each day to

facilitate glucose control Exercise enhances effects of insulin so it may cause hypoglycemia. Blood glucose monitoring before and after exercise.----LOCAL Before doing strenuous activity have a light snack-----LOCAL

FOOT CARE Inspect feet daily for dryness, cracks or ingrown toenails using mirror.----LOCAL Thoroughly cleanse and dry feet and in between toes daily. Place skin moisturizers on feet to prevent cracking.-----LOCAL Never walk around barefooted Always wear socks with shoes Allow only podiatrist to care for corns, callouses, toenails. Must be aggressive in treating any foot wounds

DURING ILLNESS OR SURGERY Must continue to take medication- CBQ More insulin will be required.- CBQ Increase frequency of blood glucose monitoring. If unable to eat, take & increased fluids, simple carbohydrates.

HYPOGLYCEMIA Blood glucose level less than 50 to 60 mg/dL Causes: Too much insulin/OHA, too little food and excessive physical activity Mild- 40-60 Moderate- 20-40 Severe- less than 20

SIGNS and symptoms???REMEMBER!!!!S--- hakinessH---ungerR---apid pulseI----rritabilityL---oss of concentrationS----eizureHYPOGLYCEMIANursing Interventions1. Immediate treatment with the use of foods with simple sugar- glucose tablets, fruit juice, table sugar, honey or hard candies2. For unconscious patients- glucagon injection 1 mg IM/SQ; or IV 25 to 50 mL of D50/503. re-test glucose level in 15 minutes and re-treat if less than 75 mg/dL 4. Teach patient to refrain from eating high-calorie, high-fat desserts5. Advise in-between snacks, especially when physical activity is increased6. Teach the importance of compliance to medications

THE ENDREFERENCES:

PORTH, CAROL MATSON, “ Essentials of pathophysiology, 2nd ed, 2007 lippincott ,USASTEIN, ALICE M., “ NSNA 5TH Edition, Delmar learning ,2005HURST, MARLENE, “Pathophysiology review”, Mc graw companies Inc. 2008, USASMELTZER, SUZANNE C. “ Brunner & suddarth’s textbook of medical surgical nursing 9th ed.,lippincott 2000SILVESTRI, LINDA, “ Comprehensive review of NCLEX-RN examination, 3rd edition 2005 Elsevier Inc.KRENTZ, ANDREW, “ Churchill’s pocketbook of Diabetes, 2000, Elsevier Inc.UDAN, JOSIE QUIAMBAO, “ Medical surgical nursing: concepts & clinical application, 2002 Educational publishing house, Philippines